Inspection on 16/05/07 for Eagle House Care Home

This inspection was carried out on 16th May 2007.

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 House Care Home 15/05/08

Eagle House Care Home 05/10/06

Eagle House Care Home 06/12/05

Eagle House Care Home 28/07/05

Eagle House Care Home 17/01/05

Eagle House Care Home 22/07/04

Eagle House Care Home 02/02/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

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 House Care Home Fleetgate Barton On Humber North Lincolnshire DN18 5QD Lead Inspector Mrs Kate Emmerson Key Unannounced Inspection 16th May 2007 09:40 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 House Care Home DS0000002782.V340551.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 House Care Home DS0000002782.V340551.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eagle House Care Home Address Fleetgate Barton On Humber North Lincolnshire DN18 5QD 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) 01652 635440 F/P 01652 635440 eaglehousech@aol.com Mr Kumar Thakerar Debbie Lisa Stephenson Care Home 40 Category(ies) of Dementia - over 65 years of age (40), Old age, registration, with number not falling within any other category (29) of places Eagle House Care Home DS0000002782.V340551.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th October 2006 Brief Description of the Service: Eagle House is situated in the town of Barton upon Humber close to all of the local amenities. The home provides care and support for up to forty service users within the categories of older people, and older people with dementia. The home is registered to support forty service users with complex needs associated with dementia. Some service users falling into this category are supported in a separate unit that has been made safe and secure but which is accessible from the main building. The unit is on the ground floor and has eleven single bedrooms. District and Community Psychiatric nurses provide the nursing element of care when required. The accommodation is provided over two floors that are accessed by stairs and a passenger lift. There are thirteen shared rooms and three single rooms on the first floor and a lounge and dining room on the ground floor. The home has a pleasant garden to the rear and side of the building with mature fruit trees and a small pond. There is ample car parking space. The atmosphere and setting of Eagle House is homely and is domestic in character. Fees for the home at the time of the inspection were £376 per week. Additional costs included chiropodist - £7.00, Escort £20 and hairdressing as per preference. Eagle House Care Home DS0000002782.V340551.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit to Eagle House was unannounced and took place over two days in May 2007. One inspector was on the site for approximately nine hours. To find out how the home was run and if the people who lived there were pleased with the care they received the inspector spent time in the home watching how the care was given and speaking to service users. The inspector spoke to 5 people who lived in the home and were able to answer some questions about the home. The inspector also spent time with other people who were not able to say much about the care they got or how the home was run but were able to say if they were happy at the home. The inspector also spoke to 3 staff that were on duty at the time of the inspection and the manager and deputy manager. Records kept in the home was also seen, to make sure checks that staff were safe to work in the home were completed and that they had been trained to their job safely. Records were checked to make sure that the home and the equipment used in it were safe and were checked regularly. The management had worked hard to meet the requirements from the previous inspection and although there are new requirements arising from this inspection the management were generally organised and working to improve the home. What the service does well: The service users were happy with the services received and commented that the staff were ‘very friendly and helpful’. Much of the home had been redecorated in recent times and the home was generally clean and tidy. All of the service users had an assessment of their needs made before they were admitted in to the home to make sure that the home would be suitable for them and their needs could be met. The service users stated that they enjoyed the meals provided and those seen were well presented. Eagle House Care Home DS0000002782.V340551.R01.S.doc Version 5.2 Page 6 The management of the home is very open and anyone could speak to them at any time. The home had systems in place to ensure service users were protected from abusive situations. The home had not received any complaints since the last inspection. Adequate staffing levels were maintained and staff received regular training to make sure that they have the knowledge and skills to meet the needs of the service users. The service users had the opportunity to access a wide variety of activities both in the home and in the community. What has improved since the last inspection? What they could do better: They could further develop the service users guide to provide more information on the specific services for those with Dementia and the homes complaints procedure. They must make sure that all service users have a care plan developed to ensure that service users assessed care needs will be met. They must make sure evaluations of care plans are more thorough to ensure that the care plan remains relevant to the care needs and that treatment and intervention is sought in a timely manner. Eagle House Care Home DS0000002782.V340551.R01.S.doc