Inspection on 30/05/06 for Eardley House

This inspection was carried out on 30th May 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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 29/11/05

Eardley House 08/06/05

Eardley House 30/11/04

Eardley House 11/05/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

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 Wendy Snell Key Unannounced Inspection 30 May 2006 9:45 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 Eardley House DS0000028913.V297357.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. Eardley House DS0000028913.V297357.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eardley House Address Moorland View Bradeley Stoke-on-Trent Staffordshire ST6 7NG 01782 234530/1 F/P 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.V297357.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th November 2005 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 accommodation is generally comfortably appointed and welcoming, although there are still some areas of the home that need decorating. Eardley House DS0000028913.V297357.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place on a Tuesday from 9.45am to 6.15pm. Four service users, four relatives, five staff and the manager were spoken with about the care that is provided in the home. The manager and five relatives completed the Commission for Social care Inspection questionnaires prior to this inspection. Four service user’s care was case tracked by examining their care files, clarifying care issues with staff and observing and talking with service users about the care they receive. Paper work, which identifies the way in which the home is managed, was also examined. What the service does well: Eardley House is a well managed home with good administration systems in place. The manager and staff were observed to work well together as a team with good communication systems in place. The staff spoken with were positive about the management style within the home which they felt was open and approachable. The home has satisfactory staffing levels with a good skill mix of staff. Staff spoken with were aware of and sensitive to the needs of the service user group. Staff were observed talking with service users in a caring and positive way. The service users within the home have dementia and therefore were unable to give detailed feedback about what its like to live at Eardley House but the responses that were given were positive. Five relatives completed the Commission for Social Care Inspection questionnaires about the home and four relatives were spoken with during the inspection. The views expressed were very positive and complimentary about the care that their relatives receive. The comments included ‘my wife is well cared for’, ‘the staff are always pleasant and helpful’ and ‘staff talk to mum and the other residents in a caring way’. Eardley House DS0000028913.V297357.R01.S.doc Version 5.2 Page 6 The food served within the home is of a good quality with good size portions. The menus show that there is a choice and variety of foods offered. The cook confirmed that special diets are catered for. The home was generally well maintained, clean and tidy. The service user’s bedroom were well decorated and comfortably furnished. What has improved since the last inspection? What they could do better: The outstanding fire work which was identified at the last fire inspection must be carried out to ensure that service users live in a home that is as safe as it can be. There needs to be a positive approach to ensuring that staff complete appropriate staff supervision and training including NVQ, first aid and vulnerable adults training. This will ensure that the staff group have the skills and the training to meet the needs of the service users in the home. It is recommended that consideration be given to analysing the amount of falls that service users have to see if they can be prevented. It is also recommended that the menu system be reviewed to incorporate pictures to enable the service users with dementia to make an informed choice. The information from quality assurance systems should be shared with people who use or visit the service and should influence future plans for the home. Eardley House DS0000028913.V297357.R01.S.doc Version 5.2 Page 7 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.V297357.R01.S.doc Version 5.2 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.V297357.R01.S.doc Version 5.2 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): 3 The home has clear assessments of service user’s individual needs, which enable staff to support them appropriately. The Quality in this area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four service user’s care files were examined as part of the case tracking process. All files had a care management assessment of need in place. Two service user files also had evidence that an ‘in house’ assessment had been carried out by the registered care manager prior to the service user being admitted to Eardley house. Eardley House DS0000028913.V297357.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Care, health and medication needs are well planned with a high level of satisfaction from relatives who visit the home. Staff were observed to treat service users with respect. