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Inspection on 30/01/07 for Eagle House Nursing Home

Also see our care home review for Eagle House Nursing Home for more information

This inspection was carried out on 30th January 2007.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

All the service users spoken to said they were well cared for by the staff. One service user described the staff as being "wonderful" and very hard working. Service users were able to visit the home for trial periods. The staff said that the manager considers carefully the needs of each prospective service user before agreeing to their admission to the home. Service users were only admitted once it had been determined that the home could meet their needs. Most service users attended a variety of religious, social and leisure activities and these were based very much on the personal preferences of each individual.Feedback was being sought on a regular basis from service. Staff interacted well with each service user and it was obvious from discussions with them that staff had developed positive relationships with them. The cook was familiar with the dietary needs of service users. The inspector observed the lunch offered to service users the food provided was of good quality, well presented and a good choice of food was offered. Documentation and discussion with six staff showed that they have had training in the specialist area of work that they work in. 48% of the staff team were qualified to NVQ level 2 and the manager is currently undertaking training equivalent to NVQ level 4. Records were in the main well ordered securely stored and up to date, the manager was keen to ensure that any issues found were addressed.

What has improved since the last inspection?

New showers have been fitted and some areas redecorated and some new furniture purchased. The Environmental Health officer last visited in April 2006 and awarded the home a certificate for an excellent standard.

What the care home could do better:

Some areas of the home still had damaged decoration, carpets and furniture. (On the day of the inspection a team of decorators were on site decorating many areas and the manager said some new furniture was on order). Some bedrooms did not have a lockable facility. The responsible individual was visiting the home regularly but she was not writing a monthly report about the conduct of the home following her visits.