Version 5.2 Page 7 They must seek professional advice to ensure that the meals provide adequate nutrition for the service users in the home. They must make sure that records are accurately maintained where they are administering medication to service users to reduce the risk of errors. Service users should be offered the option of self-medicating where a risk assessment shows this to be safe. They must ensure that records of service users finances are accurately maintained at all times. They must ensure that service users have adequate lighting in their bedrooms and that privacy and dignity is protected in double rooms. They must make sure that fire safety is maintained by ensuring fire exits are marked, fire alarms are tested weekly and linen cupboards are kept locked. They must make sure that service users health and safety is protected by completing regular safety checks on bed rails. They could audit the accidents in the home to ensure that service users are not at unnecessary risk. 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. Eagle House Care Home DS0000002782.V340551.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 House Care Home DS0000002782.V340551.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The service users needs were fully assessed before they were admitted in to the home to make sure that the home could care for them appropriately. The service users received information to assist them to make an informed choice about the services provided by the home. EVIDENCE: The service users guide and statement of purpose were available in written format and made available to service users in the reception area and via the office. The documents were adequate for purpose but would benefit from further development in terms of the specific services provided for service users with dementia. Most of the service users and relatives who responded to surveys thought that they had received adequate information about the home to make an informed choice. The manager was able to provide evidence that Eagle House Care Home DS0000002782.V340551.R01.S.doc Version 5.2 Page 10 the service users or their representative had received contracts that identified the service users terms and conditions of their residency at the home. The care files for five of the service users living at the home were examined. Where appropriate these included the details of the service users visits to the home prior to being admitted there on a more permanent basis. Each case file examined included a full assessment of the service users individual needs. These had been completed prior to the service users admission in to the home and were a combination of the homes pre-admission assessments and where appropriate care management assessments and care plans were also included. The assessments were detailed and included risk assessments where appropriate. Eagle House did not provide intermediate care services within the home. Eagle House Care Home DS0000002782.V340551.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The care plans were detailed but were not effectively evaluated to ensure that service users health care needs were being met therefore intervention or treatment may be delayed. Service users were not given the option of self-medicating. Systems for handling medication in the home were generally safe but there were a couple of gaps in medication administration records, which may increase the risk of errors in administration. Service users privacy and dignity were respected. EVIDENCE: Assessments and care plans for five of the service users living at the home were examined. All but one service user who had been admitted to the home Eagle House Care Home DS0000002782.V340551.R01.S.doc Version 5.2 Page 12 a week prior to the inspection had a care plan in place. Two service users stated to the inspector,’ I don’t think there could be anywhere better’ when referring to the care that they received at the home. Another service user said that the care was ‘good’ and another said they were ‘doing their best’. Files showed that care needs had been identified and detailed individual care plans had been developed to support the service users physical health and personal care needs. The home’s care plans clearly reflected care needs identified through the individual service users’ assessments. The deputy manager generally completed the care plans although she stated that team leaders were being trained in this area. Evaluations were completed but were not effective, as they did not evaluate all areas of the service users care over the previous month. For example although there were systems in place to manage and monitor service users challenging behaviour, these records were not evaluated monthly and any increase in episodes or levels of aggression could not be readily identified and therefore intervention or treatment may be delayed. Records showed many of the service users had lost weight over the past eighteen months and although there had been significant weight losses over the past month there was no evidence of action taken in response to this. Weight was monitored monthly but there was no evidence that outcomes were included in evaluations. However there were systems in place to monitor service users nutritional status, risk assessments were in place and the manager stated that new scales had been purchased and calibrated in March 2007. The manager and the cook were able to describe how service users diets were fortified and the service users were very complimentary about the meals. The staff were observed to assist service users patiently and the meals seen were well presented and appropriate to service users needs. Records of intake