Inspection on 29/11/05 for Eardley House

This inspection was carried out on 29th November 2005.

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

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

Other inspections for this house

Eardley House 02/01/09

Eardley House 21/02/08

Eardley House 21/08/07

Eardley House 05/02/07

Eardley House 30/05/06

Eardley House 08/06/05

Eardley House 30/11/04

Eardley House 11/05/04

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Maple Lodge

Heathlands

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Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Eardley House Moorland View Bradeley Stoke-on-Trent Staffordshire ST6 7NG Lead Inspector Lorraine Mavengere Announced Inspection 29 November 2005 9:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Eardley House DS0000028913.V261472.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. Eardley House DS0000028913.V261472.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Eardley House Address Moorland View Bradeley Stoke-on-Trent Staffordshire ST6 7NG 01782 235901 01782 234530 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) Stoke on Trent City Council Mrs Susan Mountford Care Home 44 Category(ies) of Dementia (5), Dementia - over 65 years of age registration, with number (44), Mental disorder, excluding learning of places disability or dementia (6), Old age, not falling within any other category (44), Physical disability over 65 years of age (44) Eardley House DS0000028913.V261472.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Eardley House is a care home providing both long term and respite care for up to 46 older people with dementia. The home is owned by Stoke on Trent City Council, a unitary authority, and care is directly provided by the councils staff team from the social services department. The home is located on the outskirts of the City of Stoke on Trent, in the village of Bradeley. Ity has ready access to community facilities and, including shops, pubs, post office and public transport. The home was originally purpose built to the standards current at the time, and consists of two storeys. Because of its large size, and to meet up to date good practice in care provision, it is now divided into four group living arrangements. Each area has its own living/ dining area. Assisted bathing and toilet facilities are strategically provided throughout the home, and other facilities include a smoke room and separate quiet room with a pay phone. All bedrooms are single.None of the bedrooms have en suite facilities. Access to the enclosed rear garden is from two lounge areas with ramps and hand rails provided for safety. The garden has a patio area with seating, flowers and a summer house. Overall the accomodation is generally comfortably appointed and welcoming, although there are still some areas of the home that need decorating. Eardley House DS0000028913.V261472.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and took place during the day and into the evening. During the inspection, a number of service users and staff were spoken to about the service. Their comments are included in the report. Information for the report was gathered through the pre inspection questionnaire, relatives and service users’ comment cards, observations, discussions with the manager, staff and service users, case tracking and records. No relatives were spoken to at length on this occasion. Due to the current fire regulation, three bedrooms have been shut down unofficially. This means that at present there are 42 beds. Two of the bedrooms have been assessed as not suitable for the type of residents accommodated at the home given their isolated location. These two bedrooms are therefore not in use. The registered manager is considering having the two rooms permanently shut down from a safety point of view. The home presently has 26 permanent residents, three permanent residents that are in hospital, three residents on assessment and five short stay residents (periodic short stay). There 37 residents at the home in total. It was possible to clear some matters that were raised in the last inspection. The first one that had caused much distress was a comment made in the previous report that non availability of staff resulted in visitors becoming involved in the delivery of care. The comment was made in light of observations made by the inspector at the time of inspection. The inspector had made requests to a member of staff to come and assist a resident. Visitors to the home on the day had been going to assist the service user in question; this was not acceptable. The manager and member of staff involved on the day cleared this up by explaining that the resident was not at risk as this was part of her assessed behaviours. It was also explained that relatives were repeatedly asked not to involve themselves in any level of resident care. The member of staff summoned on the occasion stated that she was observing what was going on through the glass panel dividing the lounge and the dining room where she was doing some written work. In her experience, the service user was not at risk. It was also explained that the staff member has some difficulty in hearing that prevented communication between her and the inspector being more fluent. In light of the above, the home has now committed to setting up a risk assessment for visitors in the home and their risk of involvement in the care of residents. Eardley House DS0000028913.V261472.R01.S.doc Version 5.0 Page 6 What the service does well: What has improved since the last inspection? What they could do better: There were some eye drops that needed to be refrigerated that were kept in an ordinary medication cabinet. The home therefore must improve on its practice for storing and disposing of refrigerated medicines. The home does not presently record fridge temperatures for the medication fridge and consultation Eardley House DS0000028913.V261472.R01.S.doc Version 5.0 Page 7 to do with homely remedies does not take place with either the G. P or the pharmacist. Service users’ information on trial visits could be improved. The decorative work is ongoing but not complete and staff training must be kept up to date. 