Inspection on 09/08/06 for Eagle Care Home

This inspection was carried out on 9th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Eagle Care Home 06/08/07

Eagle Care Home 02/02/06

Eagle Care Home 10/08/05

Eagle Care Home 05/01/05

Eagle Care Home 22/07/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Eagle Care Home 104 Victoria Road Elland West Yorkshire HX5 0QF Lead Inspector Cheryl Stovin Unannounced Inspection 9th August 2006 10:00 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 Eagle Care Home DS0000059046.V300819.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. Eagle Care Home DS0000059046.V300819.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eagle Care Home Address 104 Victoria Road Elland West Yorkshire HX5 0QF 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) 01422 373141 01422 373141 None Eagle Care Homes Ltd Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33) of places Eagle Care Home DS0000059046.V300819.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd February 2006 Brief Description of the Service: Eagle Care Home is a privately owned care home registered to provide accommodation and care for up to 33 older people. The establishment is situated in a residential area close to the town centre of Elland. Halifax town centre is easily accessible by public transport. The property is generally well maintained throughout and provides accommodation comprising of 27 single rooms 16 of which have en-suite facilities, and 3 double rooms. Communal areas are spacious and comfortable with a safe and accessible patio area for service users to enjoy in the warmer weather. The weekly charge at the home is £339, additional charges are made for personal toiletries, hairdressing and chiropody. There is also a charge for escorting service users to routine medical appointments. Eagle Care Home DS0000059046.V300819.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report refers to a Key Inspection of Eagle Care Home which was undertaken on 9th and 10th of August 2006 by an inspector from the Commission for Social Care Inspection. A total of 9 hours was spent on the visit. In addition to the visit to the home, when service users were consulted, relatives/visitors were invited as to their opinions of the services and facilities provided within the home by the completion of a comment card. Seven replies were received. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk What the service does well: The home has a relaxed and welcoming atmosphere and service users and visiting relatives spoken to during the inspection confirmed that this is always the case. All service users are subject to assessment prior to moving into the home, and are encouraged to visit, several times if they wish, prior to making a decision to become resident. The staff appeared to be working together as a team and meeting the needs of the service users in a sensitive and dignified manner, with appropriate use of informality and humour. The service users said they were well treated and that the staff team are kind and attend to their needs promptly. Relationships between fellow residents appeared cordial and it was apparent that friendships had been formed between service users. Eagle Care Home DS0000059046.V300819.R01.S.doc Version 5.2 Page 6 Some form of activity takes place most afternoons and service users appeared to be especially enjoying a nostalgia quiz during the inspection. In addition to activities provided within the home days and evenings out are arranged. The destinations are decided by the residents at their regular meetings. The standard of the food was described as “excellent” with one service user particularly praising the choice and quality of the breakfast served. The home is generally well maintained throughout and service users expressed satisfaction with the communal areas and their own private accommodation. Service users and visitors confirmed that standards of cleanliness and hygiene are always of a high standard. All seven of the relative/visitors comment cards received indicated that they were satisfied with the overall care provided within the home. What has improved since the last inspection? What they could do better: There is a programme of NVQ training within the home, however, only one member of the care staff holds the award. The acting manager has set a target date of January 2007 to meet the requirement of 50 of the staff team to be qualified to NVQ level II or equivalent. Eagle Care Home DS0000059046.V300819.R01.S.doc Version 5.2 Page 7 Medication practices within the home are safe, however, care needs to be taken to ensure that the appropriate codes are entered onto the Medication Administration Records when the medicine is not given for whatever reason. The laundry floor requires finishing with a floor surface that is easy to clean. The bathrooms are well equipped and clean, however, are rather stark in appearance and would benefit from redecoration to make them more welcoming. The acting manager, when formally appointed, must submit an application to be registered by the Commission for Social Care Inspection. 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. Eagle Care Home DS0000059046.V300819.R01.S.doc Version 5.2 Page 8 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 Eagle Care Home DS0000059046.V300819.R01.S.doc Version 5.2 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All prospective service users are subject to a pre-admission assessment to ensure that the home can meet their needs. The Statement of Purpose and Service User Guide requires revising as it does not reflect the current situation within the home. EVIDENCE: All service users receive a pre-admission assessment which ensures that the home can meet their needs. One service user was in the process of moving into the home during the inspection. She had visited the home on three different occasions to get the feel of the home and to meet the staff and fellow service users, prior to making the decision to become resident. All service users have a statement of terms and conditions of residence, which details the rights and responsibilities of each party, and what is and is not Eagle Care Home DS0000059046.V300819.R01.S.doc Version 5.2 Page 10 included in the weekly charge. The current additional charges, for example, hairdressing and chiropody are displayed clearly on the notice board in the entrance of the home. The