were maintained for one service user case tracked although this lacked detail in respect of the quantity they had eaten. The manager was requested to review all processes as a matter of urgency and take advice from the dietician. There was a low incidence of pressure sores in the home at the time of the inspection and there were systems in place to identify the risk of pressure sore development. Care plans had been developed and records of care provided in this area were maintained. Detailed diary records were maintained and clear records of service users deterioration in health and subsequent admission to hospital were in place. There was evidence that service users had seen and signed in agreement to their care plans and they had been signed again where there had been updates to the care plan. Eagle House Care Home DS0000002782.V340551.R01.S.doc Version 5.2 Page 13 The documentation observed by the inspector included clear records of when service users were seen by healthcare professionals that are based outside of the home. This included contact with GP’s, District Nurses and Occupational Therapists. There were no service users self-medicating at the time of the inspection and there was no evidence that this option was given to service users on admission. There was a policy and procedure in place but this needed to be further developed in relation to the actions to be taken in the event of a drug administration error. There was evidence from staff training records and discussions with staff that those staff in the home that administer medication to service users at the home have received accredited training. Staff stated that they had been observed for competency when training to administer medication. The administration of medication was observed and all of the appropriate legislation and good practice guidelines were adhered to. The medication records in relation to the receipt, storage and disposal of medication were up to date but there were a couple of gaps in administration records. Medication held as controlled drugs was observed to be appropriately stored and accurate records were maintained. The service users felt that their privacy and dignity was maintained and one service user said that the staff were ‘very good, speak nicely to you and are very kind’ and another said that the staff were always ‘ good, kind and helpful and always there for you in a loving way’. The service users preferred term of address was recorded and used by the staff. Care was taken to protect service users privacy and dignity in moving and handling tasks and when assistance was required at meal times. Service users were encouraged to maintain independence with encouragement from staff. Service users were dressed appropriately and clothing was clean and tidy. Eagle House Care Home DS0000002782.V340551.R01.S.doc Version 5.2 Page 14 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 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The service users were provided with choices throughout their daily lives at the home and a variety of activities are made available to them. These included appropriate activities for service users with dementia care needs. The meals were of good quality and well presented although many service users had lost weight. EVIDENCE: The service users stated that they had choice in all areas of their life such as routines for getting up or retiring to bed. They said they had choices at meal times and one service users said that ‘ I get offered an alternative’ if they don’t like the main meal offered. Eagle House Care Home DS0000002782.V340551.R01.S.doc Version 5.2 Page 15 The care plans included social interests and there was a varied activities plan displayed in the lounge although not prominently. The staff were observed to be interacting with the service users on a regular basis and involving them in activities. However activities and interaction was mainly directed towards those with dementia, other service users stated they read and enjoyed the singers that visited the home. The local evening paper was provided for service users at a nominal charge. The service users had a choice of where to sit in the home and the main lounge had open access to a very attractive large secure garden area with seating. Seating in the home was arranged in small groups to encourage interaction and make the environment more homely. The service users spoken to by the inspector said that they were very happy with their lives at the home. Service users spoken to by the inspector said that there were a good variety of activities at the home. This included singers and entertainers visiting the home, crafts and hobbies in the home and visits to places in the community. The manager stated that there is open visiting to the home and details were included in the information provided by the home. There were some concerns regarding service users weight loss (see Standard 7 – 11) but the service users were very happy with meals in the home. The inspector observed the lunchtime meal at the home. The mealtime was unhurried and the staff were observed offering appropriate support to service users to help them eat their meals. This was seen to be in an appropriate manner and upheld the dignity and respect of the individual service users. There was a choice of meal and differing portion sizes were offered, meals were well presented. Service users with dementia care needs were offered appropriate support to eat their meals and additional snacks and finger foods are made available to them throughout the course of the day. Drinks were available at all times and hot drinks were given at regular periods during the day. The kitchen was very well organised and cleanly