Inspection on 06/12/05 for Eagle House Care Home

This inspection was carried out on 6th December 2005.

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

Eagle House Care Home 15/05/08

Eagle House Care Home 16/05/07

Eagle House Care Home 05/10/06

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 Stephen Robertshaw Unannounced Inspection 6th December 2005 09:30 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.V272202.R01.S.doc Version 5.0 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.V272202.R01.S.doc Version 5.0 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 01652 635440 Mr Kumar Thakerar Mrs Elizabeth June Marrows 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.V272202.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th July 2005 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 eleven service users with complex needs associated with dementia. 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. Eagle House Care Home DS0000002782.V272202.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place on the 6th December 2005. The manager of the home was on annual leave so the deputy manager was responsible for the home. The information included in this report was gathered through observation of written records and the inspector’s conversations with service users, staff and management of the home. What the service does well: What has improved since the last inspection? All staff employed by the home now receive appropriate safety clearances before they commence work with the service users. All service users received a full assessment of their individual needs before they were admitted in to the home. The bathrooms in the home were no longer used as storage areas. Eagle House Care Home DS0000002782.V272202.R01.S.doc Version 5.0 Page 6 All of the exposed hot water pipes in the home had been provided with low temperature surfaces. Regulation 26 visits are now carried out at the home on a regular basis and a copy of the report if forwarded to the local office of the Commission for Social Care Inspection. All of the ground floor windows in the home have now been provided with restrainers to ensure inappropriate and unauthorised access to the building is prohibited. 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. Eagle House Care Home DS0000002782.V272202.R01.S.doc Version 5.0 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 Eagle House Care Home DS0000002782.V272202.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3 and 4 The home does not provide intermediate care. Full assessments of service users needs are completed before they are offered a placement at the home. This allows the service users to make a choice if that is where they wish to live. EVIDENCE: The inspector observed the care files for two service users. Both files included comprehensive assessments of the service users individual needs. The assessments were a combination of the home pre-admission, care management and mental health assessments. The assessments also included risk and nutritional needs of individual service users. Eagle House Care Home DS0000002782.V272202.R01.S.doc Version 5.0 Page 9 One of the files included a assessment review completed by a Community Psychiatric Nurse on 08 November 2005. The nurse quoted in the report that ‘the staff had made valiant efforts to meet MR ……. emotional welfare’. Each service users at the home also receives a statement of terms and conditions of their residency and the necessary termination periods for both parties. Observation of the documentation in the home, discussions with service users and interviews with staff confirmed that the home does have the capacity to meet the assessed needs of the service users and assures that only service users that are within its registration categories are admitted in to the home. Eagle House Care Home DS0000002782.V272202.R01.S.doc Version 5.0 Page 10 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 and 10 The home provides services that ensures that the health and personal care needs of the individual service users are met. EVIDENCE: The home has introduced new paperwork to all of the service users case files. There are very comprehensive assessments of the service users needs however the new paperwork does not produce as clear and detailed care plans as previously used in the home. The inspector suggested to the deputy manager that the homes previous care plans are reintroduced, as they were more accurate in identifying how individual needs must be met. Service users subject to the Care Programme Approach had this identified in their care plans and the co-ordinator was identified. The instances of pressure sores are well managed with the support of the district nursing service and individual service users GP’s. Eagle House Care Home DS0000002782.V272202.R01.S.doc Version 5.0 Page 11 The inspector observed the administration of medication in the home and all of the homes polices and procedures were appropriately followed. The receipt, storage, administration and disposal of medication were all accurately recorded and were up to date. Controlled medication in the home was appropriately stored and managed. Staff administering medication to service users had received accredited training provided through a local training provider. The home does not provide nursing care. The inspector observed the care file records for two service users and these clearly identified the contact that the service users had with healthcare professionals that were based in the community including GP’s, district nurses, occupational therapists and hospital specialists. Service users confirmed to the inspector that when they see health care workers to attend to their healthcare needs they are always seen in private. Eagle House Care Home DS0000002782.V272202.R01.S.doc Version 5.0 Page 12 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,and 15 The service users are provided with choice throughout their daily lives and social activities whilst living at the home. EVIDENCE: The activities that service users are involved in at the home are all fully recorded and when service users choose not to become involved in the activities also have this recorded in their files. Service users stated to the inspector that there are a variety of activities available in the home and that they can choose whether or not to become involved in them. The service users also said that they enjoyed the entertainers that regularly visit the home to sing to them. The inspector ate with a group of the service users. There was a choice at the mealtime and a service users was observed being given an alternative to what was on the menus as he did not want any of the choices available. The mealtime was observed to be unhurried and appropriate support was given to individual service users to ensure that they could eat their meals. This included verbal prompts, use of plate guards and actually assisting the service users to eat. Eagle House Care Home DS0000002782.V272202.