home makes a charge to accompany residents to routine hospital appointments, this is not made clear in the contract and the details must be included. The statement of purpose and service user guide requires revising to include details of the current management arrangements of the home. Intermediate care is not provided within the home. Eagle Care Home DS0000059046.V300819.R01.S.doc Version 5.2 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users health and personal care needs are fully assessed and recorded in their plan of care. Medication systems within the home are generally safe, however, care needs to be taken to enter the appropriate codes in the administration records. Service users confirmed that they are treated with respect and dignity. EVIDENCE: All service users have an individual plan of care. The care plans examined contained detailed information and cover all aspects of health and personal care and activities of daily living. The care plans contain manual handling risk assessments, falls risk assessments, tissue viability assessments and nutritional assessments. The care plans are reviewed on a monthly basis. A Eagle Care Home DS0000059046.V300819.R01.S.doc Version 5.2 Page 12 daily record is made in respect of each resident which clearly indicates how they have spent their time. Service users, with whom the inspector consulted, confirmed that they were treated with dignity at all times and their privacy respected. One service user described being “treated like a queen” and another felt that “moving into the home was the best thing I ever did”. The establishment uses the Boots MDS (Monitored Dose System) for the administration of medication. The stocks of medication are securely and appropriately stored. Medication practices were observed and medicines were handled appropriately. Medication Administration Records were accurately completed for medication actually given, however, appropriate codes were not used when medication was not given, for example, if a resident refused medication or was out. Care must be taken to ensure that appropriate codes are entered onto the records. Controlled drugs are securely stored with appropriate documentation completed. Senior staff are undertaking additional training in medication administration leading to the Certificate of Safe Handling of Medicines. Eagle Care Home DS0000059046.V300819.R01.S.doc Version 5.2 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The routines within the home are flexible with service users being enabled to exercise choice and control over their lives. Service users enjoy a varied and nutritious diet. EVIDENCE: The daily routines in the home are flexible to enable the service users to exercise choice as to how, where and with whom to spend their time. Service users confirmed that they choose when to get up and when to retire. A range of activities are available for the service users to participate in if they choose to do so, the activities on offer are displayed on the notice board, and on the day of the inspection some service users were enjoying playing a game of dominoes and a nostalgia quiz. In addition to social activities provided within the home service users have enjoyed outings to the theatre and meals out. Regular religious services are held at the home enabling service users to fulfil their spiritual needs. Activities and outings are one of the topics discussed at Eagle Care Home DS0000059046.V300819.R01.S.doc Version 5.2 Page 14 the monthly residents meetings, the minutes of which are displayed on the notice board. Visiting relatives, spoken to during the inspection, confirmed that they were always made to feel welcome when they visit the home and are kept informed of any issues affecting their relatives’ welfare. All of the respondents to the relative/visitor comment cards indicated that they are welcomed into the home. Service users spoken to confirmed that they enjoyed the meals provided in the home. The main meal of the day is served at lunchtime and the luncheon being served during the inspection was: mushroom soup, cottage pie or pork casserole served with fresh vegetables, followed by a choice of treacle sponge or banana and custard. One service user particularly praised the choice available to them at breakfast and described the meal as “a right good Yorkshire breakfast”. Eagle Care Home DS0000059046.V300819.R01.S.doc Version 5.2 Page 15 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home holds and displays a complaints procedure. All staff are aware of Protection of Vulnerable Adults policies and procedures. EVIDENCE: The home holds a complaints procedure which is displayed on the notice board in the entrance hall and in each of the bedrooms. A complaints log is held and any complaints received have been handled appropriately and to the complainants’ satisfaction. All of the respondents to the relative/visitors comment cards indicated that they were aware of the home’s complaints procedure. All of the staff team have received training in the Protection of Vulnerable Adults procedures. There had been a concern expressed prior to the inspection regarding a service user attending a hospital appointment without an escort. This matter was fully discussed during the inspection, and a satisfactory explanation was given. Eagle Care Home DS0000059046.V300819.R01.S.doc Version 5.2 Page 16 Eagle Care Home DS0000059046.V300819.R01.S.doc Version 5.2 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,23,24,25,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is generally well maintained and clean and hygienic throughout. Service users bedrooms are well equipped and personalised, however, are not fitted with locks. The laundry floor requires finishing with a surface that is easy to clean, and bathrooms would benefit from re-decoration. EVIDENCE: A full tour of the building was undertaken and the home was found to be clean and hygienic throughout and furnished and fitted to a good standard. Visiting relatives spoken to during the inspection confirmed that the standard of cleanliness is consistently high. Eagle Care Home DS0000059046.V300819.R01.S.doc Version 5.2 Page 18 Individual bedrooms were seen to be well furnished and equipped and the majority were highly personalised reflecting their occupants’ interests and tastes. Service users confirmed that they were satisfied with the facilities provided. All of the bedrooms have a lockable facility provided, however, the bedroom doors are not fitted with locks. Communal areas are spacious and comfortable with a range of quiet sitting areas provided. Safe and accessible outdoor seating areas are provided for the use of the residents. Infection control systems are in place with protective aprons and gloves freely available. The laundry facilities comply with regulations and are well equipped. The laundry floor, however, requires finishing with an impermeable surface for ease of cleaning. Sufficient and appropriate washing, bathing and toilet facilities are provided. The bathrooms, although well equipped, are rather stark in appearance and would benefit from re-decoration. Eagle Care Home DS0000059046.V300819.