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The four service user’s files that were examined did have care plans in place. The same care planning system was used for both permanent and short stay service users. This provides a consistent approach to care planning, which provides care staff with the detail they require to meet the care needs of the service users. It is recommended that more information be included within the care plans which relates to the service user’s history and social needs as this information is important when supporting a service user with dementia. It is acknowledged that this area is to be addressed through the advent of a new comprehensive care planning system for permanent residents but this information also needs to be sought for short-term admissions too. There was evidence that regular care plan reviews take place. This ensures that the care plan reflects the changing needs of service users. Eardley House DS0000028913.V297357.R01.S.doc Version 5.2 Page 11 Two care staff were spoken with both of whom demonstrated a good understanding of the importance of detailed care planning. Staff were observed to appropriately follow up with district nursing and the GP service health concerns in respect of a service user. The service users were unable to comment about how the home meets their individual health needs because they have dementia but four relatives were spoken with. The views expressed were positive. One relative said ‘health needs are sorted out as soon as needed’ and another said ‘my wife is receiving good health input’ It was also confirmed by relatives that care workers accompany service users to all health appointments and all were confident that the home ensures that health issues are dealt with in an appropriate and timely way. Five relatives completed the Commission for Social Care inspection (CSCI) questionnaires all stated that the home keeps them informed of important matters affecting their relatives. Health issues were recorded within individual health and medical report cards. Four of these records were examined. There was documented information relating to medical input and the outcomes of health consultations were also recorded. This is good practice. The care staff spoken with had a good understanding of where information relating to health should be recorded. The manager stated that the home have a good working relationship with local health and pharmacist services. The management within the home appropriately notify the CSCI about accidents and falls, which happen within the home. The number of admissions to hospital and falls was discussed with the manager. It is a good practice recommendation that the manager complete a falls analysis to establish if there are steps, which can be taken to reduce the number of falls at Eardley House. It is also recommended that the manager clarify whether falls advice is offered by the Primary Care Trust (PCT). The home has a smoking room. A CSCI questionnaire completed by a visitor to the home raised concerns about the level of smoke within the building. On the day of the inspection the smoke from the smoking room could be smelt in other parts of the building including in a ground floor dining room and lounge areas which are situated nearby. It was noted that the door to the smoking room was not always closed and although there is an extractor fan within the room this did not appear to be effective in preventing smoke circulating around the ground floor of the home and was regularly switched off by the service users using this room. This was discussed with the manager who was advised to consider ways in which the service users within the home can be better protected from cigarette smoke within the building. This will be a recommendation. Eardley House DS0000028913.V297357.R01.S.doc Version 5.2 Page 12 A senior member of staff was observed administering medication. She stated that all staff who administer medication have received the relevant training. The registered manager confirmed this. Medication was observed to be appropriately crossed checked with the medication administration records prior to administration and the medication administration records were appropriately completed upon administration. It was noted that the member of staff prompted and observed to ensure that the service user had taken their medication. Medication is stored safely in locked metal cabinets in a locked medication room. The manager stated that medication reviews take place. A relative confirmed that his wife’s medication had been reviewed since moving to Eardley House. Two care staff were spoken with about how staff ensure that service users privacy and dignity are upheld. Both said that staff ensured their privacy when assisting with personal care. The staff spoken with demonstrated a good understanding of how to assist with personal care in a courteous and dignified manner. It was noted that there were locks on all the bathroom and toilet doors. Privacy and dignity is incorporated into the care planning process. An example of which stated that when staff are assisting to wash and dress they should ‘explain what they are doing and try to get eye contact’ and that staff should ‘reassure throughout’. This is good social care practice and particularly important when assisting people with dementia. Staff interactions with service user was observed to courteous and respectful. One relative said that the ‘staff talk to mum and other service users in a caring way’. Eardley House DS0000028913.V297357.R01.S.doc Version 5.2 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): 12, 13, 14 & 15 Service user and relatives views about the meals, visiting and activities within this home were positive. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The pre inspection questionnaire completed by the manager states that entertainers, sing a longs, videos, knitting, painting and other indoor activities take place on a regular basis. As the majority of service users who live at Eardley House have dementia the manager stated that the activities are tailored to meet their needs. Trips out can some times present too much change in routine for service users with dementia and some forms of entertainment requires the ability to concentrate for a long period of time. Therefore more one to one work is carried out which may entail a staff member talking with, or completing an activity with, an individual or a small group of service users. The home keep a record of all activities that take place and which service users have taken part in. The manager stated that she has some additional staffing hours that are allocated to staff specifically to carry out social activities with the service users. Eardley House DS0000028913.V297357.R01.S.doc Version 5.2 Page 14 It was noted that some service user’s assessments and care plans included information relating to interests. This was not consistently recorded and a recommendation in standard seven of this report has been made accordingly. Four relatives were spoken with and five completed CSCI questionnaires. The unanimous view was that visitors are made to feel welcome in the home and are encouraged and supported to retain contact with their relatives. One relative said the staff were ‘absolutely, downright brilliant’ and that they ‘keep you up to date with everything’. Another said ‘the staff are always pleasant’. A meal time was observed. The lunchtime meal was ham and parsley sauce, potatoes and vegetables or salad followed by chocolate mousse or fresh fruit. The home has three separate dining areas which are well furnished. It was observed that staff assisted the service users who required assistance with their meals. Two cooks were spoken with. They confirmed that the care staff keep them informed about any service users requiring a special diet. They stated that each service user is asked the day before what lunchtime meal they require for the following day. Copies of the menu confirm that a choice is always available. Three service users were spoken with about the food. All stated that the food was good and that there was enough of it. The four relatives spoken with stated that they did not have any concerns about the quality or the amount of food served at Eardley House. Appropriate systems were noted to be in place within the kitchen in relation to the preparation, storage and handling of food. Both cooks confirmed that they had received appropriate food hygiene training. It was noted that there were no menus or reminders in the dining areas to inform service users what they were having at the meal time. As most of the service users have dementia they were unable to remember the choices that they had made the day before. This issue was discussed with the manager. It is recommended that consideration be given to using pictures to accompany menu selection and to remind service users of their meal choices. It is also recommended that a copy of the CSCI good practice report entitled Highlight of the Day be sought for kitchen and care staff to use. Eardley House DS0000028913.V297357.R01.S.doc Version 5.2 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): 16 & 18 The home has satisfactory complaints and protection systems in place. Staff training in the protection of vulnerable adults would further enhance service user safety. The quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager stated that has been one complaint over the past 12 months. This complaint was appropriately documented and the outcome recorded. It had been responded to within 28 days and the issue had been successfully resolved. As the service users have dementia they were unable to respond to specific questions regarding complaints. However, the service users spoken with did say that they felt safe living at Eardley House. The complaints procedure is available within the entrance area to the home. Five relatives completed CSCI questionnaires. None had made a complaint about Eardley House. Four relatives were spoken with. All said they felt confident that the managers and staff would sort out any issues in a timely way. The pre inspection questionnaire states that there have been no vulnerable adult issues at Eardley House during the past 12 months. Two cooks, a domestic and two care staff were spoken with. One staff member said that she had received vulnerable adult training some years ago and another said she briefly covered this subject in NVQ2 training. The two care staff had an understanding of reporting procedures and in discussions both demonstrated a positive commitment to protecting service users from harm. In view of the Eardley House DS0000028913.V297357.R01.S.doc Version 5.2 Page 16 vulnerability of service users with dementia it is required that all staff receive vulnerable adult training, which should include identifying and reporting procedures. This may be refresher training for those who have already attended relevant training. Eardley House DS0000028913.V297357.R01.S.doc Version 5.2 Page 17 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 & 26 Some windows need replacing and there remain a number of outstanding areas of concern particularly in relation to fire safety. The quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A recent fire officer inspection has identified some structural changes, which need to be made to the internal building. CSCI have met with Stoke on Trent and the fire service. Stoke on Trent have agreed to address the outstanding