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. Eardley House DS0000028913.V261472.R01.S.doc Version 5.0 Page 8 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 Eardley House DS0000028913.V261472.R01.S.doc Version 5.0 Page 9 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): 5 Prospective service users and their families are provided with opportunity to visit the home on a trial basis to enable them to make an informed decision about the home’s suitability for them. EVIDENCE: The registered manager stated that where possible, prospective service users are invited for pre admission visits and can stay at the home for a trial period. This however is not always possible given that some placements are emergency admissions. The manager confirmed that the pre admission visits usually consist of meals at the home, afternoons or overnight visits. Discussions with the manager also verified that where an emergency admission has taken place service users are informed of the key aspects of the service, rules and routines within 48 hours or as soon as possible dependant service users’ capacity to take it all in. A care file seen shows that prospective service users do come for trial visits where possible- this is documented in the pre admission assessment sheet and the daily report cards. The Statement of Purpose and Service User Guide do not highlight service users’ right to trial Eardley House DS0000028913.V261472.R01.S.doc Version 5.0 Page 10 visits. It is recommended that service users are informed of their right to trial visits. Eardley House DS0000028913.V261472.R01.S.doc Version 5.0 Page 11 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): 9 The home’s policies and practices for the receipt, storage, administration and disposal of medicines does not fully safeguard the wellbeing of service users. This standard, therefore had some shortfalls. EVIDENCE: The home’s policies and procedures on medication were seen during the inspection. These were comprehensive and detailed. Records show that six staff have been trained in basic administration of medication and they are the ones who are responsible for administering medicines. A refresher training course has been set up with the local pharmacist for January 2006 for the six staff. There is now a new protocol on PRN medication as part of the existing policies. The protocol is in line with the home’s current practices. The home uses the medi- dose system. The pharmacist is responsible for collecting prescriptions and dispensing the drugs into the dossette boxes. The clinical room was fully assessed during the inspection. All medication is appropriately stored and there is provisions made for refrigerated medication and controlled drugs. There were some eye drops that were in the medication cabinet but needed to be stored in the fridge. All eye drops must be stored as per instruction. It was also noted that fridge temperatures were not recorded or Eardley House DS0000028913.V261472.R01.S.doc Version 5.0 Page 12 monitored. There is the risk, therefore, of temperatures being inappropriate for the stated use. Medication fridge temperatures must be recorded and monitored. The policy on homely remedies was seen during the inspection. The policy gives a list of permissible homely remedies that are considered safe to use. It is recommended that consultation takes place with the G.P or the pharmacist to confirm that the homely remedies do not react with any other prescription drugs for individual service users. Eardley House DS0000028913.V261472.R01.S.doc Version 5.0 Page 13 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): 13, 14 The home facilitates community links in as much as possible and in accordance with service users risk assessments. The manner in which the home is run enables service users capacity to exercise personal autonomy and choice to be maximised. EVIDENCE: The registered manager stated that the residents occasionally take a walk locally. Links to the community are limited by the service users’ level of dementia. Occasionally the home organises trips to the pantomime and other community based activities but in the past this has been distressing to the residents. If however, a service user expresses an interest in going out, this will be accommodated and facilitated. None of the service users attend church but the priest from the local church comes in on request. The dementia conditions also mean that concentration spans are very low and it is therefore difficult to engage service users in community based activities. It was quite clear from the relatives comment cards received and discussions with the service users that visitors are welcome to the home at any reasonable time. Eardley House DS0000028913.V261472.R01.S.doc