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Inspection on 23/11/06 for Ealing House Residential Home

Also see our care home review for Ealing House Residential Home for more information

This inspection was carried out on 23rd November 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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

What the care home does well

Ealing House continues to be managed by a competent provider who has a very person centred approach towards the residents. A lot of thought and consideration has gone into design and decoration of the home and little touches like the brass name plaques on residents` doors have gone a long way towards making people feel secure, respected and dignified. All areas seen were extremely clean and tidy but still maintained a homely atmosphere. Disposable gloves and aprons in the toilets and bathrooms were easily accessible but were housed inside attractive material covers, which made these areas feel less clinical.The staff recruitment procedure is robust and the manager ensures all staff have all their police checks completed before they commence work. There is a wide variety of in-house training available which staff are actively encouraged to complete. All of the comment cards received indicated that residents and their relatives/friends are satisfied with the care provided.

What has improved since the last inspection?

All radiators, which posed a risk to residents` safety, have now been covered. All new staff are now required to complete the `Passport to Care` induction programme and one member of staff has commenced this. A number of areas have been completely refurbished to a very high standard and have further enhanced the `homely` feel of Ealing House.

What the care home could do better:

Although medication procedures have improved greatly since the last inspection, and audits now take place on a weekly basis, some signatures were still missing on the MAR sheets. Although the manager is at the home on a daily basis and informal supervision takes place regularly, all care staff must receive formal supervision at least six times a year. The staff have access to a wide variety of training but it is felt that they would benefit from a formal training plan to identify actual training needs. Action plans in relation to assessments for mobility and pressure sores need to contain more detailed information with regard to what is required to address any issues or risks identified.