fire work in this home by the end of August 2006. That this timescale is met will be a requirement of this report. Eardley House is a clean home. Internally the building is well maintained by a handy man and the domestic staff. The service users bedrooms, which were seen, were nicely decorated and comfortable. A number of service users had brought in furniture from their own bedrooms, which gave each bedroom an individual feel. Eardley House DS0000028913.V297357.R01.S.doc Version 5.2 Page 18 Externally there are a number of windows, which are in need of repair or replacement. A timescale and plan for this work to be carried out must be forwarded to CSCI. The laundry room was viewed. A member of the domestic staff explained the system in place to ensure soiled and clean laundry is kept separate to avoid potential cross infection. This was satisfactory. Appropriate hand washing and protective clothing was available for staff use. Relatives spoken with stated that service user’s clothes were well laundered and that the label system ensured that their relatives generally, apart from the odd mistake, wear their own clothes. Eardley House DS0000028913.V297357.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 The home is appropriately staffed with robust vetting and recruitment practices. The staff team is stable and experienced but general training and specific refresher training needs to take place to ensure that staff are skilled to meet the specific needs of people with dementia. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of the inspection the home was suitably staffed with a registered manager, assistant manager, five care staff, two cooks and two domestics on duty. The staff spoken with had worked at Eardley house for some years and were therefore, experienced and familiar with the systems within the home. The manager stated that three night staff and a sleep-in manager staff the home at night. Records indicate that the home has a consistent staff team and a low staff turnover. This ensures consistency of care for the service users. There were 31 service users resident within the home. The majority of the service users were permanent however a number were also either having a short stay or were at Eardley House having an assessment of their needs. Four relatives completed CSCI questionnaires. Three stated that there seemed to be sufficient staffing and one said that there did not always seem to be sufficient staffing on duty within the home. Four relatives were spoken with during the inspection. The general view expressed was that there were generally enough staff on duty but that ‘at times they are pushed for time’. Eardley House DS0000028913.V297357.R01.S.doc Version 5.2 Page 20 The staffing rotas were seen and indicate that the home is appropriately staffed at all times. The pre inspection questionnaire completed by the manager indicates that 38 of the care staff have achieved NVQ2 or above. This is below the 50 target for 2005 as set out within the National Minimum Standards for older people. This was discussed with the manager who stated that she was presently the only NVQ assessor for the home. She stated that it was anticipated that a further four staff would complete their NVQ training by the end of the year. NVQ training and completion must be prioritised to ensure that the staff have the knowledge and skills to meet service user’s needs. This will be a requirement. The service users spoken with were unable to give feedback about the experience and training of staff because of their dementia. However staff were observed to interact positively with service users. The atmosphere in the home was relaxed and staff spoken with demonstrated an understanding of the needs of individual service users. The feedback from relatives was positive about the experience and skills of the work force. One relative stated ‘I was pleasantly surprised by the high standard of care given at the home’. Another said ‘the staff know what they are doing and they are always pleasant’. Five staff members were spoken with about the training they had received to enable them to do their jobs. Staff stated that they had attended a range of training courses applicable to their role within the home. The pre inspection questionnaire completed by the registered manager indicates that a range of training has taken place and that additional training has been identified for the following 12 months. There were copies of nomination forms within the home. It was noted that the home had a system, which identifies which staff have attended individual training courses. In discussion with staff members and after examining training records gaps in training were identified and discussed with the manager. It was noted that there are insufficient staff members trained in first aid to ensure there are appropriately qualified staff on every shift. This must be addressed. The manager must also ensure that all staff within the home has received appropriate dementia training. It is recommended that the manager consider implementing a whole staff training matrix in order to identify any further gaps in training. The manager confirmed that all new staff receive induction training. Staff are encouraged to keep their induction files. It is recommended that proof that the induction has successfully been completed be retained within the home. The homes staff recruitment and vetting practices were inspected and found to be satisfactory. Three staff files were examined in this process. There was evidence that all three staff had appropriate police clearances and references. There was also evidence that an application form had been completed by each of the three staff members and therefore details about previous work history and experience was recorded. Proof of identification was also on the files. The Eardley House DS0000028913.V297357.R01.S.doc Version 5.2 Page 21 pre inspection questionnaire completed by the registered manager stated that all 41 members of staff have criminal records bureau (CRB) clearances. Eardley House DS0000028913.V297357.