Inspection on 13/10/06 for Eagles Rest

This inspection was carried out on 13th October 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Eagles Rest 20/06/08

Eagles Rest 09/08/07

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

CARE HOMES FOR OLDER PEOPLE Eagles Rest 10 Church Street Southport Merseyside PR8 0QT Lead Inspector Daniel Hamilton Key Unannounced Inspection 13th October 2006 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 Eagles Rest DS0000067109.V312052.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. Eagles Rest DS0000067109.V312052.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eagles Rest Address 10 Church Street Southport Merseyside PR8 0QT 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) 01204 364652 Eagles Rest Limited Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Eagles Rest DS0000067109.V312052.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users to include up to 16 Older Persons The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection 6th March 2006 Date of last inspection Brief Description of the Service: Eagles Rest (previously registered as Westbourne Grange) is a privately owned care home that is registered to provide personal care and support for up to 16 older people. The home is situated close to Southport town centre and shops and public transport are easily accessible. The home is a large, double fronted, detached property that has a lounge with a conservatory attached and a separate dining room. There are 14 single and 1 double bedrooms. Four of the rooms are fitted with en-suite facilities and bathing and toilet facilities are located throughout. A passenger lift is installed and a call bell system is available in all bedroom and communal areas. Off-road parking is available at the front of the premises and there is a large garden to the rear, which is accessible via the side of the property. Care Home Fees range from £265.50 to £323.00 per week. Eagles Rest DS0000067109.V312052.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day and lasted a total of 9 hours. Fourteen residents were living in the home at the time of the visit. Since the last inspection, a new owner had purchased the home, which had been renamed from Westbourne Grange to Eagles Rest. The new owner (Heather Jackson) demonstrated a commitment to addressing outstanding requirements and recommendations in order to improve the quality of care and environment for residents. A partial tour of the premises took place and observations were made. A selection of care, staff and service records were also viewed. The new owner, registered manager, three staff members, seven residents and a relative were spoken to during the visit. Furthermore, satisfaction survey forms “Have your say about…” were distributed to a number of residents and / or their relatives prior to the inspection, to obtain additional views / feedback about the home. All the core standards were reviewed and previous requirements and recommendations from the last inspection in March 2006 were discussed. What the service does well: Overall, feedback received from residents and their representatives was complimentary about the quality of care provided at Eagles Rest. Staff were observed to spend time chatting to residents offering support and practical assistance throughout the day. Feedback received from residents included; “The staff are very helpful and respectful” and “I rate the staff team and the care provided very highly.” Overall, the people living in the home reported that they were generally satisfied with the activities, lifestyle and meals provided in the home. Residents also confirmed they had access to health care services subject to individual need. Since the arrival of the new owner, new activities had been introduced which included external trips into the community and this had been acknowledged and appreciated by residents. For example, one resident said; “The activities are improving since Heather [new owner] has become involved.” Residents reported that they had control of their lives and that they could follow their preferred routines and receive visitors at any reasonable time. Eagles Rest DS0000067109.V312052.R01.S.doc Version 5.2 Page 6 Comments from two residents included; “I receive regular visits from my family and a close friend from Liverpool” and “My wife and daughters are encouraged to visit me whenever they can.” A range of nutritious and wholesome meals was provided and preferences and special dietary needs were accommodated. This was confirmed by a resident who said; “The standard of catering is excellent and my preferences are catered for”. At the time of the visit, the new owner was in the process of reviewing the menu in consultation with residents. No complaints had been received by the manager or the Commission for Social Care Inspection since the last visit. Residents confirmed that they felt listened to and that they were confident that any concerns would be acted upon. A resident spoken with said; “In my opinion, this is a good home and I would find it very difficult to find any faults.” Sufficient numbers of staff were on duty during the day and night to meet the needs of residents and residents confirmed that they received the care and support they required. What has improved since the last inspection? A new care plan format had been developed to enable the manager to clearly record each resident’s needs, the support required by staff and the objectives of the care plan. Since the last inspection, the manager had made improvements to the medication system to ensure secondary dispensing practice was stopped. Medication records had been updated to ensure all medication stocks were accurately accounted for and all staff responsible for the administration of medication had completed external medication