Inspection on 20/06/08 for Eagles Rest

This inspection was carried out on 20th June 2008.

CSCI found this care home to be providing an Adequate service.

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 09/08/07

Eagles Rest 13/10/06

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Eagles Rest 10 Church Street Southport Merseyside PR9 0QT Lead Inspector Daniel Hamilton Key Unannounced Inspection 20th June 2008 09:45 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.V366058.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.V366058.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eagles Rest Address 10 Church Street Southport Merseyside PR9 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) 01704530003 Eagles Rest Limited Manager post vacant Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Eagles Rest DS0000067109.V366058.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 9th August 2007 Date of last inspection Brief Description of the Service: Eagles Rest 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 main entrance of the home is accessible via a ramp. Eagles Rest 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 £365.00 to £450.00 per week. Eagles Rest DS0000067109.V366058.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced inspection was carried out over one day and lasted approximately 10 hours. 14 people were living in the home at the time of the visit. A partial tour of the premises took place and observations were made. A selection of care, staff and service records were viewed and the owner, care staff, relatives and residents were spoken with during the visit. Survey forms were also distributed to a number of residents and staff prior to the inspection, to obtain additional feedback about the home. All the key standards were assessed and action taken in response to the previous requirements and recommendations from the last key inspection in August 2007 and the Random Inspection during March 2008 were reviewed. What the service does well: Residents spoken with during the visit were generally complimentary of the service and the staff team. Comments included; “I am very happy and contented”; “I’m being well looked after” and “Heather [Owner] and the staff are very good.” Residents were observed to receive visits from relatives during the day and confirmed the routines in the home were flexible and that they could exercise choice and control over their daily lives. The AQAA detailed that all residents were offered preventative treatments and screenings as a matter of course and feedback received from service users and their representatives via Care Home Surveys and /or discussion confirmed the people living in the home had access to medical practitioners as required. Medical records viewed confirmed residents had attended appointments with General Practitioners subject to individual need. Feedback received from residents regarding the meals was generally good. Comments included: “The meals are very nice”; “The food is OK. I have no complaints” and “I enjoy the mealtimes. Alternative choices are available if we don’t like anything.” Eagles Rest DS0000067109.V366058.R01.S.doc Version 5.2 Page 6 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. Records showed that the owner had continued to commission an external consultant to undertake an annual quality assurance assessment of the service in order to ensure the views of residents and their representatives were obtained on the service. The condition of the environment was continuing to improve and areas viewed appeared clean and hygienic. What has improved since the last inspection? Since the last inspection the owner has continued to invest money into the home. The Annual Quality Assurance Assessment (AQAA) for the service detailed that a maintenance schedule had been produced and a new ramp had been built at the front of the home to improve access. Other parts of the home had been refurbished / redecorated and a new call bell system had been fitted throughout the home. The fire doors were also being replaced / updated on a phased basis. One resident reported; “I feel safe living in the home especially now we have the new call bell system” and another stated; “The new ramp has helped residents to mobilise.” Medication medication instructions handwritten correct. Administration Records (MAR) had been signed to confirm had been administered in accordance with the prescribed and arrangements had been made for two staff to sign MAR charts to confirm the information recorded was checked and Protection of Vulnerable Adult (POVA) and / or Criminal Record Bureau (CRB) checks had been obtained for new and existing staff, to ensure the welfare of the people living in the home was safeguarded. A training matrix had been developed to provide an overview of training completed by staff and records showed that the fire alarm system, emergency lighting and fire extinguishers had been tested and / or visually inspected on a weekly basis. What they could do better: A Closed Circuit Television Cameras (CCTV) had been installed since the last visit. Some of the cameras had been positioned to record activity in areas used by the people using the service and one person reported; “I feel like I’m being watched because of the cameras”. The installation of cameras must be reviewed in areas used by residents to protect their privacy. Eagles Rest DS0000067109.V366058.R01.S.doc Version 5.2 Page 7 Two of the staff files viewed did not contain references and other references were not dated and did not contain details of the name of the referee or designation. Discussion with staff also revealed