presented. Home baking was evident and the cook was knowledgeable about the dietary requirements of the service users. However the cook was not given dietary requirements in writing following assessment of each service user and this is recommended. Appropriate records were maintained although there were some gaps in cleaning records. Service users stated to the inspector that the quality of the meals at the home were ‘good’. One service user stated that ‘there is always plenty of food, it is very good and it is presented nicely’. Eagle House Care Home DS0000002782.V340551.R01.S.doc Version 5.2 Page 16 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 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The service users were protected from abusive situations at the home and felt their complaints would be listened to. EVIDENCE: There had been no formal complaints registered in the home or received by the Commission since the last inspection. The home had appropriate recording and monitoring systems to log any complaints. These were supported through the home’s complaints policies and procedures. Service users spoken to by the inspector were aware of how to make complaints in relation to the services provided at the home but they confirmed that they had not had any need to make any complaints. The complaints procedure was displayed in the hallway and the information in the service users guide directed readers to this but did not contain the full procedure and this is recommended. The home enabled service users to raise any issues through service users meetings which were called the ‘speak easy’ and service users felt they were able to raise issues in this forum and that they were listened to. Eagle House Care Home DS0000002782.V340551.R01.S.doc Version 5.2 Page 17 The home had appropriate policies and procedures to protect the service users from possible abusive situations and these were linked to the local multiagency protocols and recruitment processes were robust There had been no referrals to the local authority for protection issues at the home since the last inspection. There was evidence that staff had received training in safeguarding adults in induction and regular updates were completed annually. However records of staff training were not up to date and an audit of the records was required to ensure that all staff had completed training in this area. Eagle House Care Home DS0000002782.V340551.R01.S.doc Version 5.2 Page 18 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, 20, 22, 25, and 26. People who use the service adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The physical environment of the home provided for the individual requirements of the people who live there. The living environment is appropriate for the particular lifestyle and needs of the residents and is homely, clean, safe and comfortable and well maintained. There were a few areas to be addressed that may affect service users comfort and safety. EVIDENCE: A tour of the building was completed to observe the environment and to talk to the service users to find out what their thoughts were in relation to the decoration and comfort of the home. Eagle House Care Home DS0000002782.V340551.R01.S.doc Version 5.2 Page 19 Some areas in the home had been redecorated internally and many of the service users stated that the environment was comfortable. There was extensive use of cushion flooring throughout the home to enable ease of cleaning. The service users commented that they liked this as it could be cleaned but they missed the warmth of the carpet. Although use of the flooring was to be extended to bedrooms the manager stated service users would be able to have carpets in these areas if they wished. The manager was advised to consider whether this flooring would be suitable for all service users especially those at risk of falls. The home was clean and tidy and generally free from unpleasant odours. One of the bedrooms in the home had been developed in to a multi-sensory room. This can be used to help settle service users with dementia related problems to be in a safe, calm and relaxing atmosphere. However the manager stated that this wasn’t being used to its full potential and they were looking to move this downstairs nearer to other communal space. The grounds of the home were well maintained. A section of the grounds is easily accessible from one of the lounge areas and was secure to maintain the safety of service users with dementia. Individual service users’ care files identified what mobility equipment they required and how many staff where needed to aid them safely. Grab rails are available in all of the corridor areas. Toilet and bathroom doors were highlighted with picture signs to assist service users. The heating, lighting and water systems in the home were all domestic in character. The temperature of the hot water at the outlets is regularly monitored at the home. The Legionnaire’s certificate showed that systems had been inspected. The home had two sluice areas and the washing machines were programmable to disinfection and sluicing standards. An ironing press had been purchased to aid the ironing of sheets and quilt covers. There were some areas that required attention, a screen was required in one of the double rooms to ensure privacy can be maintained, a tap in the upstairs bedroom was difficult to turn on, there were water stains in two bedroom ceilings upstairs and a crack in one of these bedrooms ceilings, one bedroom was odorous and a linen cupboard was unlocked which is a fire hazard. Where redecoration had taken place in the home directional fire exit signs had not been replaced. The manager was able to provide evidence that new signs had been ordered and these arrived and were being put up on the second day of the inspection. Eagle House Care Home DS0000002782.V340551.R01.S.doc Version 5.2 Page 20 The bulbs in the home were low energy bulbs but were also very low wattage, which may not give adequate lighting for service users especially those who wish to read in their rooms or for those with vision impairment. The manager was advised to discuss requirements in this area with individual service users. Eagle House Care Home DS0000002782.V340551.