training. Photographs had also been attached to medication records, to enable staff to check the identity of residents prior to administering medication. Training records had been developed for each member of staff to provide information on the range of training completed. Furthermore, the home’s training matrix had been revised, to include the dates of training. Residents had been consulted about the service provided and a ‘Residents Association’ had been established, to ensure the home was run in the best interest of the people living in the home. The new owner had organised two external trips and a tea party for residents and was in the process of developing a range of person-centred activities in consultation with residents. A maintenance schedule had been produced to address the outstanding maintenance and refurbishment issues highlighted in the inspection report. Service / Maintenance Certificates had also been obtained to confirm the gas Eagles Rest DS0000067109.V312052.R01.S.doc Version 5.2 Page 7 supply, electrical wiring, portable appliances and the Arjo hoist were safe to use. The downstairs bathroom had been cleared of clutter and alternative arrangements had been made to store laundered clothing and spare commodes. What they could do better: At the time of the visit, the ‘Service User Guide’ and ‘Comments and Complaints’ procedure were in need of review and some contracts could not be located. The owner reported that new documentation was due to be developed for Eagles Rest. Copies of the documents should be given to residents or their representatives for reference, to ensure residents are aware of their rights and responsibilities. The home’s assessment and care planning system required further attention as some assessments were incomplete and care plans did not identify or provide sufficient detail on how all the needs of residents were to be met. Furthermore, risk assessments for moving and handling and the prevention of falls had not been completed for some residents, despite them being at risk of falling or in need of assistance to mobilise. Likewise, care plans had not been signed by residents or kept under regular review. These matters have been previously noted and should be addressed to ensure the welfare of the people living in the home is not put at risk. Despite a requirement at the last inspection, risk assessments had not been completed to protect the interests of all residents who self-administered medication. Risk assessments must be completed, to safeguard the health and wellbeing of residents. Additionally, a copy of the Royal Pharmaceutical Society of Great Britain – ‘Guidelines on the Administration and Control of Medicines in Care Homes’ should be obtained, to ensure best practice and the manager should keep the competency of staff responsible for medication under review. A controlled drugs register should be purchased to record any controlled drugs administered by staff. Records showed that a new staff member had commenced employment at the home before a Protection of Vulnerable Adult check had been received. Staff must be recruited correctly so that the people living in the home are fully protected. Training records showed that a number of staff had not completed training in the Protection of Vulnerable Adults and the home did not have an up-to-date copy of the local authority adult protection procedures. These matters should Eagles Rest DS0000067109.V312052.R01.S.doc Version 5.2 Page 8 be addressed to ensure staff fully understand how to recognise and respond to suspicion or evidence of abuse. Documentary evidence was not available to provide evidence that some staff had completed National Vocational Qualification training. Documentary evidence must be obtained in accordance with the Care Home Regulations 2001. Furthermore, the home must ensure that all staff complete safe working practice and receive formal supervision, to ensure staff are appropriately trained and supported in their roles. The manager should also undertake a National Vocational Qualification in Care at level 4. In order to ensure Health and Safety, the absence of radiator guards and thermostatic valves must be risk assessed for each resident and the emergency lighting and fire extinguishers should be visually inspected on a monthly basis and records maintained. As previously recommended, receipts should be obtained for all expenditure handled on behalf of residents, to ensure accountability. 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. Eagles Rest DS0000067109.V312052.R01.S.doc Version 5.2 Page 9 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 Eagles Rest DS0000067109.V312052.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents did not have access to up-to-date information on the home, to enable them to make an informed decision about the service provided. Some residents had been admitted to the home without a full assessment of needs. Unless residents needs are clearly identified, there is no assurance that individual needs will be fully met. EVIDENCE: The manager reported that the home had developed a Statement of Purpose and a Service User Guide. A copy of the Statement of Purpose was not available for inspection at the time of the visit, as the new owner had taken the copy off-site to read. A copy of the home’s Service User Guide was viewed. The document had not been updated since June 2002 and details of the Commission for Social Care Inspection had not been included. The new owner reported that a consultant had been commissioned to undertake a quality assessment of the home and that new documents would be developed for service users to reference as part of the process. Eagles Rest DS0000067109.V312052.R01.S.doc Version 5.2 Page 11 Feedback received from residents and / or their representatives via Care Home Survey forms