CARE HOMES FOR OLDER PEOPLE Eagle House Nursing Home 43 Stalker Lees Road Sheffield South Yorkshire S11 8NP Lead Inspector Janice Griffin Key Unannounced Inspection 30th January 2007 09:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Eagle House Nursing Home DS0000021777.V328772.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 Nursing Home DS0000021777.V328772.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eagle House Nursing Home Address 43 Stalker Lees Road Sheffield South Yorkshire S11 8NP 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) 0114 268 7001 0114 268 5288 townendc@anchor.org.uk Anchor Trust Carole Elaine Townend Care Home 41 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (41) of places Eagle House Nursing Home DS0000021777.V328772.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. All 41 beds are for use by persons who are 55 years and over. Any of the 41 could be used alternatively in the category MD/E, Mental Disorder for persons 65 years and over. 25 beds are registered for nursing or personal care and are in one building. 16 beds are in the category PC, personal care only and are located in the bungalows. 10th January 2006 2. 3. Date of last inspection Brief Description of the Service: Eagle house is a registered care home providing care for 41 service users over 55 years of age with a mental disorder. The home is situated in a relatively quiet area within easy reach of the lively social and shopping area of Ecclesall Road. It is also near a major bus route to the city centre. The home has been registered to provide nursing care for 25 service users and personal care for 16 service users. There is a pleasant garden at the rear of the building. Copies of the last Commission For Social care inspection report were available for service users and their families to read. The weekly fees are £348 to £488 per week. This information was provided on the 30th January 2007. The home charges extra for chiropody, toiletries, clothing, telephone, holidays and hairdressing. Eagle House Nursing Home DS0000021777.V328772.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place from 09:15am to 15:00 pm. As part of the inspection process the inspector spoke to, nine service users, six staff and the manager. The inspector would like to thank the service users, the staff and the manager for their openness and for their commitment to the inspection process. The inspector was pleased to note that all the service users spoke highly of the ongoing support provided by the staff. Observations confirmed that service users were extremely comfortable and at ease in the company of the manager and staff who were approachable, supportive and appeared sensitive to their needs and feelings of the service users. One service user described the service as ”wonderful”. A number of records were examined which included, the managers preinspection questionnaire, medication records, three service users care plans, three weeks menus and three weeks staff rotas. Records relating to staff recruitment, service users finances, staff training and the homes quality assurance systems were also checked. Several areas of the building were also inspected. Since the last inspection The Commission for Social Care Inspection has received no concern about this home. The home has a system for displaying information and bringing attention to community events and activities. Feedback on the inspection was given to the manager. What the service does well: All the service users spoken to said they were well cared for by the staff. One service user described the staff as being “wonderful” and very hard working. Service users were able to visit the home for trial periods. The staff said that the manager considers carefully the needs of each prospective service user before agreeing to their admission to the home. Service users were only admitted once it had been determined that the home could meet their needs. Most service users attended a variety of religious, social and leisure activities and these were based very much on the personal preferences of each individual. Feedback was being sought on a regular basis from service. Eagle House Nursing Home DS0000021777.V328772.R01.S.doc Version 5.2 Page 6 Staff interacted well with each service user and it was obvious from discussions with them that staff had developed positive relationships with them. The cook was familiar with the dietary needs of service users. The inspector observed the lunch offered to service users the food provided was of good quality, well presented and a good choice of food was offered. Documentation and discussion with six staff showed that they have had training in the specialist area of work that they work in. 48 of the staff team were qualified to NVQ level 2 and the manager is currently undertaking training equivalent to NVQ level 4. Records were in the main well ordered securely stored and up to date, the manager was keen to ensure that any issues found were addressed. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Eagle House Nursing Home DS0000021777.V328772.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Eagle House Nursing Home DS0000021777.V328772.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 and 6. Quality in this outcome area is: good. This judgement has been made using available written evidence, discussion with nine service users, six staff, the manager and a visit to the home. No service users have moved into the home without having their needs assessed, this ensures that individual care needs can be met. Service users were able to have informal introductory visits to the home at the time of their admission, service users confirmed that this helped them to get to know everyone at the home, which made them feel less anxious. They had been provided with a contract containing the relevant information. Intermediate care is not provided at this home. Eagle House Nursing Home DS0000021777.V328772.R01.S.doc Version 5.2 Page 9 EVIDENCE: The home had an up to date statement of purpose. Detailed full needs assessments had been completed by the referring social workers for all service users admitted to the home. Service users spoken to said at the time of their admission they were able to have informal introductory visits to the home. Service users had been provided with a contract/statement of terms and conditions and signed copies were retained on individual files. These clearly detailed the fees, including any extra charges, the services and facilities provided by the home. Eagle House Nursing Home DS0000021777.V328772.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. Quality in this outcome area is: good. This judgement has been made using available written evidence, discussion with nine service users, six staff and a visit to the home. Service users were encouraged and supported by staff to make decisions. This protects the rights and well being of service users. Information in care plans was satisfactory; it gave the staff knowledge of the service users physical, social, health, religious and cultural needs. Risk assessments had been reviewed on a regular basis. This protects the service users from harm. There was evidence in the care plans to show that service users are involved with the care planning production and the review. This allows the service users to have a say in how their care needs will be met. The procedures in place to ensure the safe management of medication are satisfactory. The policies and procedures protect the service users from harm. A pharmacist had checked the home’s medication systems in November 2006 and some issues of change were recommended. The manager said the recommendations have been actioned. This is good practice. Eagle House Nursing Home DS0000021777.V328772.R01.S.doc Version 5.2 Page 11 EVIDENCE: Staff were observed knocking on bedroom doors and they waited to be invited in before entering. Three service users plans of care were checked. Each set out individual service users needs and the action required and taken by staff to ensure those needs were met. Discussion with six staff identified that a range of health professionals visited the home to assist in maintaining health care needs. Service users weight was being checked on a regular basis. A range of aids to assist service users with mobility problems was provided; these included lifting hoists, assisted baths, walking frames and wheelchairs. The risk assessments in care plans had been reviewed on regular basis. Service users had been invited to take part with production of the care plans and their reviews. Systems were in place to ensure the safe storage, administration and disposal of medication. Records were kept of medication received, and disposed of. A pharmacist had checked the home’s medication systems in November 2006; and some recommendations had been made following the visit. The manager said the recommendations had been actioned. Eagle House Nursing Home DS0000021777.V328772.