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 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. . There were always appropriate numbers of staff on duty to meet the needs of the service users and they received appropriate training to ensure that they had the knowledge and skills to work with the service users. EVIDENCE: The management of the home use the Residential Forum to determine the staffing levels to ensure that the appropriate levels of staffing are available so that service users individual needs can all be met. These workings and staff rotas were examined and found to be appropriate to the level of dependency of the service users living in the home at the time of the inspection. Team leaders work both days and nights on a rota system and found this was useful to be able to see the care needs of service users over a 24-hour period. Additional ancillary staff were employed to work in the home including kitchen staff, domestic staff and a handyman. Eagle House Care Home DS0000002782.V340551.R01.S.doc Version 5.2 Page 22 Staff recruitment files for two of the care staff recently employed in the home were examined. These files provided evidence that full safety vetting had been completed before they began to work at the home. There were 25 care staff working at the home and information provided by the home stated that 14 staff had completed their NVQ 2 award. The home has a training matrix to ensure that the staff undertake all of the mandatory training and specialist training in relation to the needs of older people. The staff received training specific to the needs of older people and people with dementia related problems. A training plan and certificates to evidence which training had been completed were in place and staff stated that they had received a wide variety of training whilst working at the home. All staff received an individual copy of the General Social Care Councils codes of conduct. And the homes induction plan was linked to the national requirements. Service users stated staff were ‘very good’ and ‘there were always enough staff’. A visitor stated that ‘they always put my mothers needs first. She is looked after very well’, ‘ I would trust every member of staff to look after my mother’. Another visitor stated that ‘they all seem to be well trained’ and ‘ I always have peace of mind knowing they receive such loving care’. A member of staff stated that there were sufficient staff on duty and staff were well trained. They stated that new staff were able to shadow other staff before being counted in the staff numbers for as long as was necessary to feel confident in their role. Eagle House Care Home DS0000002782.V340551.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, 32, 33, 35 and 38 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home was generally well organised and management supported the needs of the service user and staff groups. There was a discrepancy in the service users financial records and deficiencies in the management of health and safety that may put the service users at risk. EVIDENCE: The manager of the home is still undertaking the Registered Manager’s Award and has completed approximately half of the units since commencing at the Eagle House Care Home DS0000002782.V340551.R01.S.doc Version 5.2 Page 24 home. The manager has completed the process with the Commission to be the Registered manager of the home. There was evidence that staff had received regular formal supervision at intervals that meet the minimum recommendations. Records showed that there had been regular staff meetings held at the home and service users were encouraged to be involved in the home through regular meetings which were called the ‘speak easy’. Service users felt they could raise issues in this forum and that they would be taken seriously. Eagle House has attained the local authority’s Gold Award in April of 2006 and in March 2006 they also achieved the Investors in People Award. The home’s quality assurance and monitoring systems were examined. The questionnaires were given to visitors, staff and service users in order to gather their views on various aspects of the service including food and activities. These had recently been returned and the management were still working on analysis of the information and the development of an action plan. The results of the returns were discussed with staff, service users and visitors at quality circle meetings. Records of service users’ finances were maintained in the home. The inspector randomly sampled three service users’ pocket money accounts and these were all up to date. However the amount on a receipt had not been correctly copied and entered into the records, which meant that the balance of one service users account was not correct. The manager was advised to audit the accounts and provide a report to the Commission. The staff training records provided evidence that they all received at least the minimum recommendation of three days paid training per year. All of the confidential information in the home was stored in accordance with the Data Protection Act 1998 and other statutory requirements. The majority of the home’s maintenance and safety