confirmed that the people living in the home had received information on the service before they had moved in. Some residents spoken with reported that they could not remember whether they had received any information due to the length of time they had lived in the home. Two files were examined during the visit. One file was for a new resident who had moved into Eagles Rest since the last inspection and the other was for a resident who had lived in the home for approximately one year. The file for the new resident contained a written pre-admission assessment. Some areas of the assessment had not been completed. For example, there was no information on the religious, cultural, personal care, oral health and / or foot care needs of the resident. A copy of the social work assessment had also been obtained, as the resident had been referred via Social Services. The other file viewed contained a functional assessment of the resident’s needs, which had been completed by the home. A social work assessment was not available as the resident was privately funding. Advice was given to the manager and new owner on how the assessment process could be further developed in order to assess the diverse needs of individuals accessing social care services. A copy of each resident’s contract could not be located during the visit and some care home survey forms returned did not indicate whether contracts had been received. Eagles Rest DS0000067109.V312052.R01.S.doc Version 5.2 Page 12 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Shortfalls were noted in care planning practices, which have the potential to place residents at risk. Residents had access to a range of health care services and care was provided in accordance with the needs, rights and expectations of the people living in the home. EVIDENCE: Two files were examined during the visit. One file was for a new resident who had moved into Eagles Rest since the last inspection and the other was for a resident who had lived in the home for approximately one year. Only one of the residents’ files viewed contained a Care Plan. The manager agreed to produce a care plan for the other resident during the inspection. Since the last visit, the manager had introduced a new format for care plans, which detailed the ‘needs’, ‘actions’ required by staff and the ‘aims’ of the plan. The care plan viewed provided limited information on the needs of the resident and the support required by staff. For example, some health care and dietary issues identified at the assessment stage had not been addressed in the Eagles Rest DS0000067109.V312052.R01.S.doc Version 5.2 Page 13 resident’s plan. Records showed that the care plan had not been kept under monthly review and was not signed by the service user or their representative. Supporting documentation including; personal information records; daily record sheets, accident records, care reviews, medical appointment and personal care records were also in place for each resident. Personal care records had not been kept up-to-date and one record had not been updated for over eight months. Furthermore, risk assessments had not been completed for residents who required assistance with their mobility and who were at risk of falling. Similar concerns were also noted at the last inspection. Feedback received from service users and their representatives via Care Home Survey forms and through discussion confirmed the people living in the home received support or assistance to access health care practitioners when required. Comments received from two residents included; “I receive regular visits from a district nurse” and “The manager always contacts the doctor if anyone is unwell.” A relative reported; “They’ve taken my mother to hospital and stayed with her when she has not been well.” Medical appointment summary records viewed detailed that residents had maintained contact with a range of health care professionals including; chiropodists, dentists, general practitioners and hospital staff. The home had developed a brief medication policy and local procedures / guidance. A copy of guidelines issued by the Royal Pharmaceutical Society of Great Britain was not available for staff to reference. The manager reported that one resident self-administered medication. No risk assessment had been completed, to safeguard the welfare of the resident. A record of staff authorised to administer medication together with sample signatures and a system to check the identity of residents prior to administering medication had been established. Discussion with the manager and examination of training records confirmed that the nine staff responsible for the administration of medication had completed training via the home’s chemist. Records showed that the home’s pharmacist had undertaken an inspection during April 2006. The home used a blister pack system and medication was stored in a small medication cabinet and lockable cupboard. Medication stocks had been reduced and the manager had made arrangements to stop the secondary dispensing of liquid medication as noted at the last visit. Boxes of medication had been dated to provide an audit trail and a record of medication returned to the pharmacist was in place. Eagles Rest DS0000067109.V312052.R01.S.doc Version 5.2 Page 14 Medication administration records checked were maintained to a good standard. Details of medication received had not been recorded on the medication administration records, as a separate record had been established for this purpose. The manager was advised to obtain a Controlled Drugs Register as the home was using a separate book to record the administration of Tamazepam and did not have a suitable register to record any controlled drugs prescribed to residents in the future. Furthermore, the manager was advised to establish a system to review the