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 and 18 The home has an easy to use complaint procedure and the management and staff do everything within their power to protect the service users from any form of abuse. EVIDENCE: Since the last inspection there was a complaint made directly to the Commission for Social Care Inspection in respect of services provided at the home. In November 2005 a complaint was made directly to the Commission for Social Care Inspection. The complaints were:1. Mrs x did not receive an appropriate or adequate diet at the home. 2. Mrs x’s daughters were told her mother did not have pressure areas but she did have on arrival at hospital. 3. Mrs x’s was admitted in to hospital with a vaginal and blood infection. 4. Mrs x was sent to hospital unaccompanied in an ambulance. 5. Mrs x was given another service users flannel, towel and socks to go to hospital. 6. When Mrs x’s belongings were collected from Eagle House they were given three bin bags of dirty clothes. 7. A gold t-bar necklace had gone missing whilst Mrs x was resident at the home. 8. Mrs x’s false teeth and spectacles were missing, and Mrs x wore other people’s false teeth when she was at the home. Eagle House Care Home DS0000002782.V272202.R01.S.doc Version 5.0 Page 14 9. Mrs x’s daughter had seen service users eating meals at the home and those requiring support to eat their meals did not receive it and therefore did not get their meals. The investigation concluded the following:1. Mrs x was provided with an appropriate diet at the home. Not upheld. 2. Mrs x had pressure areas that were managed by the home. Not upheld. 3. Mrs x was admitted in to hospital with a vaginal and blood infection that the home were aware of. Not upheld. 4. Mrs x was unaccompanied to go to hospital. Upheld. 5. Mrs x was admitted in to hospital with another service users personal belongings. Upheld. 6. When her clothes were picked up from the home they were dirty. Unresolved. 7. A gold t-bar necklace had gone missing at the home. Unresolved. 8. Mrs x wore other service users teeth at the home and her spectacles were lost. Not upheld. 9. Service users that require support to eat their meals are provided with the appropriate support. Not upheld. The home has updated its policies and procedures for when service users are admitted in to hospital to ensure that their personal belongings are sent with them and whenever possible and practicable a member of staff accompanies the service user to hospital as long as this does not place all of the other service users at risk. The management and staff were very open with the inspector in the investigation of the complaint. The home has a simple and clear to use complaints policy and procedure. Since the last inspection there were two complaints recorded at the home. The records made by the home showed that both issues had been resolved internally and appropriate actions had been taken. Service users living at the home have their legal rights protected. Care files observed by the inspector indicated when service users financial affairs were Eagle House Care Home DS0000002782.V272202.R01.S.doc Version 5.0 Page 15 the responsibility of other people directed by the Power of Attorney or Court of Protection procedures. In these cases their legal representatives were identified. The home also held a register of all of the service users that were eligible to vote at local and national elections. The staff training records identified that they undertake Protection of Vulnerable adults training as part of their initial induction and training that ids provided through the local authority. Staff intervie1wed by the inspector were aware of the needs of vulnerable adults ant the homes policies and procedures to protect the service users from abuse. Eagle House Care Home DS0000002782.V272202.R01.S.doc Version 5.0 Page 16 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): 19,20,21,22,25 and 26 The home provides an environment that is homely and comfortable and meets the needs of the service users. EVIDENCE: The home has recently bad new grab rails fitted to the corridors to aid the mobility of the service users. A tour of the premises by the inspector confirmed that all of the hot water pipes in the home are now provided with low temperature surfaces to ensure the safety of the service users. The grounds to the home are well maintained and safe for the service users. The floors in the dining area and corridors have been risk assessed and alternative surfaces have been provided that are non-slip and easy to clean. Eagle House Care Home DS0000002782.V272202.R01.S.doc Version 5.0 Page 17 The home is currently undergoing redecoration of all the corridor areas and some of the individual rooms. The decoration, furniture and fittings and lighting in the home are all domestic in character. The home has an emergency lighting system and the records indicated that it is regularly tested and monitored. The toilets and bathrooms are well spaced throughout the home. One of the bathrooms includes a very short bath that would not suit most service users at the home. The management should consider removing the bath and changing the bathroom in to a shower room that may be more appropriate. The side panels to the baths have been curt away to allow hoist access to the bath. The recesses need to be made tidy as they are very roughly cut. The toilets and bathrooms were very clean and the service users stated that this was always the case at the home. The home has sluice facilities these are located away from where food is prepared, cooked and eaten. The sluice rooms are not accessible to the service users. Individual service users case files provided evidence of when they had received specialist assessments for their mobility and personal care needs. The maintenance records showed that the home call bell system is regularly monitored and maintained. The windows in the home are provided with restrainers to ensure that they only open to a certain depth to discourage individuals attempting to enter the building through open windows and to protect the service users. The tour of the building by the inspector found it to be very clean and was free of any offensive smells. The home