that some employees had been asked to obtain references on behalf of the Owner. Staff must only be confirmed in post if two up-to-date satisfactory written references have been applied for and received by the owner, to safeguard the welfare of the people using the service. Some staff spoken with during the visit reported that they had not received / completed any training since commencing employment in the home however the training matrix identified that the majority of staff had completed inductions and / or training in the Protection of Vulnerable Adults and Infection control since the last key inspection. Some staff spoken with during the visit lacked knowledge and understanding of key subjects e.g. abuse, dementia care, equality and diversity issues and safe working practice topics. The training matrix also highlighted a number of outstanding training needs. All staff must complete training appropriate to the work they perform and documentary evidence of any relevant qualifications and training must be obtained to provide evidence that the people using the service are supported by staff who are trained and competent. The Owner must also ensure that records of money handled on behalf of the people using the service are at all times available for inspection, as they could not be located on the day of the visit to provide evidence that the financial interests of the people using the service are safeguarded. The Statement of Purpose should be updated to include the date the document was last reviewed and the size of the rooms in the home. Furthermore, the Service User Guide should be updated to include the correct contact details of the Commission for Social Care Inspection and the terms and conditions in respect of accommodation to be provided for service users, including as to the amount and method of payment of fees. This will help to provide evidence that the people using the service have up-to-date information on the home. Some residents spoken with could not remember whether they had received a Contract / Statement of Terms and Conditions as noted at the last inspection. Signed copies of Contracts should be available on each resident’s file, to provide evidence that the people using the service are aware of their rights and obligations. An Assessment and Care Planning system had been developed however further work is needed to improve the quality of information recorded. Assessments should be reviewed to ensure they clearly identify the needs of prospective residents and care plans should outline the routine health care needs of the people using the service and be sufficiently detailed for the complexity of the service to be provided. Furthermore, supporting documentation including; care plan reviews, personal care and weight records and daily diary sheets should be kept up-to-date to ensure a clear audit trail and best practice. Eagles Rest DS0000067109.V366058.R01.S.doc Version 5.2 Page 8 Residents spoken with reported that there had been a decline in the frequency of activities since the last visit and records of activities were not up-to-date. For example, comments from three residents included; “The activities used to be very good but we’ve not had as many activities recently”; “It would be nice to have more to do through the day” and “I’m able to occupy myself but a few more activities would be most welcome.” Likewise, a staff member stated: “We could do better by having more activities.” The range and frequency of activities both within and outside the home should therefore be reviewed, to satisfy the recreational needs and preferences of the people using the service. The layout of furniture in the lounge and dining areas should be risk assessed to safeguard the welfare of the people living in the home when mobilising. Likewise, the clutter in the laundry, communal areas and corridors should be removed in order to safeguard the health and safety of residents. Day staff should receive fire instruction refresher training every six months and night staff every three months, to ensure they are fully aware of the correct procedures to follow in the event of a fire. 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. Eagles Rest DS0000067109.V366058.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.V366058.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3. Standard 6 is not applicable. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of service and assessment information is in need of further attention, to ensure prospective residents are able to make an informed decision as to whether the home can meet their needs. EVIDENCE: A Statement of Purpose / Service User Guide had been developed in a standard format to provide residents and / or their representatives with key information on the service. The Annual Quality Assurance Assessment (AQAA) detailed that residents had a copy of the documentation in their rooms. The Owner was advised to record the date the Statement of Purpose was last reviewed and to include details of the size of the rooms in the home. Furthermore, the owner was recommended to update the Service User Guide to include the correct contact details of the Commission for Social Care Inspection and the terms and conditions in respect of accommodation to be provided for service users, including as to the amount and method of payment of fees. Eagles Rest DS0000067109.V366058.R01.S.doc Version 5.2 Page 11 Previous inspection records confirm that a Contract had been developed to outline residents’ rights and responsibilities. Residents spoken with during the visit reported that they could not remember whether they had received a Contract / Statement