CARE HOMES FOR OLDER PEOPLE Ealing House Residential Home 86 Repps Road Martham Great Yarmouth Norfolk NR29 4QZ Lead Inspector Debra Allen Unannounced Inspection 23rd November 2006 09:00 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.V321565.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. Ealing House Residential Home DS0000033998.V321565.R01.S.doc Version 5.2 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 14 Category(ies) of Dementia - over 65 years of age (14), Old age, registration, with number not falling within any other category (14) of places Ealing House Residential Home DS0000033998.V321565.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th January 2006 Brief Description of the Service: Ealing House is a care home providing personal care and accommodation for 14 older people with or without dementia and is owned and managed by Mrs Sally Watson. Ealing House is located in the centre of the village of Martham close to shops, pub and local amenities. The home has been open for thirty-three years and consists of a detached two-storey house, 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.V321565.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care Services are judged against outcome groups, which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out, by using information from previous inspections, information from the providers, the residents and their relatives, as well as others who work in or visit the home. This has included a recent unannounced visit to the home. This report gives a brief overview of the service and the current judgements for each outcome group. Following comments from the provider, the draft report was amended regarding the fact that the home provides personal care and accommodation for people with or without dementia and has been open for thirty-three years. Also, the statement and requirement regarding fire alarm tests not being carried out regularly has been removed following receipt of a copy of the completed fire alarm log booklet. This key inspection was unannounced and took place over four hours by two inspectors, Debby Allen and Hilary Richards. During this time the inspectors carried out a tour of the premises and looked at samples of residents’ care plans, staff files and the home’s health and safety records. Further information was obtained from the home’s pre-inspection questionnaire and thirteen Relatives/Visitors comment cards and eight Service User Surveys that were returned prior to the inspection. A comment card from the GP was also received. Four requirements and two recommendations have been made as a result of this inspection. What the service does well: Ealing House continues to be managed by a competent provider who has a very person centred approach towards the residents. A lot of thought and consideration has gone into design and decoration of the home and little touches like the brass name plaques on residents’ doors have gone a long way towards making people feel secure, respected and dignified. All areas seen were extremely clean and tidy but still maintained a homely atmosphere. Disposable gloves and aprons in the toilets and bathrooms were easily accessible but were housed inside attractive material covers, which made these areas feel less clinical. Ealing House Residential Home DS0000033998.V321565.R01.S.doc Version 5.2 Page 6 The staff recruitment procedure is robust and the manager ensures all staff have all their police checks completed before they commence work. There is a wide variety of in-house training available which staff are actively encouraged to complete. All of the comment cards received indicated that residents and their relatives/friends are satisfied with the care provided. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ealing House Residential Home DS0000033998.V321565.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ealing House Residential Home DS0000033998.V321565.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 (Standard 6 was not applicable) Quality in this outcome area is good. The provider follows a robust assessment procedure and visits prospective residents and their families prior to admission to ensure their needs can be met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans were inspected for two residents who have moved into the home since the last inspection. Both of these confirmed the continuity of the robust procedure, which is followed to assess prospective residents. Six out of eight residents stated in the service user surveys that they had received a contract and enough information about the home before they moved in. One stated not applicable and the other stated that they had stayed, following an emergency admission. Ealing House Residential Home DS0000033998.V321565.R01.S.doc Version 5.2 Page 9 Since the completion of recent refurbishment works, the service user’s guide and the statement of purpose both need to be updated in order to accurately reflect the home and service provision and a requirement has been made to this effect. As further refurbishment is planned during the course of 2007, consideration should also be given to the fact that these documents will require reviewing and updating on a regular basis. Ealing House Residential Home DS0000033998.V321565.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, Quality in this outcome area is good. Care plans are very detailed with regard to how residents’ needs are met but action plans following mobility and pressure sore assessments need to contain more information. Medication must be signed for every time it is administered. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The two care plans inspected clearly identified residents’ needs, aims, goals and action required. A good level of detail was seen with regard to how residents’ needs are met. However, although comprehensive assessments were in place, which highlighted risks relating to mobility and pressure sores, the action plans do need to contain more information and a recommendation has been made for more detail regarding the action being taken to address these matters. Ealing House Residential Home DS0000033998.V321565.R01.S.doc Version 5.2 Page 11 Medication procedures have improved greatly since the last inspection and audits take place on a weekly basis. However, some gaps were still noted on the MAR sheets, which have been highlighted during the Home’s auditing process and confirmed as ‘administered but not signed for’. A requirement has been made to ensure accurate recording of medication once it has been administered. The inspectors found the atmosphere in the home to be very comfortable and welcoming and the staff on duty were observed having very caring and professional approach towards residents. Staff were heard speaking to individuals appropriately and explaining what was happening while attending to any personal needs. It was also noted that the home has a very empowering culture with regard to assisting residents to remain as independent as possible and a number of personal aids and assistive equipment were seen to be in use. Thirteen Relatives/Visitors comment cards were received prior to the inspection and some contained comments such as: “This home operates to the highest standards.” “My relative is receiving 1st class care and attention” and “Well run by caring and thoughtful people. It is comfortable, friendly and cheerful”. From these observations, the opinion is formed that residents are treated naturally with respect and dignity and their right to privacy is upheld. The staff and management are commended for the high standards of care observed. Ealing House Residential Home DS0000033998.V321565.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is excellent. Residents are able to exercise choice wherever possible about their lifestyle and contact with family/friends is encouraged and maintained. The menu offers a good choice and appears to be balanced and nutritious. Alternative options are also available. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the inspection some residents were seen to be sitting the communal lounges or the dining area and three people had chosen to have breakfast in their rooms. The hairdresser was also present on the day of the inspection and two residents were having their hair done. Although only limited activities were observed at the time of the inspection, residents’ daily notes and other evidence confirmed that a variety of activities occurred on a regular basis and these appeared to be very person centred. Ealing House Residential Home DS0000033998.V321565.R01.S.doc Version 5.2 Page 13 The cook was in the process of preparing lunch during the inspection and was seen to be using fresh ingredients. The manager confirmed that the home purchases fresh produce from the local butcher and greengrocer. The four-week rolling menu was looked at, which offered a good choice and appeared to be balanced and nutritious. The manager confirmed that alternatives were available as and when required. Although no visitors were actually seen on the day of the inspection, 13 relatives/visitors had returned comment cards, all of which stated that they were welcome at any time, could visit in private and were satisfied with the overall care. Ealing House Residential Home DS0000033998.V321565.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18, Quality in this outcome area is good. No complaints have been received since the last inspection and residents and their relatives/friends have confirmed that they know how to make a complaint. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Of the thirteen relatives/visitors comments received, ten said they were aware of the Home’s complaints policy although none stated that they had ever made one. Six out of eight residents stated they knew who to speak to if unhappy and that they knew how to make a complaint. The manager confirmed that no complaints have been made since the last inspection. The staff training records seen confirmed that staff continue to undergo training in adult protection. Ealing House Residential Home DS0000033998.V321565.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26, Quality in this outcome area is Excellent. Residents live in a safe, well-maintained and homely environment and have rooms which are very individualised and contain their personal possessions. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Home has recently undergone a considerable amount of refurbishment and further improvement works are scheduled for 2007. There is a high standard of decoration throughout the home and the new and renovated areas have been done to a very high specification. All areas of the home were seen to be clean, comfortable and pleasant smelling. Each resident’s room was seen to be very personalised, including brass name plaques on the doors. A number of assistive aids were noted. The enclosed garden is very attractive and well maintained and could be viewed comfortably and clearly from the dining area. Ealing House Residential Home DS0000033998.V321565.R01.S.doc Version 5.2 Page 16 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, 30 Quality in this outcome area is good. Residents continue to be cared for and supported by competent staff and robust recruitment procedures are maintained. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Personnel files were inspected for four staff who have been recruited since the last inspection and all contained evidence that a robust recruitment procedure continues to be followed. The manager confirmed that new staff are now required to complete the ‘Passport to Care’ induction programme and one member of staff has commenced this. There was a clear record of the training that staff had undergone, which included dementia care, and the home has a very innovative incentive scheme with regard to staff evidencing what they have learnt. However, it is felt that staff would benefit from a formal training plan to identify training needs rather than what currently appears to be a somewhat ad-hoc system. A recommendation has been made for this. Ealing House Residential Home DS0000033998.V321565.R01.S.doc Version 5.2 Page 17 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, 32, 33, 35, 36, 37, 38 Quality in this outcome area is adequate. Residents continue to live in a safe and well-maintained home that is well run by a competent proprietor. All care staff need to receive formal supervision at least six times per year. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All radiators have been covered except one, for which a risk assessment has been carried out, which confirms that it is not deemed as being a risk. Quality assurance has been monitored annually with surveys being sent to relatives, staff and healthcare professionals. Although feedback from the surveys is addressed a recommendation has been made for a development plan to be produced and made available to everyone involved with the service. Ealing House Residential Home DS0000033998.V321565.R01.S.doc Version 5.2 Page 18 As the manager is at the home on a daily basis, informal supervision takes place regularly. However, the only recorded supervision sessions noted at the time of the inspection were dated July and October 2006. A requirement has been made that all care staff must receive formal supervision at least six times a year. Accident records were inspected and although staff had experienced a number of minor accidents and there were a number of falls recorded for residents, there was no regular pattern relating to any individual or any particular place in the home. A requirement has been made for a copy of the accident records to be placed in the residents’ files where appropriate. Equipment servicing was seen to have been carried out on a regular basis and all servicing was up to date. Comprehensive room-by-room fire risk assessments were seen, were up to date and appropriate action had been taken where requirements were identified. Fire alarm tests showed as having been carried out regularly. The home keeps small amounts of money for residents’ personal items and records of transactions were inspected and found to be accurate and appropriate. Ealing House Residential Home DS0000033998.V321565.R01.S.doc Version 5.2 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 4 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 3 3 3 3 4 3 4 3 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 1 2 3 Ealing House Residential Home DS0000033998.V321565.R01.S.doc Version 5.2 Page 20 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 OP1 Regulation 6 Requirement Timescale for action 31/01/07 2 OP9 17 3. OP36 18 4. OP37 17 The Registered Person must ensure the Statement of Purpose and Service User’s Guides are revised and accurately reflect the home and service provision. The Registered Person must 23/11/06 ensure Medication Administration Records (MAR) are signed every time medication is administered. The Registered Person must 31/12/06 ensure that all care staff receive formal supervision at least six times a year. The Registered Person must 31/12/06 ensure a copy of the records relating to accidents or incidents are placed on the relevant residents’ files. Ealing House Residential Home DS0000033998.V321565.R01.S.doc Version 5.2 Page 21 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 OP8 Good Practice Recommendations The Registered Person is recommended to ensure that Service Users who have been identified as being at risk with regard to pressure sores or mobility, have the appropriate intervention recorded in their plan of care. Also, that any treatment and outcomes, are recorded in the service user’s plan of care and reviewed on a continuing basis. The Registered Person is recommended to produce a formal training plan for staff to identify training needs for each individual. 2. OP30 Ealing House Residential Home DS0000033998.V321565.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Ealing House Residential Home DS0000033998.V321565.R01.S.doc Version 5.2 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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