competency of staff responsible for the administration of medication and to obtain copies of patient information leaflets for staff to reference. Pre-inspection records detailed that the home had policies and procedures on the values of privacy, dignity, choice, fulfilment, rights and independence. Staff reported that they had access to the policies and discussed the needs of residents and the principles of care as part of their induction training. Staff spoken with were able to provide examples of how they promote and safeguard the privacy and dignity of residents in their daily practice. Staff were observed to spend time chatting and offering supporting to residents throughout the visit and were seen to be patient and sensitive towards residents’ individual needs. Feedback received from residents and their representatives via Care Home Surveys and discussion confirmed that people living at Eagles Rest received the care and support they required and were satisfied with the service provided. Comments included; “The staff are very helpful and respectful”; “I rate the staff team and the care provided very highly” and “I consider myself to have a good relationship with the staff and they are very caring.” Eagles Rest DS0000067109.V312052.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The routines of daily living were flexible and determined by residents. Social activities were subject to ongoing review, to ensure the preferred routines and recreational interests of residents were identified and planned for. Service users received a balanced and varied selection of food and their preferences and needs were catered for. EVIDENCE: A programme of activities had not been developed, as recommended at the last visit and a record of activities coordinated was not available for inspection. Discussion with the manager and residents confirmed that a musician / pianist continued to visit the home every three weeks and that a quiz and bingo session was facilitated every other week. A hairdresser also visited the home. None of the residents received input from local churches / ministers of religion at the time of the visit however two residents attended a local church and regularly accessed their local community. The manager confirmed that arrangements would be made to support residents to observe their religious beliefs, subject to individual need. Eagles Rest DS0000067109.V312052.R01.S.doc Version 5.2 Page 16 Feedback received from residents via care home surveys and through discussion confirmed that activities were arranged by the home and that some new activities had been introduced since the arrival of the new owner. One of the residents reported that he had recently been appointed as the secretary of the newly established ‘Residents Association’ and was responsible for finding out which residents were interested in activities and external trips. Discussion with other residents and the new owner revealed that two trips had been organised during September 2006. One had been to visit the Scarisbrook Festival of Transport and the other to see a Fireworks Championship. A residents’ friends and family tea party had also been coordinated during September, to introduce the new owner. Photographs had been taken of all the activities for residents to view. Residents spoke highly of the new owner and her commitment to developing the service. One resident said; “The activities are improving since Heather [New owner] has become involved” and another reported; “We are in the process of planning a trip to see the lights at Blackpool”. The new owner acknowledged the need to further improve the range of recreational activities for residents living at Eagles Rest and reported that she was planning to organise tea dances, computer training, church services, swimming, dominoes, scrapbooks and trips to the cinema. Written information on the home’s policy on visiting and maintaining contact with family, relatives and friends was included in the home’s Service User Guide. Residents spoken with during the visit confirmed that they were able to receive visits from family and friends at any reasonable time and that visitors were always made to feel welcome. Comments received from two residents included; “I receive regular visits from my family and a close friend from Liverpool” and “My wife and daughters are encouraged to visit me whenever they can.” Residents were observed to receive visitors in the privacy and comfort of their own rooms during the inspection. The routines in the home appeared to be flexible and geared towards the needs and preferences of residents. Residents spoken with during the inspection confirmed that they were able to exercise choice and control over their lives and that they could follow their own routines. Rooms viewed had been personalised by residents and contained personal possessions including pictures and ornaments. Eagles Rest DS0000067109.V312052.R01.S.doc Version 5.2 Page 17 Eagles Rest had a four-week rolling menu in place. The menus had not been updated to offer a choice of meal for each sitting as recommended at the last visit. The owner reported that the menu was due to be reviewed in consultation with residents with a view to also introducing alternative choices for residents. Examination of the menus and discussion with residents confirmed that a range of nutritious and wholesome meals was provided. Records of meals provided were not available for inspection. Preferences and food dislikes were recorded in the kitchen and discussion with the residents and the manager confirmed that special dietary needs were catered for. Additional drinks were offered throughout the day and residents were able to eat their meals in their rooms if they wished. Meals were served in the home’s dining room at set times. The manager confirmed that the home was flexible