of Terms and Conditions and only one file viewed contained a signed declaration to confirm the resident had received a copy of a Service User Guide and Contract. Furthermore, signed copies of Contracts had not been retained by the owner as previously recommended. The AQAA detailed that policies and procedures for ‘Referral and Admission’ had been developed for staff to reference. A sample of residents’ files was viewed during the visit. Records showed that an ‘Initial Assessment’ had generally been completed for each resident prior to admission however one was dated after a person had been admitted to the home. A copy of an assessment from a Social Worker had also been obtained for a resident who was not self-funding. Assessments completed by the Owner had generally been completed satisfactorily however some sections contained limited / vague information on the needs of the people using the service. For example, the ‘Personal Care’ section of one assessment detailed; “Has had a carer to look after her 2 x day” and no information had been recorded on the personal care needs of the resident to inform the care plan process. Likewise, another resident had been admitted to the home whose primary assessed needs were outside of the Registered Category of the home. The Owner reported that the service was able to meet the needs of the individual however the majority of staff had not completed training in dementia and some staff lacked awareness of the support needs of the individual. Other examples were discussed with the owner and advice was given on how to improve the assessment process as similar issues were noted at the previous inspection. Eagles Rest DS0000067109.V366058.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. 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. Some records relating to the care of service users are in need of review in order to fully safeguard the health and welfare of the people using the service. EVIDENCE: The Annual Quality Assurance Assessment (AQAA) for the service detailed that a policy on ‘Individual Planning and Review’ had been developed for staff to reference. A sample of residents’ files was viewed during the visit. Records showed that a Care Plan had been developed for each resident, which outlined individual needs, goals and support required. Eagles Rest DS0000067109.V366058.R01.S.doc Version 5.2 Page 13 Issues were noted with one plan. For example, the information in the care plan produced by Eagles Rest personnel was not consistent with the information received from a Social Worker i.e. the social work assessment detailed that the resident required assistance, prompting and encouragement from one carer with all aspects of personal hygiene and the care plan produced by the home detailed that the resident was independent in this area. Likewise, the social work assessment detailed the resident had a history of wandering and history of falls and the care plan produced by Eagles Rest detailed that the resident was steady when walking and not at risk of falling in the home. The Owner was advised to review the information and detail provided in the plan as it did not adequately address all of the assessed needs of the individual and was not appropriate for the complexity of the service to be provided. Furthermore, the Owner was recommended to include more information on how the routine health care needs of all the people using the service were to be met. A basic system had been developed for reviewing care plans. Some records were not up-to-date and / or did not include information on who had undertaken the review. A range of supporting documentation was in place. This included; daily diary sheets, personal care records, risk assessments, declaration of wishes in regard to medication, accident records, medical records, personal information booklets and conversation forms. No weight records had been maintained and some records had not been kept up-to-date and / or required more information to fully safeguard the welfare of the people using the service. The AQAA detailed that all residents were offered preventative treatments and screenings as a matter of course. Feedback received from service users and their representatives via Care Home Survey forms and through discussion confirmed the people living in the home had access to medical practitioners as required. Medical records viewed also confirmed residents had attended appointments with General Practitioners subject to individual need. The home had developed a new ‘Policy for the procedure for supply, storage, prescription and administration of medication’. A copy of guidelines issued by the Royal Pharmaceutical Society of Great Britain was also available for staff to reference. Advice was given on how to further develop the medication policy. The Owner reported that staff responsible for administering medication had completed in-house and external medication training via the dispensing pharmacist and this was confirmed in discussion with staff. Eagles Rest DS0000067109.V366058.R01.S.doc Version 5.2 Page 14 A record of staff authorised to administer medication and a system to check the identity of residents prior to administering medication had been established. No progress had been made in undertaking competency assessments for staff responsible for administering medication. A declaration of each resident’s wishes in relation to the administration of medication was available on files viewed and risk assessments had been completed to assess and control potential risks for people who selfadministered. Advice was given on how the risk assessment process could be further improved, as