Inspection on 15/07/08 for Hadrian House

This inspection was carried out on 15th July 2008.

CSCI found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Hadrian House 27/04/06

Hadrian House 26/09/05

Hadrian House 28/01/05

Hadrian House 10/12/04

Hadrian House 02/03/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Hadrian House Garden Street Thurmaston Leicester Leicestershire LE4 8DS Lead Inspector Linda Clarke Unannounced Inspection 15th July 2008 09:45 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hadrian House DS0000032914.V368366.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hadrian House DS0000032914.V368366.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hadrian House Address Garden Street Thurmaston Leicester Leicestershire LE4 8DS 0116 2694397 0116 2694397 ahorobin@leics.gov.uk www.leicestershire.gov.uk Leicestershire County Council Social Services Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Angela Pauline Horobin Care Home 40 Category(ies) of Dementia (40), Learning disability (40), Mental registration, with number disorder, excluding learning disability or of places dementia (40), Old age, not falling within any other category (40), Physical disability (40), Sensory impairment (40) Hadrian House DS0000032914.V368366.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Dementia - Code DE Learning Disability - Code LD Mental Disorder, excluding learning disability or dementia - Code MD Sensory Impairment - Code SI The maximum number of service users who can be accommodated is 40 27th April 2006 2. Date of last inspection Brief Description of the Service: Hadrian House is a care home providing personal care and accommodation for forty older persons, who may have associated conditions, which may include dementia, mental disorder, learning disability and sensory impairment. The home also provides two beds offering respite facilities and a rehabilitation unit. The forty single bedrooms are without en-suite facilities. The home has a central and surrounding garden. Accommodation is provided over two floors with access between floors being via stairs or a passenger lift. Hadrian House is situated close to Thurmaston town centre where service users have access to shops, pubs and other amenities. Information is located on site detailing the range of services offered, which includes the Statement of Purpose, in addition to this Hadrian House has copies of the Commission of Social Care Inspections, Inspection Reports, which are located in the foyer and are available upon request. The maximum weekly fee is £490.00, which was provided in documentation submitted by the Registered Manager. There are additional costs for individual expenditure such as Chiropody, Optician and hairdressing services, and the fee will depend on the services received. Hadrian House DS0000032914.V368366.R01.S.doc Version 5.2 Page 5 Inspection reports regarding the home are available and can be accessed via the CSCI website: www.csci.org.uk. Further information about the home is available from the Registered Manager. Hadrian House DS0000032914.V368366.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star. This means the people who use this service experience adequate quality outcomes. ‘We’ as it appears throughout the Inspection Report refers to ‘The Commission for Social Care Inspection.’ The inspection process consisted of pre-planning the inspection, which included reviewing the Annual Quality Assurance Assessment (AQAA), which is selfassessment tool completed by a representative of the service, reviewing previous Inspection Reports, and any information we have received. We sent surveys to people who use the service of which three were completed and returned, five staff surveys were sent out of which two were returned, and health care professional surveys were sent out of which two were returned. The unannounced site visit commenced on the 15th July 2008, and took place between 09:45 and 18:00 The focus of the inspection is based upon the outcomes for people who use the service. The method of inspection was ‘case tracking’. This involved identifying people with varying levels of care needs and looking at how these are being met by the staff at Hadrian House. Four people accessing services were selected. Discussions were held with five people living at the Home, a relative and two members of care staff and members of the Management Team. What the service does well: People at living at Hadrian House are supported by staff who are enthusiastic and committed to delivering care and support, relationships between people living at the Home and staff are positive, and many people living at the Home view the people that support them as friends and family. There is a range of activities and outings that people can take part in, and the views of people living at the home are sought to ensure that they decide what trips and excursions are available. Hadrian House is decorated to a good standard, and provides a homely environment with numerous communal areas for people to spend time and relax; in addition people in residence have access to a private garden. Hadrian House DS0000032914.V368366.R01.S.doc Version 5.2 Page 7 We sent surveys to people and asked them for their views about the service they receive or observe, surveys contained comments about what the service does well, which included: • • I could not have better care anywhere, I have care, love and attention in the latter years of my life, I could not ask for more. The staff are very dedicated to the residents in Hadrian House. What has improved since the last inspection? What they could do better: People living at the Home need to be confident that there care and welfare is supported and recognised, and this starts from when they move into the Home and the information made available to them. People