CARE HOMES FOR OLDER PEOPLE
Ealing House Residential Home 86 Repps Road Martham Great Yarmouth Norfolk NR29 4QZ Lead Inspector
Hilary Shephard Announced Inspection 12th January 2006 10.10 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 Ealing House Residential Home DS0000033998.V273073.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ealing House Residential Home DS0000033998.V273073.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Ealing House Residential Home Address 86 Repps Road Martham Great Yarmouth Norfolk NR29 4QZ 01493 740227 01493 740227 ealinghouse@mac.com 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) Mrs Sally Watson Mrs Sally Watson Care Home 10 Category(ies) of Dementia (10), Old age, not falling within any registration, with number other category (10) of places Ealing House Residential Home DS0000033998.V273073.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 16th June 2005 Brief Description of the Service: Ealing House is a care home providing personal care and accommodation for 10 older people with dementia. It is owned and managed by Mrs Sally Watson. The home is located in the centre of the village of Martham close to shops, pub and local amenities. The home has been open for thirty years and consists of a detached two-storey house. The bedrooms comprise of four single and three shared rooms, with a variety of communal space. The building is situated within its own grounds, with an enclosed garden at the rear. Ealing House Residential Home DS0000033998.V273073.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This routine announced inspection took place over 6 ½ hours during which time the inspector spoke with all residents, 2 relatives and 2 staff. The views of residents, relatives and staff, where appropriate, are reflected in the findings in the report. The inspector looked at samples of care plans and staff files and information was also obtained from six completed questionnaires from residents/relatives and the homes pre-inspection questionnaire. At the end of the inspection feedback was given to the Proprietor. An inspection was also made of the attached building currently undergoing refurbishment. When finished this will provide four additional en-suite bedrooms, a lounge and another seating area. A total of two requirements and two recommendations were made as a result of this inspection. Following receipt of the Providers action plan, minor amendments have been made to the report correcting a factual inaccuracy regarding staff qualifications. What the service does well: What has improved since the last inspection?
Ealing House Residential Home DS0000033998.V273073.R01.S.doc Version 5.0 Page 6 The proprietor has had a proper central heating system installed and once the radiators are covered, it will provide residents with a safe central heating system. To enable residents to get about the home more easily, new handrails have been fitted to the corridors and to ensure residents are moved safely, two new hoists have been bought. Signage on toilets has improved, making them easier to find. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ealing House Residential Home DS0000033998.V273073.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ealing House Residential Home DS0000033998.V273073.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards not assessed at this inspection. EVIDENCE: Ealing House Residential Home DS0000033998.V273073.R01.S.doc Version 5.0 Page 9 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): Standards 7, 9 and 10 Care plans have improved and provide really good information about residents care needs and staff treat residents respect and dignity. By omitting signatures on medication administration records (MAR) medication may not be properly administered. EVIDENCE: Care plans for three residents were inspected and they contained really good detailed information about how care staff should meet the residents’ needs. Senior staff are involved in compiling the care plans which they do with input from residents and their relatives. Care plans are very detailed about how the residents want to be cared for, are individualised and focus on the residents’ abilities, needs and wants. All the residents and two relatives were spoken with said that care staff treated them well and with respect. Care staff were observed being kind and gentle with residents. Medication was inspected, and numerous gaps were found on the MAR charts indicating staff had failed to sign once medication had been given. A requirement has been made.
Ealing House Residential Home DS0000033998.V273073.R01.S.doc Version 5.0 Page 10 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): Standards not assessed at this inspection. EVIDENCE: Ealing House Residential Home DS0000033998.V273073.R01.S.doc Version 5.0 Page 11 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): Standards 16 and 18 Staff felt they could discuss concerns with the proprietor and would act as advocates for residents, staffs knowledge about the adult protection is good, but were unsure about the reporting procedure. EVIDENCE: Five out of the six comment cards received from relatives/visitors indicated they were aware of the homes complaints policy. Two relatives were spoken with and said they would raise concerns with the proprietor/manager, or the Commission. Most residents have dementia and would be unable to raise concerns verbally, but staff said they would act on their behalf and speak to the proprietor. Most staff have received training in adult protection and one had a very good understanding about recognising signs of abuse. Staff would report any concerns to the proprietor or the Commission, but one was a little unsure of what to do if the proprietor was unavailable. A recommendation has been made regarding staff awareness of the adult protection reporting procedure. Ealing House Residential Home DS0000033998.V273073.R01.S.doc Version 5.0 Page 12 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): Standards not assessed at this inspection. EVIDENCE: Ealing House Residential Home DS0000033998.V273073.R01.S.doc Version 5.0 Page 13 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): Standards 28, 29 and 30 Residents are well cared for by competent staff and are also protected by robust recruitment procedures. EVIDENCE: Three out of thirteen care staff are qualified to NVQ level 2, two have NVQ level 3 and one has commenced NVQ level 2. Staff have received training in care practices and health and safety mostly through videos and attending some training courses. Dementia care training has been provided through videos and staff were seen to be giving appropriate care to residents with dementia. However, more dementia care training needs to be provided and the proprietor has identified this as a need for the coming year. Changes in senior staff have been made and the new deputy manager has recently completed team leader training, which she found useful. Files of newly recruited staff were inspected, and contained all the required checks, which were obtained prior to their commencement. Induction is provided on an informal basis and lasts as long as the staff member needs. At the moment induction is done by the staff member shadowing an existing member of staff and reading the homes policies and watching training videos. This is good induction, however, it needs to be formalised into a training programme and a recommendation has been made. Ealing House Residential Home DS0000033998.V273073.R01.S.doc Version 5.0 Page 14 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): Standards 31, 33 and 35 Residents’ benefit from living in a safe and well-maintained home that is well managed by a competent proprietor. Residents also benefit because the home monitors and measures the quality of service provided. Some errors were noted with residents’ finances indicating these could be managed better. EVIDENCE: The proprietor who is also the manager of the home is a qualified nurse and has achieved the Certificate in Management studies. Staff said the proprietor was approachable and was good at listening to their ideas and would implement changes that would benefit the residents. The home monitors quality by involving relatives, staff and healthcare professionals in a yearly survey. A report is made and displayed on the notice board. Any feedback from that is addressed. Care plans and care practice is also reviewed on a regular basis.
Ealing House Residential Home DS0000033998.V273073.R01.S.doc Version 5.0 Page 15 The home keeps small amounts of money for residents’ personal items and records of transactions were inspected. Although appropriate records are kept, money held for two residents did not match the records of transactions made. The proprietor has had a new central heating system installed, and once the radiators are covered will provide a safer form of heating, a requirement has been made. Ealing House Residential Home DS0000033998.V273073.R01.S.doc Version 5.0 Page 16 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 X 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Ealing House Residential Home DS0000033998.V273073.R01.S.doc Version 5.0 Page 17 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP38 Regulation 23 Requirement The Registered person must ensure that radiator covers are fitted to all radiators, commencing with those deemed a high risk of harm to residents. The Registered person must implement a system for auditing the medication administration records to reduce the risk of recording errors. Timescale for action 31/03/06 2 OP9 13 (2) 12/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP18 OP30 Good Practice Recommendations The Registered person is recommended to increase staffs awareness of the correct reporting procedure for adult protection issues. The Registered person is recommended to implement a formal induction system. Ealing House Residential Home DS0000033998.V273073.R01.S.doc Version 5.0 Page 18 Ealing House Residential Home DS0000033998.V273073.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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