an example viewed was brief and did not adequately address all areas of potential risk. The home used a blister pack system and medication was stored in a medication cabinet and lockable cupboard. Separate storage and recording facilities were available for controlled medication. Medication Administration Records (MAR) had been correctly completed to account for medication received and administered. Separate storage and recording facilities were available for controlled medication. Staff were observed to interact with residents in a positive manner however some staff lacked a clear understanding of equality and diversity issues. This training need was discussed with the Owner. Feedback received from the people living in the home was generally good and confirmed the people were generally satisfied with the service provided. Comments included: “I am very happy and contented”; “I’m being well looked after” and “Heather [Owner] and the staff are very good.” Eagles Rest DS0000067109.V366058.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. 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. Residents are able to exercise choice and control over their daily lifestyle however the range and frequency of social activities is in need of review in order to fully satisfy the recreational needs, expectations and preferences of residents. EVIDENCE: Discussion with the Owner and examination of the Annual Quality Assurance Assessment (AQAA) confirmed a programme of weekly activities was developed which was advertised on a white board. The Owner confirmed that the programme had been based upon the recreational needs and interests of the people living in the home. On the day of the visit the white board in the dining room was blank. Furthermore, the summary record of activities provided was not up-to-date and the last entry was dated 2nd June 2008. Individual records of activities had been recorded in each resident’s daily diary sheets and records viewed highlighted that residents had participated in a limited range of activities. Eagles Rest DS0000067109.V366058.R01.S.doc Version 5.2 Page 16 The white board in the dining room detailed that the following activities were being coordinated during the week: Monday (Out and About), Tuesday (Baking am and Film and Curry pm), Wednesday (Crafts); Thursday (Hair and Nails am) and Quiz (pm) and Friday (Games am and Monopoly and Board Games pm). The Owner reported that the home continued to offer a range of activities for the people using the service including: trips to the shops, baking, gardening, aromatherapy, board games, scrabble, quizzes and scrap booking. Furthermore, a pianist continued to visit the home every three weeks and chair-based activities were organised every two weeks. The AQAA detailed that ministers of religion were welcomed into the home subject to the individual wishes of the people using the service. Two residents attended a local church and regularly accessed their local community independently. Residents spoken with reported that they had noticed a reduction in the range and frequency of activities provided since the last visit. Comments included: “The activities used to be very good but we’ve not had as many activities recently”; “It would be nice to have more to do through the day” and “I’m able to occupy myself but a few more activities would be most welcome.” Likewise, a staff member stated: “We could do better by having more activities.” The general atmosphere in the home was warm and friendly and residents spoken with confirmed they were able to follow their preferred routines and receive visits from family and friends at any reasonable time. The AQAA confirmed that there were no restrictions on visiting times and residents reported that they could meet with visitors in the communal parts of the home or in the privacy of their own bedrooms. Likewise, relatives spoken with during the inspection confirmed that they could visit at any reasonable time and were made to feel welcome. Rooms viewed had been personalised by residents and contained personal possessions including pictures and ornaments. The Owner reported that a new three-week rolling menu had been introduced since the last visit and plans were in place to extend the menu over a 4-week period. The daily menu was displayed in the dining room and a record of each person’s dietary intake was recorded in individual daily diary records. The menus were viewed during the inspection and confirmed that the people living in the home received a varied and nutritious diet. Alternative meals were provided and the AQAA detailed that each resident’s dietary intake was based upon an assessment of individual needs. It was noted that the alternatives for tea-time meals were not clear and that the full menu had not been typed up / displayed for residents to view. The Owner agreed to address these matters. Eagles Rest DS0000067109.V366058.R01.S.doc Version 5.2 Page 17 Records confirmed that residents were offered three full meals each day and that additional drinks, fruit and / or snacks were available throughout the day, suppertime and during the night. Mealtimes were considered to be a social occasion and meals were served in the home’s dining room unless a resident (s) preferred to eat their meals in private. The dining room is adjacent to the kitchen and tables were equipped with tablemats, tablecloths and condiments. Since the last visit, arrangements had been made to ensure there was a supply of paper napkins for residents. Mealtimes were unhurried and staff were observed to be available during mealtimes to offer help and support as required. Feedback received from residents regarding the meals was generally good. Comments included: “The meals are very nice”; “The food is OK. I have no complaints” and “I enjoy the mealtimes. Alternative choices are available if we don’t like anything.” Eagles Rest DS0000067109.V366058.