need to be consulted about all aspects of the care and support they require, and need to have their care needs comprehensively and accurately recorded to ensure that the care they receive is appropriate to them. To achieve this the Home needs to make time to develop care plans, and ensure that staff responsible for developing and reviewing care plans receive the appropriate training and support, which is then used to develop care plans and care practices. People living at the Home, need to be provided with the information about what they should do if they are unhappy, or feel insecure or unsafe. The information should contain information about how to raise concerns, and other agencies that can be contacted. The information needs to be in a format suitable to the needs of people, and the information reinforced at appropriate opportunities. Hadrian House DS0000032914.V368366.R01.S.doc Version 5.2 Page 8 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Hadrian House DS0000032914.V368366.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hadrian House DS0000032914.V368366.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s experience of moving into Hadrian House is not consistent, with regards to the information they are provided with, peoples needs are assessed which enables staff at the Home to have information about a persons needs before moving in. EVIDENCE: Hadrian House has information about the services offered by the home, information is in the form of two documents known as the Statement of Purpose and Service User Guide, copies of which are located in the entrance foyer of the Home. The presentation of the information may make it difficult for some people to comprehend and understand, and consideration by the Home should be given Hadrian House DS0000032914.V368366.R01.S.doc Version 5.2 Page 11 as to how information is provided, by the use of plain English, large print and photographs, enabling people to have greater access to information. We received information from the Home prior to the site visit that people are provided with information about the Home, and have a comprehensive assessment of their needs to ensure that the Home is appropriate for them, when we asked people and looked at the records of people this was found not to be accurate in all instances. We spoke with one person who was staying at Hadrian House for two weeks on respite care; we asked them if they were given any written information about the Home, they said that they hadn’t. We looked at the records of one person who had recently moved into Hadrian House, there was a checklist in the persons notes which details the information that people moving into the Home should be provided with, including being advised as to the layout of the Home and how to use the call bell system, the checklist was not completed. We received two surveys from people who live at Hadrian House, to the question did you receive enough about the Home to enable you to make a decision one person said yes, whilst the other said no but made an additional comment. ‘But Hadrian House has a good reputation.’ Everyone moving into Hadrian House have their needs assessed by a representative of Social Services to enable the management team of the Home to ascertain as to whether they can meet the needs of a person. Hadrian House has beds dedicated to Intermediate Care, but they are currently not being utilised. Hadrian House DS0000032914.V368366.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The lifestyle and care people receive is not fully supported as care plans do not comprehensively reflect the health, personal and social care needs of people living at the Home or record an individuals expectations and decisions. EVIDENCE: We looked at the care plans of four people who live at Hadrian House; care plans were not comprehensive and in some instances contained conflicting information to that detailed within their initial assessment. Not all information was reflected in care plans and was not regularly updated; the lack of information and consistency of information may compromise the care a person receives. The care plan of one person made reference to the fact that the person had Dementia, and maybe disorientated in ‘time and place’, but no information was given as to the role of staff or the use of equipment in supporting the person. Hadrian House DS0000032914.V368366.R01.S.doc Version 5.2 Page 13 One persons care plan said that they had a history of falls and continued to be at risk of falling, there was no information in the persons initial assessment with regards to their risk of falling, not did the care plan detail how staff were to reduce the risk of falls. We looked at an assessment of risk for one person, that detailed how staff were to ensure the safety of the person living at the Home and there safety when delivering personal care, as in some instances the person could be challenging at this time due to there having Dementia. The persons care plan made no mention of this stating only that the person needed support with personal care, including dressing. We noted there was no evidence that other documentation such a risk assessments and nutritional assessments had not been reviewed, in some instances for up to three years. Care plans were found to contain minimal information about a person’s life prior to moving into the Home, and there was no guidance on how the information could be used to support the person’s lifestyle choices. An example of this being a persons hobbies including crosswords and jigsaw puzzles, with no information as to how this interest could be continued to be supported within the Home. Information about a persons life before moving into the Home can be used to ensure that there lifestyle continues to be respected and promoted, such as their preferred daily routine, what