had a current programme of refurbishment and redecoration. Eagle House Care Home DS0000002782.V272202.R01.S.doc Version 5.0 Page 18 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 and 30 The home follows good practice in the employment procedures for new staff. This ensures the safety of the service users is upheld at all times. EVIDENCE: The home uses the Residential Forum to determine the staffing levels at the home to ensure that the service users individual needs can all be met at Eagle House. The home employs domestic staff to clean to the home and work in the homes laundry. Additional ancillary staff are employed to work in the homes kitchen. Since the last inspection all new prospective staff to work at the home had received a minimum of a POVA first clearance before they were allowed any contact with the service users. The staff personnel files were observed buy the inspector. These all included all of the information required by regulation. This included application forms, references, personal identification documents and appropriate safety clearances. Eagle House Care Home DS0000002782.V272202.R01.S.doc Version 5.0 Page 19 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): 32,33,34,35,36,37 and 38 The management of the home create an open and inclusive atmosphere at the home and are easily accessible to the service users. EVIDENCE: The manager of the home was on annual leave on the day of the inspection. The inspector was therefore unable to determine how far she was off from completing the Registered Manager’s Award. The deputy manager has completed NVQ 2 and 3 in care and is an NVQ work base assessor. The deputy manager has also taken on the responsibility for the homes training and the training for the staff in the companies other homes. The home employs twenty-nine care staff. Nine of the staff had completed NVQ2 in care. The home has transferred its NVQ training to another training Eagle House Care Home DS0000002782.V272202.R01.S.doc Version 5.0 Page 20 agency as the previous company did not keep up to the agreed commitments to the home. The management and staff interviewed by the inspector had a positive approach towards NVQ training. The homes induction and foundation training for the staff met the requirements and specifications of the National Training Organisation. Discussions with service users and visitors to the home and interviews with staff confirmed that the management exceed that standard for being open, inclusive and responsive. This information was supported through the recordings of service users and staff meetings. Service users stated to the inspector that the management of the home were always very accessible and listened to what they had to say. The homes quality assurance and monitoring systems are improving. The latest questionnaires were sent out on 5th December 2005. These were sent out to the staff group. Earlier questionnaires had been distributed to the service users and their relatives. These had recently been returned and the management were working on the analysis of the information and the development of an action plan. The home has a quality forum that is represented by management, staff and three relatives of service users living at the home. Issues raised in the quality assurance were acted upon. This included the redecoration of the corridors in the home and training issues for staff. The home did not have a current business and financial plan that provided evidence of the homes financial viability. Service users finances are well maintained and monitored ion the home. The inspector randomly sampled three service users pocket money accounts and these were all up to date and were accurately recorded. The home keeps a record of any valuables that are handed over by service users for safekeeping. The staff training records showed that they all receive at least the minimum of three days paid training per year. Staff interviews and observation of the homes training records support that this is in fact true. Eagle House Care Home DS0000002782.V272202.R01.S.doc Version 5.0 Page 21 The staff records identified that not all of the homes staff received the minimum of six formal recorded supervision periods in the last twelve months. However the majority of the homes staff had met this requirement. All of the confidential in the home were stored in accordance with the Data Protection Act 1998 and other statutory requirements. The homes maintenance and fire safety requirements all ensured that as far as is possible the service users health, safety and welfare is upheld. The home had current certificates for insurance and to verify the safety of the gas and electrical systems in the home. The Fire service inspected the home in July 2005 and their visit was satisfactory. Eagle House Care Home DS0000002782.V272202.R01.S.doc Version 5.0 Page 22 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 X 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 2 3 X X 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 4 2 1 3 2 3 3 Eagle House Care Home DS0000002782.V272202.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? 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 OP34 Regulation 25 Requirement The registered person must provide a business and financial plan that is open for inspection and shows the financial viability of the home. First required 30 September 2003 and still not met. Timescale for action 30/01/06 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 4 Refer to Standard OP7 OP21 OP21 OP28 Good Practice Recommendations The registered person must ensure that all of the individual care plans in the home detail how individual needs must be met. The registered person should consider changing the use of the small bathroom to a shower room to allow better access and more choice for the service users. The registered person must ensure that the bath panels are well maintained. The registered person must ensure that a minimum of 50 of the homes care staff have achieved NVQ 2 or equivalent by 31 December 2005. DS0000002782.V272202.R01.S.doc Version 5.0 Page 24 Eagle House Care Home 5 6 OP33 OP36 The registered person must ensure that the home has an effective quality assurance and monitoring system in place. The registered person must ensure that all care staff working in the home receives the minimum of six formal recorded supervision periods per year (pro-rata). Eagle House Care Home DS0000002782.V272202.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 House Care Home DS0000002782.V272202.R01.S.doc Version 5.0 Page 26 - 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!