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. 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. Staff lack awareness of how to recognise and respond to suspicion or evidence of abuse and this may place the welfare of vulnerable people at risk. EVIDENCE: A Complaints procedure had been developed for Eagles Rest. A copy of the procedure was displayed in the reception area of the home and the Annual Quality Assurance Assessment (AQAA) detailed that a copy of a user-friendly version had been placed in each resident’s room. 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. Two areas of concern were brought to the attention of the inspector during the visit. One resident reported concern regarding the installation of Closed Circuit Television and stated; “I feel like I’m being watched because of the cameras.” Three other residents expressed concern regarding the decline in activities. The AQAA detailed that two complaints had been received since the last inspection however upon examination of records one of the complaints was dated prior to the last inspection. Eagles Rest DS0000067109.V366058.R01.S.doc Version 5.2 Page 19 Examination of the complaint records for Eagles Rest revealed that the complaint was made by a resident with support from a friend. The complaint concerned the conduct of a former member of staff. Examination of records and discussion with the Owner confirmed that disciplinary procedures were invoked in response to the incident. Given the nature of the complaint the matter should have also been referred to the local authority safeguarding adult team and advice was given to the owner on the correct procedures to follow. Two concerns had also been raised with the Commission for Social Care Inspection since the last visit. One was regarding the management of financial records and the other concerned the absence of a ramp at the front of the premises. The latter has been addressed since the concern was raised. Policies and procedures were in place to protect the people living in the home from abuse. A copy of the local authority adult protection procedures for the City of Liverpool and Borough of Sefton was also available for reference. The training matrix for the home detailed that the majority of the staff team had completed training in the Protection of Vulnerable Adults however staff spoken with during the visit reported that they had not received training in this subject and / or lacked awareness of how to recognise and respond to suspicion or evidence of abuse. Eagles Rest DS0000067109.V366058.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment has continued to receive investment and this is improving the standard of accommodation provided for residents. EVIDENCE: The Owner reported that she had appointed a Cook / Handyperson since the last visit who was responsible for assisting the Owner with minor maintenance work. A maintenance book was in place to record maintenance issues and the Annual Quality Assurance Assessment (AQAA) detailed that a maintenance schedule had been produced. Contractors were hired for major and specialised work as and when required. Eagles Rest DS0000067109.V366058.R01.S.doc Version 5.2 Page 21 Since the last visit the environment had continued to receive further refurbishment / investment. A ramp had been built at the front of the home to improve access and new carpets had been fitted to the dining room, lounge, hall and part of the staircase. Four bedrooms had been redecorated and recarpeted and two profiling beds had been purchased. New tablecloths, dried flower arrangements, placemats and crockery had been purchased for the dining room and the oven and fridge had been replaced in the kitchen. A new call bell system had been fitted throughout the home and the fire doors were being replaced / updated on a phased basis. One resident reported; “I feel safe living in the home especially now we have the new call bell system” and another stated; “The new ramp has helped residents to mobilise.” Overall, areas viewed during the visit appeared to be maintained to a reasonable standard however some maintenance / refurbishment issues were noted. For example, the carpet was threadbare on the top level of the staircase and the laundry, upstairs sitting area and corridors were cluttered with objects, which presented a potential risk to people when mobilising and / or a fire hazard. Wallpaper was also starting to peel in rooms that had recently been redecorated and the owner advised that this matter was to be addressed. The Owner was requested to risk assess the layout of the furniture in the lounge areas and to remove the clutter throughout the home as accident records confirmed that a resident had fallen and sustained an injury on a drawer that was sited in the lounge area. Likewise, the Owner was requested to undertake individual risk assessments to address the absence of thermostatic valves and window restrictors in some parts of the home and to maintain records of health and safety checks. During the visit it was noted that eight Closed Circuit Television Cameras (CCTV) cameras had been fitted. Three cameras had been fitted to the front of the premises and other cameras had been sited on the side entrance, the back garden and laundry area. A camera had also been fitted in the kitchen and another had been sited near to where the medication was stored. The owner reported