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. Quality in this outcome area is: good. This judgement has been made using available written evidence, discussions with nine service users, six staff and a visit to the home. Service users had access to a range of leisure activities based on their individual choices and preferences. Service users confirmed that the routines of daily living were flexible and suited their individual preferences. Service users were supported with maintaining and developing contact with their family and friends, whom they said were always welcome at the home. This creates a home that people want to visit. A good choice of food was offered to service users at lunchtime. Six service users were being offered special diets on a regular basis. This promotes the rights of service users. Eagle House Nursing Home DS0000021777.V328772.R01.S.doc Version 5.2 Page 13 EVIDENCE: The aims and objectives of this home reinforced the importance of treating service users with respect. Service users confirmed that staff were extremely supportive and always encouraged them to become integrated into the local community, when they felt able to do this and with the appropriate staff support provided. Some service users visit the local shops, church and pubs. Staff confirmed that they were encouraged to support service users with discovering how to enjoy social situations and activities. The cook was familiar with the dietary needs of service users. The inspector observed lunch being offered to service users the food provided was of good quality, well presented and a good choice of food was offered. Six service users were receiving special diets. Special cutlery and crockery was provided for those service users who had difficulty using knives and forks. Eagle House Nursing Home DS0000021777.V328772.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is: good. This judgement has been made using available written evidence, discussions with nine service users six staff and a visit to the home. The homes complaints procedure was clear, accessible and contained the necessary information. This protects the rights of service users. Service users were protected from abuse by the awareness of staff through training and the homes procedures. EVIDENCE: The complaints procedure was available for visitor, relatives and staff. The manager confirmed that this would be available in alternative formats and languages should this be requested. Service users spoken to said that they knew that they could complain if they were not happy about anything and that they felt able to discuss any issues or concerns that they may have with the manager and staff. They also said that staff were always available and that they were encouraged to talk about anything that troubled them or caused them anxiety. The staff had received training on recognising and dealing with abuse. Staff had been made aware of the action to take in dealing with third party information. Eagle House Nursing Home DS0000021777.V328772.R01.S.doc Version 5.2 Page 15 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): 19,24, and 26. Quality in this outcome area is: adequate. This judgement has been made after discussion with nine service users and using available evidence including a visit to the home. On the day of the inspection the home was clean. Some areas had damaged decoration, carpets and furniture (easy chairs and bedroom furniture). This made the home look shabby in parts. The bedroom doors were fitted with locks but lockable facilities were not provided in all rooms. All service users had been provided with a key to their bedroom door. This promotes the privacy of service users. Eagle House Nursing Home DS0000021777.V328772.R01.S.doc Version 5.2 Page 16 EVIDENCE: Service users said that the home was always clean. Some rooms had damaged decoration, carpets and furniture. Bedroom doors were fitted with suitable door locks but lockable facilities were not provided in all the bedrooms. All the service users spoken to had a key to their bedroom door. Each floor had a number of toilets and bathrooms, assisted baths and showers were provided for those service users with mobility problems. Toilets were easily accessible as they were close to lounge and dining areas. All the toilets had been adapted for service users with physical disabilities and a good supply of equipment was also available for those service users. The home had a proactive infection control policy and they work closely with external specialists, e.g. the Health Authority, Environmental Health and their own staff to ensure infections are minimised. Clinical waste is properly managed and stored. Staff confirmed that they were provided with protective clothing if they needed it and that all the equipment was in good working order and that it had been serviced as required. Eagle House Nursing Home DS0000021777.V328772.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. Quality in this outcome area is: good. This judgement has been made after discussion with nine service users, six staff and using available evidence including a visit to the home. The staff had a range of skills and experience, which effectively supported the service users. This will ultimately benefit the health and welfare of the service users. The homes recruitment procedures were satisfactory, as they did meet the required standards. The home had a training and development plan and all staff had completed a range of training relevant to their role. This allows the staff to ensure they meet the individual assessed needs of service users. 48 of the staff is trained to NVQ level 2. This shows the managers and providers commitment to staff development Eagle House Nursing Home DS0000021777.V328772.R01.S.doc Version 5.2 Page 18 EVIDENCE: The service users said that the staff worked very hard and described them as “very caring, kind and understanding”. Staff were approachable and sensitive to the needs of service users and were able to communicate effectively with each person. The staff and service users said that there was always enough staff on duty. Three staff files were checked; the files demonstrated that a satisfactory recruitment processes had been followed as required by the Care Homes Regulations. Criminal record checks had been done for all three staff, two references had been obtained and no gaps were noted in staff’s employment history. Staff spoken to had an understanding of the home’s fire procedures; they had received training on moving and handling, fire, food safety and infection control and abuse. Staff files checked and discussions with six staff and the manager confirmed that all staff had completed detailed induction training. 48 of the staff team were qualified to NVQ level 2. Eagle House Nursing Home DS0000021777.V328772.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 and 38. Quality in these outcome areas is: good. This judgement has been made after discussion with the manager, nine service users, six staff and using available written evidence including a visit to the home. The service users and six staff spoken to said the manager was approachable and very professional. Records were in the main up to date and well ordered to ensure the best interests of service users. The homes policies and procedures met the required standards. Staff were being formally supervised at the frequency required. This ensures individual staff development and the monitoring of care practices. The manager is a trained nurse and she is currently undertaking her NVQ 4 equivalent training in management. This shows the managers commitment to her own development. Eagle House Nursing Home DS0000021777.V328772.R01.S.doc Version 5.2 Page 20 EVIDENCE: The manager had a job description that clearly defined her roles and responsibilities and staff were aware of her role. Staff said she was committed to ensuring that the home provides a high standards of care, she completes regular internal audits on all aspects of the service provided by the home. She is currently undertaking her NVQ level 4 equivalent training in management. Staff spoken to had an understanding of the home’s fire procedures; they had received training on moving and handling, fire, food safety and infection control and abuse. The responsible individual visit the home on a regular basis but a report is not always written following the visits. Staff were being formally supervised at the frequency required. No fire exits were blocked and hazardous substances were securely stored. The manager handles money on behalf of some service users, account sheets were kept, receipts were available for all transactions and a second individual witnessed all transactions. The accounts are audited annually. All records were available for inspection up to date and securely stored. Eagle House Nursing Home DS0000021777.V328772.R01.S.doc Version 5.2 Page 21 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 3 8 3 9 3 10 3 11 N/A DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X 2 X 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 3 X 3 X 3 3 X 3 Eagle House Nursing Home DS0000021777.V328772.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2. 3 4. 5. Standard OP19 OP24 OP28 OP31 OP33 Regulation 23 16 18 9 26 Requirement The damaged decoration carpets and furniture must be replaced. All bedrooms must have a lockable facility. A minimum of 50 of the staff team must be qualified to NVQ level 2. The manager must completed NVQ level 4or equivalent in management. The responsible individual must complete a written report following her monthly visits to the home. Timescale for action 01/08/07 01/04/07 01/07/07 01/12/07 01/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Eagle House Nursing Home DS0000021777.V328772.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Eagle House Nursing Home DS0000021777.V328772.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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