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are sufficient levels of staff to meet the needs of the service users. There is a programme of NVQ training within the home, however, only one member of the staff team have completed the award. Service users are protected by the home’s recruitment practices. EVIDENCE: Staff rotas examined indicated that during the hours of 8am until 10pm there is a team leader, supported by a team of three carers on duty. Catering and domestic staff are also employed. From 10pm until 8am there are two carers on waking nights, plus a team leader sleeping in. Five of the respondents to the relatives/visitors comment cards felt that in their opinion there were always sufficient numbers of staff on duty. Two did not, with one making the additional comment “understaffing is an issue”. The staff team were observed to be meeting the needs of the service users in a sensitive manner with appropriate use of informality and humour. Service users expressed satisfaction with the staff team as a whole, and made the Eagle Care Home DS0000059046.V300819.R01.S.doc Version 5.2 Page 20 following comments: “they can’t do enough for you”, “they are all very kind”, and “the girls are lovely”. . There is a programme of NVQ training in place and all staff are expected to undertake their NVQ II award. At the time of the inspection only one member of the staff team had completed the award. In addition to the NVQ training, other recent training opportunities have included, moving and handling, first aid, abuse in the care home and food hygiene. Induction training is provided to Skills for Care Council specification. Staff consulted were enthusiastic about the training provided. The home operates a safe recruitment procedure and staff files examined indicated that an application form is completed, two written references received and a CRB and POVA disclosure are required prior to commencing employment. All members of staff receive a contract of employment and a statement of terms and conditions. Eagle Care Home DS0000059046.V300819.R01.S.doc Version 5.2 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35 36,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is being managed by an acting manager. The home is well managed; the interests of the residents are seen as important to the manager and staff. Staff are appropriately supervised. Residents’ financial interests are safeguarded. Health, safety and welfare are promoted. EVIDENCE: Eagle Care Home DS0000059046.V300819.R01.S.doc Version 5.2 Page 22 The home is currently being managed by an acting manager who is undertaking a six months trial period. The acting manager is experienced and is committed to ensuring an open and positive atmosphere is prevalent within the home. At the end of the trial period, if the acting manager is confirmed in post, an application must be submitted to be registered by the Commission for Social Care Inspection. Health and safety is promoted within the home with all staff receiving training in safe working practices, moving and handling and food hygiene. Detailed risk assessments are in place. Certificates were seen indicating compliance with health and safety regulations. Quality monitoring systems are in place undertaken on a regular basis by the completion of a consumer quality survey. The results of which were seen to indicate satisfaction with the services and facilities provided within the home. All staff receive regular supervision, records seen indicate that recorded supervision session take place six times per year. Any money held on behalf of the service users is securely held with two signatures being required to record any transaction. The acting manager audits the money on a weekly basis. A selection of individual pockets were inspected and cash held reconciled with records kept. Eagle Care Home DS0000059046.V300819.R01.S.doc Version 5.2 Page 23 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 1 2 3 x x N/A 3 3 2 x 3 2 3 1 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 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 3 17 x 18 3 STAFFING Standard No Score 27 3 28 1 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 3 3 x 3 3 x 3 Eagle Care Home DS0000059046.V300819.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? yes 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 OP31 Regulation 9 Requirement An application must be made to the CSCI for registration of the manager when appointed. The statement of purpose and service user guide must be revised to reflect the current situation within the home. The laundry floor must be finished with an impermeable floor covering. A minimum of 50 of care staff must be qualified to NVQ II or equivalent. Timescale for action 30/10/06 2. OP1 4 30/10/06 3 4 OP26 OP28 13 18 30/10/06 31/01/07 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. Refer to Standard OP26 Good Practice Recommendations Locks to be fitted to bedroom doors. Eagle Care Home DS0000059046.V300819.R01.S.doc Version 5.2 Page 25 2 3 4 OP9 OP2 OP21 Care should be taken to ensure that correct codes are used on Medication Administration Records when medication is not given for whatever reason. Details of additional costs for routine escort to hospital appointments should be included in the contract. Consideration should be given to re-decorating the bathrooms to make them more welcoming. Eagle Care Home DS0000059046.V300819.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB National Enquiry Line: 0845 015 0120 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 Eagle Care Home DS0000059046.V300819.R01.S.doc Version 5.2 Page 27 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!