records were up to date and well organised. However the fire alarm records showed that the system had not been tested weekly in both January and April 2007. Fire safety notices and directional signs had not been immediately replaced following redecoration of communal areas. The manager was able to provide evidence that these had been ordered and they arrived and were being put up on the second day of the inspection. There some bedrails in use in the home and the manager stated this equipment was generally used as a last resort in the home following risk assessment. Agreement to use the equipment was sought from the service Eagle House Care Home DS0000002782.V340551.R01.S.doc Version 5.2 Page 25 users or their representatives. However the bed rails once in use were not checked regularly to ensure that they continued to be safe to use. Accident records were completed but there was no formal auditing to establish the prevalence of accidents in the home and this was recommended to the manager. Eagle House Care Home DS0000002782.V340551.R01.S.doc Version 5.2 Page 26 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 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 2 17 X 18 2 2 3 X 3 X X 2 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 3 3 X 2 X X 2 Eagle House Care Home DS0000002782.V340551.R01.S.doc Version 5.2 Page 27 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 OP7 Regulation 15 Requirement Timescale for action 01/07/07 2 OP7 15 3 OP8 13(4) 12(1) The registered person must ensure that all service users have a written plan of care developed to ensure that service users assessed care needs will be met. The registered person must 01/07/07 ensure that evaluations of care plans are more thorough and take into account all the care needs and outcomes such as weight and episodes of challenging behaviour to ensure that the care plan remains relevant to the care needs and that treatment and intervention is sought in a timely manner. 20/06/07 The registered person must review all the service users nutritional status and the systems to support service users where assistance with taking diet and fluids is required, professional advice with regard to the nutritional values of the menu must be sought in order to ensure that service users nutritional status is being adequately maintained. DS0000002782.V340551.R01.S.doc Version 5.2 Eagle House Care Home Page 28 4 OP9 13(2) 5 OP9 13(2) 17(1) 6 OP18 13(6) 7 OP19 16(2)(c) 8 OP19 23(2) 9 OP19 23(4) 10 OP25 23(2)(p) 11. OP34 25 (1a) The registered person must further develop the medication policy and procedure to include the actions to be taken in the event of a drug administration error to protect service users health and safety. The registered person must ensure that accurate medication administration records are maintained to minimise the risk of medication administration errors. The registered person must audit training records to ensure that all staff have completed updates in safeguarding adults in the last year and provide protection for service users. The registered person must ensure that all double rooms are provided with a screen to protect service users privacy and dignity. The registered person must ensure that taps are fully operational, water stains and cracks in bedrooms ceilings are repaired and unpleasant odours are eliminated to ensure a safe and comfortable environment for service users. The registered person must ensure that directional fire exit signs are replaced and that the linen cupboards are kept locked at all times to ensure fire safety is maintained. The registered person must discuss requirements regarding lighting in bedrooms with individual service users and ensure that this is adequate to meet their needs to ensure comfort and safety with for service users. The registered person must provide a business and financial DS0000002782.V340551.R01.S.doc 01/07/07 20/06/07 01/07/07 01/07/07 01/08/07 17/05/07 01/07/07 01/08/07 Page 29 Eagle House Care Home Version 5.2 12 OP35 17(2) 13 OP38 23(4) 14 OP38 13(4) plan that is open for inspection and shows the financial viability of the home and forecasts future spending and income. (This standard was not assessed at this inspection.) A copy must be provided to the Commission. The registered person must audit 01/07/07 the records of service users money and investigate the discrepancy found at the inspection to protect service users. The registered person must provide a report on the findings to the Commission The registered person must 17/05/07 ensure that the fire alarms are tested weekly to ensure fire safety. The registered person must 20/06/07 regularly safety check bed rails and maintain as per manufacturers instructions and Medicines and Healthcare Regulatory Agency (MHRA) guidance to maintain service users safety. 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 3 Refer to Standard OP1 OP9 OP16 Good Practice Recommendations The registered person should further develop the service users guide in relation to the services provided specifically for those with dementia. The registered person should ensure that following risk assessment service users have the option to selfmedicate. The registered person should include the full complaints DS0000002782.V340551.R01.S.doc Version 5.2 Page 30 Eagle House Care Home 4 OP38 procedure in the service users guide to ensure full access to all service users and visitors. The registered person should audit accidents in the home to assist in assessment of risk to service users. Eagle House Care Home DS0000002782.V340551.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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. 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