Version 5.0 Page 14 The clerical manager stated that where possible, service users are encouraged to handle their own finances. The service user guide has information on contact details for outside agencies such as the Commission for Social Care Inspection. Service users spoken to stated that they were able to bring in their own personal possessions. Eardley House DS0000028913.V261472.R01.S.doc Version 5.0 Page 15 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): 18 The home’s policies and procedures serve to promote the protection of service users against abuse. EVIDENCE: The home uses the Stoke on Trent Interagency Protection policy. The policy incorporates Whistleblowing and is in line with the Public Interest Disclosure Act 1998 and the Department of Health Guidance No Secrets. The procedures are robust and clearly outline action to be taken in the event of suspicion or evidence of abuse. Records show that most of the staff team have received training in Protection against Abuse. The few that have not completed the training are scheduled to do so in the near future. Staff spoken to expressed clarity on the reporting and recording processes for alleged or actual abuse. There have been no Vulnerable Adult proceedings since the last inspection and no staff have been referred to POVA. The home’s recruitment policy ensures that only suitable candidates are employed to care for service users. Eardley House DS0000028913.V261472.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 The location and layout of the home is suitable for its stated purpose enabling service users to benefit from acceptable accommodation. EVIDENCE: A brief tour of the premises showed the home to be clean and tidy. The manager explained that due to the deterioration in the dementia of service users at the home, it has become increasingly difficult to keep the home as domestic in nature as preferred. This is because of the level of risk that certain domestic items may have on individual service users. The home is therefore not as domestic in nature as it used to be. The home has been on an ongoing programme of decoration. The decorative work is still incomplete. It is recommended that decorative work is completed in a timely manner. Service users have unlimited access to all communal areas of the home and the garden areas. However, because of some risk factors, some of the access to certain areas such as the garden and the outside areas have to be supported. There is a chain on the door that prevents service users from wandering out of the building. The registered manager stated that this bit of restriction has been Eardley House DS0000028913.V261472.R01.S.doc Version 5.0 Page 17 risk assessed and found to be in the best interests and safety of the service users. Eardley House DS0000028913.V261472.R01.S.doc Version 5.0 Page 18 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): 28, 30 Staff are provided with a TOPSS certified induction to ensure that service users are in safe hands at all times. Staff have the training and support necessary to do their jobs enabling service users to benefit from a competent staff team. EVIDENCE: Information provided in the pre inspection questionnaire show that 38 of the care team are qualified to NVQ2 or above. The manager confirmed that the home is constantly looking to meet the 50 target. Records show that a number of staff are enrolled on the NVQ training. Once these staff have completed their training, the home would have met their 50 target. The home’s training and development programme covers all mandatory training and is in line with the National Training Organisation workforce training targets. The registered manager confirmed that all new staff receive a TOPSS certified induction that covers all areas of the home’s stated purpose. Training records seen show that some training is still outstanding. It is recommended that all training is completed on schedule. Eardley House DS0000028913.V261472.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35, 38 The home has effective quality monitoring systems in place to enable the home to be run in the best interests of the service users. The home’s policies and procedures on service users money enables service users or their families to manage their finances unless they do not wish to do so, or if they lack the capacity. The home’s safe working practices and policies ensure that service users, staff and visitors’ safety and wellbeing are maintained. EVIDENCE: Discussions with the registered manager highlighted that Carer’s meetings held on average twice a year. The attendance for this has been reported to be poor but the meetings will continue as planned. The home has questionnaires for service users, their representatives and stakeholders. The questionnaires seen all gave positive feedback. The home is now developing a strategy for collating all the information received and putting it into a comprehensive report. The Eardley House DS0000028913.V261472.R01.S.doc Version 5.0 Page 20 manager stated that the report would highlight a planned way forward using as a result of information received. The home routinely has the regulation 26 visits carried out and these are sent to CSCI monthly. The quality monitoring systems are satisfactory and in line with the home’s stated purpose. Policies and procedures are reviewed by the organisation annually or as required. Some annual budgets were seen for various aspects of the home. The clerical manager