time they wish to get up, would they prefer a cup of tea before get dressed, where would like to eat their breakfast. In addition peoples work and family life experiences impact on the way a person may choose to live their lives, and this needs to be recognised and understood when caring for people, particularly those with Dementia to ensure that their needs are met. Records evidenced that people living at the Home are supported by relatives or by staff to access health care where necessary, we observed people attending appointments on the day of the site visit, and the surveys we received from people who live at Hadrian House expressed satisfaction about their health care. We received surveys from two General Practitioners who support people who live at the Home, both expressed general satisfaction with the care and support their patients receive at the Home, and one General Practitioner made an additional comment ‘the staff are very committed and work very well with our surgery to maximise the optimise the health and well-being of their residents.’ Hadrian House DS0000032914.V368366.R01.S.doc Version 5.2 Page 14 We looked at the records and medication of the four people whose records we viewed, and were found to be in good order. Currently there is no one living in the Home who is prescribed a controlled drug, but this has been the case in the recent past. Amendments to legislation require that Controlled Drugs stored in care homes are in a cupboard designed for the specific person, it is the responsibility of the Registered Manager to ensure that storage facilities comply with current legislation. Certain aspects of the management of the Home, directly affects the dignity of people living at the Home and places restrictions on their decisions and the control they have on their daily lives. We read in care plans where staff were responsible for aspects of managing a persons life, including medication and cigarettes. The four care plans we viewed stated that the staff at the Home are responsible for all aspects regarding the persons medication, including ordering, storage and administration, two of the four peoples whose care plans we looked at smoked, and care plans stated that staff kept cigarettes in the office, and were given to the person at their request. There was no risk assessment or record detailing how this decision had been reached or whether the person had been consulted. We spoke with several people who lived at the Hadrian House, all expressed satisfaction with the care they receive, and complimented the staff on their attitude and approach. Information we received in the three surveys we received expressed differing views as to whether people receive the care and support they need, one person said always and wrote “I could not be better cared for anywhere, I have care, love and attention in the latter years of my life, I could not ask for more.” The two remaining surveys indicated that they usually receive the care and support they need, and one person also wrote, “I have had difficulties in obtaining the help of a key worker and subsequently have not received baths or showers.” Hadrian House DS0000032914.V368366.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People residing at Hadrian House have access to a range of recreational activities, and are provided with an appealing and balanced diet, in pleasant surroundings. EVIDENCE: Hadrian House employs an Activity Organiser, who organises and facilitates a range of activities for people who reside at the Home to participate in; activities include arts and crafts, bingo, music and movement and sing a longs and trips out. We spoke with several people who said that they had been to Twycross Zoo, in June and that they had really enjoyed themselves and hoped to go again. There were photographs in the entrance foyer of the Home, of the trips to both Twycross Zoo and Woburn Safari Park. We viewed the records of people living at the Home which recorded their involvement in activities and outings, in some instances people living at the Home have regular contact and in some instances visits and holidays with members of their family. Hadrian House DS0000032914.V368366.R01.S.doc Version 5.2 Page 16 On the day of our visit a majority of people sat in the main lounge, the radio was on throughout the day, no other activities were taken place, as the Activity Organiser was not at work. We spoke with a small group of people who sat in a smaller lounge, and were watching television. One person said that they had been a member of two social clubs before moving into Hadrian House and that they continued to go and that the Club provided the transport. The person went onto say that they sometimes went to stay with family at the weekend, and that when they did they went to their local Church, which is not possible when they’re at Hadrian House as they do not have access to transport, but said that they attended the Church services held within the Home. People living at the Home have the opportunity to attend meetings, the minutes of meetings were viewed and discussions with the people who lived at the Home focused on the range of activities and any trips or events they would like to take part in, and their views about the range and choice of meals available. We observed the lunchtime meal, and noted that the dining room was decorated to a good standard, and was homely and comfortable to sit in. The tables were set, and included a menu detailing the choices for the day. Vegetables were placed in serving dishes on the table so that people could serve themselves. Hot drinks were served throughout the day, and cold drinks were available in all communal areas. We received surveys from three people who live at the Home; all expressed satisfaction with the range of activities provided and indicated that they liked the meals. One person we spoke, who had Diabetes said that the Cook was very attentive in ensuring that the specialist diet they required was available and included a wide range of choice. Hadrian House DS0000032914.V368366.