and that alternative arrangements could be made to accommodate individual needs upon request. Tables viewed were equipped with napkins, condiments and tablemats. Feedback received from residents via Care Home Survey forms and through discussion confirmed that residents enjoyed their meals. Comments from two residents included; “The food is very good” and “The standard of catering is excellent and my preferences are catered for.” Eagles Rest DS0000067109.V312052.R01.S.doc Version 5.2 Page 18 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 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. No complaints had been received since the last inspection and residents were confident that their views would be listened to and acted upon. Some staff had not completed training in adult protection and lacked awareness of how to respond to suspicion or evidence of abuse. EVIDENCE: A ‘Comments and Complaints’ policy was in place. The policy was in need of review as it had been written for ‘Westbourne Grange’ and contained contact details of the National Care Standards Commission as noted at the last inspection. The manager was advised to place an updated copy of the procedure in the reception area of the home for residents and their representatives to refer to. Overall, residents confirmed via care home surveys and through discussion that they felt listened to, were aware of who to speak to if they had any concerns and how to make a complaint. None of the residents spoken with during the inspection had any complaints about the service provided at the home and examination of the home’s complaints record showed that no complaints had been received since the last visit. Comments included; “I am very happy and no complaints”; “In my opinion this is a good home and I would find it very difficult to find any faults” and “The new owner is doing very well. I have noticed some positive improvements already.” Eagles Rest DS0000067109.V312052.R01.S.doc Version 5.2 Page 19 Policies and procedures were in place to protect the people living in the home from abuse. These included a ‘Guarding against Abuse’, ‘Whistleblowing’ and ‘Safeguarding Residents’ Money policies’. At the time of the visit, the home did not have a copy of the new local authority procedures for the City of Liverpool and Borough of Sefton. Training records showed that a number of staff had not completed training in the Protection of Vulnerable Adults from Abuse and some staff lacked awareness of the different types of abuse and how to respond to suspicion or evidence of abuse. Pre-inspection records detailed that training in the Protection of Vulnerable Adults was due to be organised in the future for the staff who had not completed the training and this was confirmed in discussion with the manager. Eagles Rest DS0000067109.V312052.R01.S.doc Version 5.2 Page 20 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, 25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some parts of the home were in need of refurbishment and systems had been established to improve the environment for residents and to ensure the home is fit for purpose. Risk assessments had not been completed to minimise and control potential risks to service users. EVIDENCE: The main entrance of Eagles Rest had not been fitted with a ramp to improve access as recommended in the home’s ‘Assessment of the Premises and Facilities’ (2004) report. Likewise, no action had been taken to replace the worn carpet in the hallway and the staircase by the previous owner. The new owner reported that she was aware of the outstanding maintenance and refurbishment issues and had produced a maintenance plan for the period October 2006 to August 2007. The schedule indicated that the owner had prioritised available resources to address a number of key safety and maintenance issues, which included fitting ramps to the rear garden and front entrance and a new carpet to the entrance hallway and staircase. Eagles Rest DS0000067109.V312052.R01.S.doc Version 5.2 Page 21 The home did not employ a maintenance person. The owner reported that she was responsible for minor maintenance and the upkeep of the garden areas. Contractors were used for all other maintenance tasks as required. Weekly audits were undertaken to review the physical environment of the home. Overall, areas viewed during the visit appeared to be maintained to a reasonable standard, safe and clean. The external grounds were tidy and attractive. Residents spoken with confirmed that the owner and manager had promptly responded to any matters requiring repair / maintenance. The pre-inspection questionnaire detailed that one bedroom had been redecorated and carpeted since the last visit. The downstairs bathroom had been cleared of clutter and was not being used to store laundered clothes or to wash commodes. Despite a requirement at the last inspection, risk assessments had not been undertaken to address the absence of radiator guards, thermostatic valves and window restrictors in some areas of the home. Records showed that the home employed one domestic and the home was clean and fresh. Infection control policies and procedures and Control of Substances Hazardous to Health data sheets were available for staff to reference. Cleaning products were stored in the home’s laundry, which was situated outside. The laundry was equipped with two washing machines and a drier. One of the washing machines was equipped with a sluice wash and staff spoken with confirmed that they were provided with protective clothing / gloves. ‘Cleaning Cards’ had been developed by the manager to outline cleaning duties for domestic, day and night staff to follow. Training records showed that only three staff had completed infection control training. Feedback received from residents via care home surveys and through discussion confirmed