stated that all service users have a Financial Assessment as part of their care plans when they are first admitted into the home. The service users who are not able to manage their own finances have a plan in place by which either social services or their relatives manage their finances. The systems for depositing and withdrawing money are comprehensive and easy to trail. Records show that one service user is on Guardianship and three are on power of attorney. Where relatives are in charge of service users monies, cheques are always made out in the service users name so that it can be deposited in their bank or post office account. Under no circumstances is cash ever given to a third party on behalf of the service user. The home uses the purse system. This is audited monthly. The home also has a financial monitoring system in place. A full financial audit was carried out in January 2005 and was seen to be in compliance with Financial Regulations. Receipts and financial sheets are kept for seven years after the resident is deceased. Safe Working Practices: Training matrix show that all staff receive the relevant safe working training such as manual handling, and fire training. The home has all the safe working policies and procedures. These include Accident Reporting and investigation, Manual Handling, Health and Safety First Aid at Work, Infection Control, Risk Assessments and Verbal Aggression Monthly summary forms. Additional training has been implemented through the infection control nurse with regards to residents coming back from hospital with MRSA and other communicable disease. Obviously this has been a priority, and as a result some of the manual handling and food hygiene training is not up to date. The manager confirmed that the Assistant Catering Manager will be carrying out in house food hygiene updates, and infection control training in the near future. The home is actively setting the training programmes up to ensure that this is done in the new year. The first aid updates are planned for the 18th of January 2006. The manager at Eardley home is a certified Mapper trainer and will be providing this training to Eardley House alongside other homes that deliver care to people with dementia. There is a no smoking policy throughout the home except in the designated smoking areas. The home has two smoking rooms; one for service users and one for staff. A Certificate of Conformity was done by Chubb to verify that all fire regulations have been met (April 05). The home is divided into fire 7 zones. Each fire zone is tested weekly by the handy person. This means that each zone is tested once every two months. The home has three dorgards and the rest are fire doors. These are also tested weekly. Emergency lighting is tested monthly. Portable fire fighting equipment is tested monthly. Records Eardley House DS0000028913.V261472.R01.S.doc Version 5.0 Page 21 show eight fire drills have been carried out this year. The home holds records of staff participation in Fire Drills. Most staff are up to date with the drills. (Management of Health and Safety at Work Regulations Corporate risk assessments). The generic risk assessments were seen during the inspection. These cover all areas of identified risk within the home and help to ensure safety for service users, staff and visitors. These risk assessments are comprehensive. There is outstanding fire work (cross corridor doors intubation strips that either need upgrading or replacing). Discussions with the manager highlight that is beyond her scope and is being dealt with on a corporate level. All testing of portable appliances was carried out on the 16th of February 2005. Records show that testing of portable appliances is done annually. The home has a designated training budget through Learning and development, but the manager holds the budget for maintenance for the home. All staff have to do their TOPSS training within six weeks of commencing employment. The home complies with relevant legislation Eardley House DS0000028913.V261472.R01.S.doc Version 5.0 Page 22 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 3 X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 X X X X X X X STAFFING Standard No Score 27 X 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 4 X X 3 Eardley House DS0000028913.V261472.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? 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 OP2 Regulation 5(1) Requirement The home must provide all service users with a contract/ statement of terms and conditions All eye drops must be stored as per instruction Medication fridge temperatures must recorded and monitored. Service users must consulted about their wishes concerning death and dying. Timescale for action 31/10/05 2. 3. 4. OP9 OP9 OP11 13(2) 13(2) 12(2)(3) 29/11/05 29/11/05 31/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard OP5 OP30 OP19 OP9 Good Practice Recommendations It is strongly recommended that service users are informed of their right to trial visits. It is strongly recommended that all training and development is kept updated. It is recommended that decorative work is completed on schedule. It is recommended that homely remedies are only DS0000028913.V261472.R01.S.doc Version 5.0 Page 24 Eardley House administered after consultation with the general practitioner or the pharmacist. Eardley House DS0000028913.V261472.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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