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People’s ability to express a concern or complaint is limited by the information made available to them; the limited training staff have received regarding protecting people from abuse and limited information in care plans compromises the welfare of people living at the Home. EVIDENCE: Hadrian House has a complaints procedure, which was displayed within the Home, we spoke with people living at the Home, who gave mixed views as to whether they had received information when they moved into the Home, which included information about how to make a complaint. People need to made aware of their rights and how to make a complaint, and be given information about advocacy services so that they are empowered to report their concerns. We did not look at the complaints records of the Home, as information given to us by the Registered Manager before the visit said that the Home had not received any complaints within the last twelve months. We observed that there is a positive and open rapport between people living at the Home and the staff, and people we spoke with were very positive about the care they receive and the attitude of staff. The three surveys we received from people living at the Home gave a mixed response as to whether they Hadrian House DS0000032914.V368366.R01.S.doc Version 5.2 Page 18 know how to make a complaint, but all said that staff listen and act upon what they say. We spoke with two members of staff, of which one had received training on ‘safeguarding’, which provides staff with information on the forms in which abuse may occur, and the possible signs individuals may display in they are suffering abuse. We viewed the training records of four members of staff; none had received training on safeguarding. During our site visit we observed that some people living at the Home were affected by the behaviour of one person, for a brief period of time in the afternoon. This was discussed with the Registered Manager of the Home, as to how people should be supported and how the Home needs to respond to protect the welfare of all people. We felt that the situation we observed on the day had not been managed well, but acknowledge there were many factors that contributed to how this was dealt with. People who live at the Home need to be protected from abuse, by a pro-active approach, which can only come about by staffing receiving the training, that gives them the knowledge and confidence to manage issues well, and by comprehensive care plans which provide staff with information as to how to manage situations and provide appropriate support. Hadrian House DS0000032914.V368366.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People in residence at Hadrian House stay in a homely and well maintained environment, which is suitable to their individual and collective needs. EVIDENCE: The ground floor of Hadrian House provides the main lounge and dining room, along with smaller lounges, bedrooms, toilet and bathing/shower facilities, access to the first floor is via a stairwell or passenger lift, where additional small lounges, bedrooms and toilet and bathing/shower facilities can be found. The Home is decorated to a good standard throughout, and provides a homely atmosphere for to people to live. Hadrian House DS0000032914.V368366.R01.S.doc Version 5.2 Page 20 There is a central courtyard garden, which is accessible to people living at the Home, one person we spoke with said that there was talk about providing a path around the garden, so that people could walk around, but this had not happened, they went onto say that “the garden could be better looked after if we had a gardener, the roses need ‘dead heading’ now, if they were it’d flower again.” The garden has a patio area with seating and tables provided, and flowers and shrubs are planted in tubs, hanging baskets and garden beds, there is also an area a grassed area. The surveys we received from people living at the Home said that in their view the home was fresh and clean. People we spoke with expressed satisfaction with the décor and cleanliness of the Home; one person told us “my only criticism in that I wish my bedroom was bigger.” Hadrian House DS0000032914.V368366.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An enthusiastic, competent and knowledgeable staff team, who have undergone a robust recruitment process, support people staying at Hadrian House. EVIDENCE: We observed that people living at the Home are supported by staff who are able to respond to their needs in a timely manner, staff we spoke with said that in the afternoon and evening when there are less staff on duty it was sometimes difficult to observe people at all times. We received two surveys from members of staff who gave conflicting views as to whether in their opinion there are sufficient staff to meet the needs of people living at the Home. Surveys we received from people living at the Home indicated that staff are available when they need them, one person wrote ‘the staff are very dedicated to the residents in Hadrian House.’ We spoke with people living at the Home and asked them their views about the staff one person said “the staff have a good sense of humour, and they’re always happy to help.” Whilst someone else said, “the girls are very good, they’re excellent.” Hadrian House DS0000032914.V368366.R01.S.doc Version 5.2 Page 22 Throughout the day we observed staff supporting people, in a kind and friendly manner, and approached people with consideration to their dignity and welfare. Staff had time to stop and speak with people living at the Home. Care staff are supported by staff that are responsible for the maintenance and cleanliness of the Home, and by catering staff that prepare and cook the meals. Information supplied by the Registered Manager prior to the site visit, states that 63 of care staff have attained a National Vocational Qualification (NVQ) in Care. We spoke with two members of staff, who told us about the training they received, and the surveys we received from staff indicated that they are satisfied with the training, and feel confident that the training they receive a enables them to meet the needs of people in their care. We viewed the recruitment records of four members of staff, records kept evidence that the Home operates a robust recruitment practice, which includes all staff obtaining a satisfactory Criminal Record Bureau (CRB) disclosure, prior to confirmation of a job offer and commencement of employment. The robust recruitment process promotes the welfare of people living at the Home. We spoke with staff who provided information about the training they receive, all training is related to the safety and welfare of people using the service, along with training which is specific to their health and care needs, the care plans we viewed did not detail how the training staff had attended, is used to influence the care people in the Home receive. Hadrian House DS0000032914.V368366.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at Hadrian House reside in a Home, which is managed well and has quality assurance systems in place to enable people to comment on the care they receive. EVIDENCE: Angela Horobin, the Registered Manager has managed the Home for several years, and has attained a National Vocation Qualification (NVQ) level 4 and the Registered Managers Award. Ms. Horobin attends training courses to maintain and continue her professional development. Ms. Horobin is supported by a Managerial Team, which includes a Deputy Manager and three Assistant Hadrian House DS0000032914.V368366.R01.S.doc Version 5.2 Page 24 Managers, all of which have attained a National Vocational Qualification in Care. We looked at the most recent Quality Assurance report, which was dated July 2007, the report collated information from various sources, including comments from people using the service and their relatives. A financial audit report was also viewed, and recommendations made had been acted upon, the care plans we viewed stated that relative’s manage the person’s finances. People using the service have the opportunity to attend meetings, where their views and ideas can be obtained, in addition staff attend meetings, to ensure that they are able to affectively care for the people living at the Home by keeping up to date with current practices. We spoke with staff that said they receive regular supervisions, which are conducted by their line Manager and are recorded. Supervisions are used to discuss the individual care of people living at the Home where the staff member is their keyworker, and to identify training needs, and discuss their care practices. We spoke with staff that said that the Managerial Team is supportive and are always available if you need them, and surveys we received from staff confirm this. Information provided in the AQAA and within the Quality Assurance report, provides information about the maintenance of the building, including fire equipment, heating and fire systems. Hadrian House DS0000032914.V368366.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Hadrian House DS0000032914.V368366.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? N/A STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement People accessing services at Hadrian House to have a care plan which accurately reflects in detail the care and support they require. The Registered Manager to establish whether the cabinet which stores Controlled Drugs at Hadrian House complies with the Misuse of Drugs (Safe Custody) Regulations 1973. If it is found current storage facilities do not meet the regulations then a storage system, which does comply with the Misuse of Drugs (Safe Custody) Regulation 1973 is to be purchased and installed. 3 OP10 12(2) People accessing services at Hadrian House should be consulted and have risk assessments in place where decisions have been made that restrict choice and impacts on the control they have over their daily lives. All those who access services at DS0000032914.V368366.R01.S.doc Timescale for action 15/11/08 2 OP9 13(2) 15/10/08 15/10/08 4 OP16 22(6) 15/10/08 Page 27 Hadrian House Version 5.2 5 OP18 13(6) Hadrian House, to be provided with a copy of the Homes complaints procedure in a format that is appropriate to their needs. A training schedule to be developed that ensures all staff responsible for the care and welfare of people living at the Home, receive training as to their roles and responsibilities in protecting people from abuse or being harmed, or placed at risk. 15/10/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP1 OP7 Good Practice Recommendations The Statement of Purpose and Service User Guide to be provided in a format, which promotes greater understanding of its contents to people using the service. People living at the Home would benefit from Person Centred Care Plans that have a holistic approach to care and reflect all aspects of their daily lives, including their preferred daily routine. People living at the Home, along with their relatives and friends to be provided with information on agencies and professionals who they can contact if they feel frightened or unsafe, including advocacy services. 3 OP16 Hadrian House DS0000032914.V368366.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hadrian House DS0000032914.V368366.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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