the home was kept clean and fresh. Comments included; “My room is cleaned every day” and “The home is always tidy and clean” Eagles Rest DS0000067109.V312052.R01.S.doc Version 5.2 Page 22 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Sufficient numbers of staff were deployed to meet the needs of the people living in the home. Recruitment practice remained poor and did not provide adequate protection for residents. Some staff had not completed all the necessary training and some certificates were not available to evidence staff were trained and competent for their roles. EVIDENCE: Examination of rotas, direct observation and discussion with the manager and residents confirmed the staffing levels in the home had not changed since the last visit. Two care staff were on duty from 8.00 am to 10.00 pm. The manager and new owner also worked alongside staff to offer support and direction. During the night, two staff were on duty. One staff member worked a waking night and the owner provided a sleep in service. At the time of the visit the home had no vacancies for staff. Feedback received from residents via care home surveys and through discussion confirmed that staff were available when needed and that they received the care and support they required. Residents complimented the staff team, manager and owner. Comments included “The manager and staff are smashing” and “Everyone involved in the running of this home takes a genuine interest in the people living here.” Eagles Rest DS0000067109.V312052.R01.S.doc Version 5.2 Page 23 The home had a Recruitment of Staff policy in place. Only one member of staff had commenced employment since the last inspection. The personnel file of the new employee was viewed. Records showed that the member of staff had commenced employment at the home before the results of a Protection of Vulnerable Adults (POVA) check had been completed. Similar concerns had also been noted at the last inspection. The file also contained other records required under the Care Home Regulations. These included a copy of the employee’s application form, two satisfactory written references, a Criminal Record Bureau check and a copy of a training record. The manager reported that the home employed 16 care staff. The home’s training matrix detailed that 8 staff (50 ) had completed a National Vocational Qualification (NVQ) at level 2 or above. At the time of the visit certificates were available for only 4 staff (25 ). The home had developed an in-house induction programme. This did not meet the specification of the National Training Organisation (Skills for Care). Records showed that manager had arranged for the majority of staff to complete the Working in Care Induction Standards Course via an external training provider. Discussion with staff and examination of training records confirmed staff had access to a range of training. The home’s training matrix had been updated to include the dates of training and records showed that the majority of staff had completed moving and handling and fire training earlier in the year. Despite a requirement at the last inspection, a number of staff had still not completed training in all safe working practice topics including; health and safety, first aid, basic food hygiene and infection control training. Eagles Rest DS0000067109.V312052.R01.S.doc Version 5.2 Page 24 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems had been established to ensure the home was run in the best interests of residents. Staff did not have access to formal supervision, to ensure their learning needs, support requirements and performance was regularly reviewed. Some administration / records within the home require further attention, to ensure the welfare of residents is fully safeguarded. EVIDENCE: The manager (Mrs Dawn Butterworth) was registered with the Commission for Social Care Inspection and had managed the home for approximately four years. Records showed that the manager had completed the National Vocational Qualification (NVQ) level 4 Registered Managers Award and had undertaken additional training that was relevant to her role. All safe working practice training was up-to-date. Eagles Rest DS0000067109.V312052.R01.S.doc Version 5.2 Page 25 At the time of the visit the manager did not have a qualification equivalent to NVQ level 4 in Care. Since the last visit, the new owner and manager had undertaken a residents’ satisfaction survey. This involved distributing a questionnaire to residents or their representatives to seek their views on different aspects of the service provided. The results had been collated and a range of graphs produced to illustrate the findings. The owner and manager were advised to publish and make available the results for current and prospective residents and their relatives to view. The new owner reported that she had also commissioned an external consultant to undertake a quality assessment of the home and review polices and procedures. This was scheduled to take place on 24/10/06. A ‘Residents’ Association’ had also been established, which meets the last Saturday of every month. Residents spoken with felt this was a good idea and an opportunity to share collective and individual views. The home had a policy on handling / storage of resident’s money. The manager reported that she was the appointee for three residents and that all the other residents looked after their financial affairs with support from their family members or solicitors. The new owner reported that arrangements had been established for the majority of residents to pay their fees into the company’s bank account via standing order. Alternative arrangements had been established for one resident. At the time of the visit, the manager looked after the personal spending money for ten residents. Two of the ten records were viewed