that the system was not working at the time of the visit and that the CCTV system had been fitted in order to improve security following vandalism to the front of the premises and the theft of medication and food supplies in the home. The owner reported that she had consulted residents prior to the installation of CCTV. The majority of residents spoken to during the inspection reported that they did not object to the presence of cameras however one resident expressed concern regarding the location of the cameras and the potential for them to impinge on their privacy. For example, some of the residents in Eagles Rest are encouraged to participate in cooking in the kitchen and others like to sit out in the back garden in the summer months. Eagles Rest DS0000067109.V366058.R01.S.doc Version 5.2 Page 22 The annual quality assurance assessment for the service detailed that policies and procedures were in place for Communicable Diseases, Infection Control and the Control of Substances Hazardous to Health. Training records showed that some staff required infection control training as previously noted. The home continued to employ one housekeeper and areas viewed were generally clean, fresh and hygienic. The laundry was appropriately equipped to meet the needs of the people living in the home. Records showed that an Environmental Health Inspection had taken place during January 2008. The owner confirmed that all of the contraventions had been addressed with the exception of the absence of fly screens. The Owner also reported that Fire Officer had visited the home since the last inspection however a copy of the report was not available on the premises for inspection. Eagles Rest DS0000067109.V366058.R01.S.doc Version 5.2 Page 23 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 poor. This judgement has been made using available evidence including a visit to this service. Shortfalls in recruitment practice and staff training are in need of review in order to protect the welfare of the people using the service. EVIDENCE: Examination of rotas, direct observation and discussion with the Owner confirmed two care staff were on duty from 8.00 am to 10.00 pm each day. One additional care assistant also worked from 9.00 am to 2.00 pm. During the night, two staff were on duty. One staff member worked a waking night and the Owner provided a sleep in service. Ancillary staff were employed for working in the kitchen and cleaning duties. Feedback received from residents confirmed that staff were available when needed to provide help and assistance. Comments included; “The girls are very caring”; “The staff do their best to help us” and “I have always found the staff to be helpful and have no complaints.” The Annual Quality Assurance Assessment for the service detailed that the home had a policy on staff recruitment. The Owner reported that eight new care staff had commenced employment in the home since the last visit. Eagles Rest DS0000067109.V366058.R01.S.doc Version 5.2 Page 24 The personnel files of the eight new staff were viewed. Files viewed contained application forms and evidence that Protection of Vulnerable Adult (POVA) and / or Criminal Record Bureau (CRB) checks had completed. It was not possible to verify that the checks had been completed before staff had commenced employment in the home, as the start dates had not been recorded on some files as previously noted. The owner agreed to address this issue. Two of the files did not contain references. Likewise, a number of references were not dated and did not contain details of the name of the referee or designation, as this information was missing from the home’s reference request form. Examination of records and discussion with staff and the Owner confirmed that some staff had commenced employment before references had been received and that the Owner had not routinely written to referees for references prior to appointing staff. Staff also reported that they had been asked to obtain references on behalf of the owner. Evidence was also on file to confirm that POVA and / or CRB checks had been completed for staff who did not have evidence of these pre-employment checks on their files at the previous inspection, however shortfalls with references were noted as outlined above. The Owner reported that the home employed 13 care staff. The Owner reported that 4 staff (30.77 ) had completed a National Vocational Qualification in Care at level 2 or above in Care however certificates were available for only 3 staff (23.08 ). A further 7 staff (53.85 ) were working towards the award at the time of the visit. Only four of the eight staff who had commenced employment since the last visit had documentary evidence on file that they had completed an induction programme that met the requirements of the ‘Skills for Care’ Common Induction Standards. Some staff reported that they had not received an induction upon commencing employment and / or had been provided with a book that they had been expected to complete with minimal input from senior staff. Two of the induction records viewed had not been dated or signed off by the Owner and a certificate of completion was not on any of the files to confirm the staff had successfully completed the induction and were ‘Safe to Leave’. Advice was given to the Owner on where to obtain certificates and a copy of a manager’s guide to the Common Induction Standards. Since the last visit the Owner had updated the training matrix to include dates that staff had completed various training courses. Records detailed that fifteen staff had completed Protection of Vulnerable Adult and ten staff Infection Control Training