Inspection on 05/02/08 for Engelberg

This is the latest available inspection report for this service, carried out on 5th February 2008.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Engelberg 04/07/06

Engelberg 10/05/05

Engelberg 17/09/04

Engelberg 28/04/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Engelberg Engelberg Ash Hill Compton Wolverhampton West Midlands WV3 9DS Lead Inspector Sue Woods Unannounced Inspection 5th February 2008 10:15 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 Engelberg DS0000030104.V355733.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. Engelberg DS0000030104.V355733.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Engelberg Address Engelberg Ash Hill Compton Wolverhampton West Midlands WV3 9DS 01902 420613 01902 713587 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) home.fxg@mha.org.uk Methodist Homes for the Aged Angela Jeavons Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Engelberg DS0000030104.V355733.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Females 60 years and above, males 65 years and above. Maximum of 2 residents with Mild Dementia. Date of last inspection 6th November 2007 Brief Description of the Service: Engelberg is registered with the Commission for Social Care Inspection to provide accommodation and personal care to a maximum of 32 older people. The registered provider is Methodist Homes for the Aged and the registered manager is Angela Jeavons. The extended building has been adapted to provide for the needs of physically frail older people. There are thirty-two single rooms, twelve of which have an en suite facility. The home is situated in a very peaceful area of Compton in Wolverhampton, but is within easy reach of the city centre and local facilities. There is a large and very well maintained garden that is accessible to all people who live there. Consultation with people who live at the home takes the form of an internal audit that also seeks the views of relatives, representatives and staff. People who use the service and their representatives are able to gain information about this home from the Statement of Purpose and Service User Guide. Inspection reports about this service can be obtained direct from the provider or are available on our website at www.csci.org.uk Engelberg DS0000030104.V355733.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means that people who use this service experience good quality outcomes. The unannounced key inspection of Engelberg took place on 5th February 2008. The inspection started at 10.15 am and lasted five and a half hours. The purpose of the inspection was to review improvements made since the last key inspection of the service on 6th November 2007. The inspection reviewed all twenty two of the key standards for care homes for older people and information to produce this report was gathered from the findings on the day and also by review of information received by CSCI prior to the inspection date. A quality rating based on each outcome area for service users has been identified. These ratings are described as excellent/good/adequate or poor based on findings of the inspection activity. As part of the inspection the inspector met with a number of people living at the home, a relative and with staff on duty at the time of the visit. The inspector also handed out surveys for completion by relatives, staff and a visitor to the home. Eleven were returned. Support for the inspection came from the registered manager and the assistant manager who were available throughout. Three care files were reviewed in detail and extracts were seen from others. What the service does well: People who live at Engelberg told the inspector that it is a ‘good home’. People feel that their privacy and dignity is respected and they have good opportunities to celebrate their religious beliefs. One relative said that the home was ‘very nice, food provided is very good and cleanliness very good indeed’. Visitors to the home are always made very welcome and a regular visitor to the home said that Engelberg is ‘the best home in Wolverhampton’. The home works closely with district nurses and provides a dedicated service to people upon death and after they have died. Staff feel that they have good support and training opportunities. Engelberg DS0000030104.V355733.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: 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. Engelberg DS0000030104.V355733.R01.S.doc Version 5.2 Page 7 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 Engelberg DS0000030104.V355733.R01.S.doc Version 5.2 Page 8 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): Standards 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate procedures are in place to ensure that the home can meet the care and support needs of someone who comes to live at Engelberg. EVIDENCE: The inspector saw the pre admission assessments of three people who have recently moved in to Engelberg. They had all been completed by the manager with support from the person moving in where possible, and family members. One person, who was funded by the local social services department, had also had a Community Care assessment. Assessments were seen to form the basis of the care plans. The home’s Statement of Purpose contained information to enable people who want to live at the home to know what services Engelberg can and cannot offer. Engelberg DS0000030104.V355733.R01.S.doc Version 5.2 Page 9 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): Standards 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at Engelberg are protected by effective systems for the administration and monitoring of medication and people receive excellent care during and after death. Care plans reflect people’s changing care and support needs enabling staff to offer effective care and support. EVIDENCE: Care files seen were well organised and up to date. There was clear evidence that the senior team had reviewed them monthly. People’s changing needs were seen to be recorded and systems were in place to monitor changing health needs. The home works closely with health care professionals who were seen to have a good rapport with manager and the staff team. Engelberg DS0000030104.V355733.R01.S.doc Version 5.2 Page 10 Arrangements for the recording of administration of medication were seen to be good and the assistant manager has developed rigorous monitoring systems to ensure all medication is accounted for. Staff who administer medication have been trained to do so. The home excels in its support for people who are near the end of life. The home can organise funerals and staff have received training to support all aspects of death and dying. The manager promotes discussions in relation to end of life support with people who live at the home and relatives. Engelberg DS0000030104.V355733.R01.S.doc Version 5.2 Page 11 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): Standards 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 who live at Engelberg are able to choose their life style, social activities and keep in contact with family and friends People enjoy a varied diet according to their assessed needs and individual choice. EVIDENCE: Since the time of the last key inspection of the home in November 2007 an activities coordinator has taken up her role at the home. People who live at Engelberg and staff members all spoke positively about the activities programme. On the day of the