during the visit. Personal monies were not pooled and appropriate records were in place. The manager was advised to obtain receipts for all expenditure, as one record did not contain receipts for chiropody services and to ensure signatures are obtained for all money paid out on behalf of residents. Discussion with staff and examination of records highlighted that staff did not have access to regular supervision. Some files viewed did not contain any evidence of formal supervisions and other records showed that staff had not received formal supervision since November 2003. The home had a Health and Safety Policy and procedure in place. Preinspection records detailed that maintenance and associated records were available for all key areas with the exception of an electrical wiring certificate. A copy of an electrical wiring certificate was available for inspection dated July 2006. A gas landlord safety certificate could not be located however a British Gas Safety certificate dated March 2006 was in place. The manager was advised to Eagles Rest DS0000067109.V312052.R01.S.doc Version 5.2 Page 26 check whether the certificate from British Gas would be sufficient to fulfil her legal obligations. Fire records were viewed during the visit. A certificate of testing was in place for the alarm, extinguishers and emergency lights. Records showed that the fire alarm system was checked on a weekly basis and that staff had received fire instruction refresher training. A fire risk assessment had been completed during January 2006. Monthly visual checks on the fire extinguishers and emergency lighting had not been undertaken as recommended at the last visit. Some staff had not completed all safe practice training as identified in Standard 30. Eagles Rest DS0000067109.V312052.R01.S.doc Version 5.2 Page 27 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 2 2 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X 2 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 2 X 2 Eagles Rest DS0000067109.V312052.R01.S.doc Version 5.2 Page 28 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 Each resident must have a plan of care that identifies their individual needs (as detailed in the assessment) and the action required by care staff to ensure that identified needs are met. [Previous timescale of 7/10/05 not met]. Risk assessments must be completed before residents are supported to self-administer medication. [Previous timescale of 30/04/06 not met]. The absence of radiator and pipework guards and thermostatic valves must be risk assessed for each service user. Planned installation work must be prioritised according to the level of risk identified. [Previous timescale of 1/03/05 not met]. Documentary evidence of any relevant qualifications of staff must be obtained. DS0000067109.V312052.R01.S.doc Timescale for action 13/12/06 2 OP9 13 (4) 13/12/06 3 OP25 13 (4) 13/12/06 4 OP28 19 13/01/07 Eagles Rest Version 5.2 Page 29 5 OP29 19 6 OP30 18 (1) 7 OP35 17 (2) 8 OP36 18 (2) Staff employed since the 26th July 2004 must only be confirmed in post if full and satisfactory information has been obtained via a POVA check, a CRB has been applied for and two satisfactory references have been received. [Previous timescale of 30/04/06 not met]. Safe practice training must be completed by all staff and refresher training must be completed periodically. [Previous timescale of 07/11/05 not met]. Receipts must be obtained for all money handled on behalf of residents. [Previous timescale of 30/04/06 not met]. Staff must receive regular formal supervision. 13/12/06 13/02/07 13/12/06 13/12/06 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 5 6 7 Refer to Standard OP1 OP2 OP3 OP3 OP7 OP7 OP9 Good Practice Recommendations A copy of the new Statement of Purpose / Service User Guide should be made available to each resident. Contracts should be available for each resident. Assessments should clearly identify all the needs of residents. The assessment documentation should be revised to ensure assessment headings are not grouped together. Risk assessments for moving and handling and the prevention of falls should be completed as part of the care planning process, for residents identified as being at risk. Care plans should be signed by residents or their representatives. The home should obtain a copy of the Royal Pharmaceutical Society of Great Britain guidelines; ‘The DS0000067109.V312052.R01.S.doc Version 5.2 Page 30 Eagles Rest 8 9 10 11 12 13 14 15 16 OP9 OP9 OP18 OP30 OP31 OP16 OP33 OP35 OP38 Administration and Control of Medicines in Care Homes’. The manager should establish a system to monitor the competency of staff who administer medication. A controlled drugs register should be obtained to record controlled medication. All staff should complete training in the protection of vulnerable adults as a matter of priority and a copy the new local authority procedures should be obtained. The home’s induction programme should be updated to ensure it meets the specification of the National Training Organisation. The manager should undertake a National Vocational Qualification in Care at level 4. The complaints procedure should be updated to include details of the Commission for Social Care Inspection. The results of quality assurance surveys should be made available to current and prospective residents to view. Receipts should be obtained for all money / expenditure handled on behalf of residents. The emergency lighting and fire extinguishers should be visually inspected on a monthly basis and records maintained. Eagles Rest DS0000067109.V312052.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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 Eagles Rest DS0000067109.V312052.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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