since August 2007. Eagles Rest DS0000067109.V366058.R01.S.doc Version 5.2 Page 25 Examination of the matrix revealed that a number of staff had not completed all Safe Working Practice topics and gaps were noted for First Aid, Basic Food Hygiene, Moving and Handling, Infection Control, Fire Safety and Health and Safety training. None of the staff files viewed contained documentary evidence of training completed and some staff spoken with reported that they had completed no training since commencing employment in the home. Eagles Rest DS0000067109.V366058.R01.S.doc Version 5.2 Page 26 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 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Management and Administration systems remain in need of ongoing development and review, to ensure the home operates efficiently, safely and in the best interest of the people using the service. EVIDENCE: The home did not have a Manager who was registered with the Commission for Social Care Inspection and an application for registration as the manager had not been received from the Owner (Heather Jackson) who was in day-to-day charge of the service. The Owner reported that she would submit an application to the Commission for Social Care Inspection to register as the manager of the home within two weeks. Eagles Rest DS0000067109.V366058.R01.S.doc Version 5.2 Page 27 Previous inspection records confirm that the Owner had completed the NVQ level 4 Registered Managers Award and was in the process of working towards a NVQ level 4 in Health and Social Care. A training record and documentary evidence of training completed by the owner could not be checked at the time of the inspection, as the records could not be located. Prior to the inspection the owner completed a document known as an Annual Quality Assurance Assessment (AQAA). The AQAA is a self-assessment that focuses on how well outcomes are being met for the people living in Eagles Rest and provides some numerical information about the service. All sections of the document had been completed however some of the information was vague and not evidence based as parts of the text had been extracted from the ‘Care Homes for Older People National Minimum Standards’. Records showed that the Owner had continued to commission an external consultant to undertake a quality assessment of the home. This was last completed during November 2007. No surveys had been distributed to residents and / or their representatives by the owner since May 2006. Furthermore, discussion with the Owner and the people using the service revealed that the ‘Resident’s Association’ had not met on a regular basis for some time and minutes could not be viewed as they had been filed away. The Annual Quality Assurance Assessment (AQAA) for the service detailed that the home had a policy on the management of service users’ money and that suitable accounting and financial procedures had been adopted. The Owner reported that she did not act as an appointee for any of the residents and that the people using the service looked after their financial affairs independently or with support from family members or personal representatives. Arrangements had been established for residents to pay their fees into the company’s bank account via standing order. Alternative arrangements had been established for one resident who preferred to pay by cheque. At the time of the visit the Owner looked after the personal spending money for three residents. Records of residents’ personal spending money could not be checked on the day of the visit as the Owner was unable to locate a file, which contained a record of individual financial transactions. This issue was discussed with the owner as a letter of concern had also been received from a Social Worker regarding a poor response to telephone calls and written requests regarding the documentation and management of a resident’s finances. Eagles Rest DS0000067109.V366058.R01.S.doc Version 5.2 Page 28 Staff spoken with reported that they had not received formal supervision and written records of supervision were not available on files viewed. The (AQAA) for the service detailed that Health and Safety related policies and procedures had been developed for staff to reference. The document also confirmed that equipment and services within the home had received regular maintenance / safety checks. The Owner reported that the Portable Appliance Testing had recently been completed and a certificate was due from the Contractor. Fire records were viewed during the visit. The fire file contained an equipment and fire plan and documentary evidence was available to confirm a fire risk assessment had been completed. Records showed that the fire alarm, emergency lighting and fire extinguishers had been tested or visually inspected on a weekly basis. A certificate of testing was also in place to confirm the fire alarm, extinguishers and emergency lights had been appropriately serviced. No records of fire instruction training for day and night staff had been established as recommended at the last inspection. Some staff had not completed all safe practice training as identified in Standard 30. Eagles Rest DS0000067109.V366058.R01.S.doc Version 5.2 Page 29 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 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X 3 X X X 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.V366058.R01.S.doc Version 5.2 Page 30 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 OP19 Regulation 12(4)a Timescale for action The CCTV cameras installed in 20/08/08 the home in all areas used by residents must be removed to ensure privacy for