inspection a group of people were playing ‘netball’ and ‘magnetic darts’ in the lounge. It sounded like all were having fun and feedback was very positive. Staff said, in discussions and in the surveys that activities have improved over the last six months. Two staff members told the inspector about the fund raising events that take place throughout the year. Staff were clearly Engelberg DS0000030104.V355733.R01.S.doc Version 5.2 Page 12 enthusiastic about the events and photographs showed that at the last event a good time was had by all. Visitors to the home told the inspector that they are always made very welcome. People living at Engelberg have regular opportunities to celebrate their religious beliefs although others prefer not to take part in the regular worship sessions. The inspector spent time talking with the cook who had a very good knowledge of the likes, dislikes and dietary needs of people living at Engelberg. The cook spends time talking with people and incorporates favourite dishes into the menus. People who spoke with the inspector said that they liked the meals. Engelberg DS0000030104.V355733.R01.S.doc Version 5.2 Page 13 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): Standards 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at Engelberg have access to a complaints procedure, which enables their views to be listened to and the home involves outside agencies as appropriate to investigate concerns and allegations openly. EVIDENCE: Since the time of the last inspection of the home the manager and assistant managers have familiarised themselves with the organisation’s policy for investigating allegations of abuse and have liaised with the local adult protection team to ensure that referrals are made appropriately and openly. Staff training has been organised although there is a slight delay in accessing it due to the availability of the training. Likewise training to support people with challenging behaviour has also been arranged but will not be accessed until next month. It was noted that this training is no longer a priority, as the home no longer supports someone who displays such behaviours. There have been no complaints about the home since the time of the last inspection. In fact people continue to compliment the home for its effective care and support. Engelberg DS0000030104.V355733.R01.S.doc Version 5.2 Page 14 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): Standards 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Engelberg is clean and well maintained providing the people who live there with a comfortable place to live. EVIDENCE: At the time of the key inspection in November 2007 the inspector found all areas were clean. Bedrooms were personalised and no hazards were identified. Staff with responsibility for the maintenance and cleaning of the home were knowledgeable of their roles and were seen to be wearing appropriate personal protective clothing. Staff were aware of the need for data sheets and risk assessments to support the use of chemicals and these documents were available for review near to where the products are stored. The maintenance worker said the home had a budget for repair and maintenance and the office had just been painted and decorated and a new fire panel installed. Engelberg DS0000030104.V355733.R01.S.doc Version 5.2 Page 15 The home is currently having patio doors fitted to the music room that will open onto a patio area overlooking the garden. People are looking forward to this being completed. The Environmental Health Officer visited the home on 23rd November 2007 and awarded them 4 stars. Engelberg DS0000030104.V355733.R01.S.doc Version 5.2 Page 16 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): Standards 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. The people who live at Engelberg benefit from being supported by a well trained and committed staff team enabling their needs to be effectively met within the home. EVIDENCE: All staff who spoke with the inspector enjoyed working at the home. They felt they had good support and training opportunities. Staff gave examples of ongoing training courses and certificates seen at the time of the inspection reflected that mandatory training is updated when required. Since the time of the last inspection of the home the manager has reviewed staff files and requested additional information to support a thorough recruitment process. There have been no new staff appointed at the home since the last inspection but the administrative assistant gave an example of how she was checking a piece of information received in order to protect vulnerable people. The manager could evidence an investigation into working practices that she had carried out and said that outcome letters are now on individual files. All staff working at the home are re-completing their induction training to demonstrate that all staff have received the basic level of information relating Engelberg DS0000030104.V355733.R01.S.doc Version 5.2 Page 17 to the home. New staff to the home will complete the Common Induction Standards. Staff still feel that maybe more staff on duty would further improve the quality of the service. The manager will continue to monitor staffing levels in line with peoples assessed needs and is aware that people’s needs are increasing as they become older. Staff feel that teamwork and the high standard of care provided are a strength of the home. The manager showed the inspector how the home manages money for people when required. The procedure was robust and protects people from error due to the monitoring systems that are built in to the process. Engelberg DS0000030104.V355733.R01.S.doc Version 5.2 Page 18 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): Standards 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live at Engelberg benefit from being supported by an effective management team enabling them to lead a good quality of life. The health and safety and welfare of people living at the home and the staff team is promoted and protected. EVIDENCE: The manager has made improvements to the home by addressing all requirements and recommendations made at the time of the last inspection. She has worked hard with her senior team to review and update care plans as well as to ensure that the home only supports peoples whose needs they can meet. Engelberg DS0000030104.V355733.R01.S.doc Version 5.2 Page 19 The manager has now completed The Registered Managers Award and is working with the local adult protection team to ensure practice meets current guidelines. The manager developed an improvement plan following the last inspection of the home and has implemented it as far as she is able. Outstanding requirements relate to training and dates have been arranged for all training identified. The improvement plan was submitted to CSCI in good time and the manager also produced an immediate response to requirements made. Engelberg DS0000030104.V355733.R01.S.doc Version 5.2 Page 20 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 3 X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 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 Engelberg DS0000030104.V355733.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Engelberg DS0000030104.V355733.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Engelberg DS0000030104.V355733.R01.S.doc Version 5.2 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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