residents. The Owner must obtain two up- 20/08/08 to-date references for new and existing staff, including, where applicable, a reference relating to the person’s last period of employment, which involved work with children or vulnerable adults of not less than three months duration. The date, name of referee and designation must be clearly recorded on references to provide an audit trail and to safeguard the welfare of the people using the service. Documentary evidence of any 20/08/08 relevant qualifications and training must be obtained to provide evidence that the people using the service are supported by staff who are trained and competent. [Previous requirement of 4/5/08 not met] Requirement 2. OP29 19 3. OP30 19 Schedule 2 Eagles Rest DS0000067109.V366058.R01.S.doc Version 5.2 Page 31 4. OP30 18 (1) (c) (i) 5. OP35 17 (3) (b) All staff must complete training 20/10/08 appropriate to the work they perform so that service users are supported by trained and competent staff. The Owner must ensure that 20/07/08 records of money handled on behalf of the people using the service are at all times available for inspection, to provide evidence that the financial interests of the people using the service are safeguarded. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP1 Good Practice Recommendations The Statement of Purpose should be updated to include the date the document was last reviewed and the size of the rooms in the home. This will help to provide evidence that the people using the service have up-to-date information on the home. The Service User Guide should be updated to include the correct contact details of the Commission for Social Care Inspection and the terms and conditions in respect of accommodation to be provided for service users, including as to the amount and method of payment of fees. A signed copy of a Contract should be available on each residents file for reference, to provide evidence that the people using the service are aware of their rights and obligations. Assessments of need should always be completed prior to admission and clearly identify the needs of prospective residents. This will help the home to determine whether it is suitable and able to meet the needs of prospective residents and provide clear information to inform the care planning process. 2. OP1 3. OP2 4. OP3 Eagles Rest DS0000067109.V366058.R01.S.doc Version 5.2 Page 32 5. 6. OP7 OP7 7. OP7 9. OP12 10. OP18 11. 12. 13. 14. 15. OP19 OP19 OP19 OP19 OP30 16. OP30 Inconsistencies between care management and internal care plans should be reviewed and closely monitored to ensure the health and welfare of residents is maintained. Care Plans completed by Eagles Rest staff should be reviewed to ensure they include information on how the routine health care needs of the people using the service are to be met. Furthermore, Care Plans should be checked to ensure they are sufficiently detailed to address the complexity of the service to be provided. Supporting documentation including; care plans reviews, personal care and weight records and daily diary sheets should be kept up-to-date to ensure a clear audit trail and best practice. The range and frequency of activities both within and outside the home should be reviewed, to satisfy the recreational needs and preferences of the people using the service. All staff working in the home should complete refresher training in abuse awareness and familiarise themselves with the local authority adult protection procedures. This will help to ensure an appropriate response to suspicion or evidence of abuse. The Owner should undertake a ‘Privacy Impact’ assessment to determine the effect of the installation of Closed Circuit Television on the daily lives of residents. The clutter in the laundry, communal areas and corridors should be removed in order to safeguard the health and safety of residents. Health and safety audits should be undertaken periodically and records maintained to minimise potential risks and to ensure best practice. The layout of furniture in the lounge and dining area should be risk assessed to safeguard the welfare of the people living in the home when mobilising. Staff should be supported to complete the ‘Skills for Care’ Common Induction Standards within 12 weeks of commencing employment in the home. Furthermore, progress logs and a certificate of completion should be signed off by the Owner to confirm staff are competent and ‘safe to leave’. Action should be taken to ensure all care staff complete abuse, first aid, moving and handling, basic food hygiene, infection control, fire safety, equality and diversity, dementia and other training relevant to their role, to ensure they are trained and competent in caring for vulnerable adults. DS0000067109.V366058.R01.S.doc Version 5.2 Page 33 Eagles Rest 17. 18. 19. OP36 OP38 OP38 Staff should receive formal supervision at regular intervals and written records of the meetings should be maintained. Written records of health and safety audits should be maintained to ensure best practice. Day staff should receive fire instruction refresher training every six months and night staff every three months, to ensure they are fully aware of the correct procedures to follow in the event of a fire. Eagles Rest DS0000067109.V366058.R01.S.doc Version 5.2 Page 34 Commission for Social Care Inspection North West Regional Contact Team Unit 1, 3 Floor Tustin Court Port Way Preston PR2 2YQ 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 Eagles Rest DS0000067109.V366058.R01.S.doc Version 5.2 Page 35 - 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. 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