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 36 & 38 Service users live in a home which is well managed and where there are systems in place to protect their health and safety. Consistent supervision arrangements of staff could further enhance care and management practices within this home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The manager is appropriately qualified and experienced to manage the home having gained experience in care and management in both local authority and private older peoples homes. Eardley House DS0000028913.V297357.R01.S.doc Version 5.2 Page 23 The manager demonstrated a commitment to ensuring that the home is run in the best interests of the service users who live at Eardley House. She demonstrated a good understanding of the National Minimum Standards and her responsibilities as outlined within the Care Homes Regulations. The manager has appropriately liaised with CSCI in relation to the running of the home and has ensured that the appropriate authorities are notified of events and/or incidents, which occur within the home. Staff spoken with during the inspection stated that the manager is ‘very approachable’. All the comments received from service users, staff and relatives were positive about the management style within the home. The home has a quality assurance system in place. There was evidence that service users, relatives and other stakeholders are asked to comment on the running of the home. This information now needs to be analysed and used to inform the future planning of the home. It was noted that the previous CSCI inspection report was not easily accessible within the home for relatives or visiting professionals. It is acknowledged that it may not be practical to display the report because of the needs of the service user group living within the home. However, it is recommended that the manager considers how the outcomes from CSCI inspections and their own internal quality assurance systems are shared with prospective service users, their representatives and other interested parties. Five staff were spoken with about supervision. It was noted that whilst all staff had or were due to have supervision there was a lack of consistency in this area which must be addressed. The manager stated that a new system was in the process of being developed to ensure that regular supervision take place. Records were checked to ensure that the health and safety of service users were appropriately protected. The fire records indicated that regular fire drills and testing takes place. Two staff were spoken with about fire training and fire procedures. Both confirmed that they had received fire training and were aware of the fire procedures within the home. A fire risk assessment was in place. Appropriate first aid facilities were available within the home. First aid training is referred to in standard 30 of this report. Staff spoken with stated that they had received training relevant to their roles such as health and safety, infection control and food hygiene. There was proof that the gas and electricity system has been appropriately serviced. A range of risk assessments in respect of safe working practices was available within the home. The home had up to date insurance cover. Eardley House DS0000028913.V297357.R01.S.doc Version 5.2 Page 24 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 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 1 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x 3 x x 2 x 3 Eardley House DS0000028913.V297357.R01.S.doc Version 5.2 Page 25 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 OP2 Regulation 5(1) Requirement The home must provide all service users with a contract/ statement of terms and conditions(Previous timescale 31/10/05 not met) Outstanding fire works as stated in the fire report must be completed. Staff training in NVQ must be improved in line with the guidance set out in the National Minimum Standards. The number of staff trained in first aid must be increased. The manager must ensure that the home is suitably staffed with staff qualified in first aid at all times. All staff must receive vulnerable adults training. A timescale for the completion of the outstanding repair/replacement work to identified windows must be forwarded to the CSCI. All staff must receive regular and DS0000028913.V297357.R01.S.doc Timescale for action 31/08/06 2. OP19 23(4) 31/08/06 3. OP28 18(1)©(i) 31/12/06 4. 5 OP30 OP30 13(4) 13(4)© 31/08/06 30/05/06 6 7 OP18 OP19 18(1)©(i) 23(2)(b) 31/10/06 31/08/06 8 OP36 18(2) 31/08/06 Page 26 Eardley House Version 5.2 frequent supervision. 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. Refer to Standard OP33 OP30 OP33 Good Practice Recommendations Feed back from quality assurance surveys should be analysed and the information should be used to inform any future plans for Eardley House. The manager should consider implementing a whole staff training matrix which identifies gaps in training. The manager should consider ways to share with service users, relatives and stakeholders the information about quality gained from quality assurance surveys and the CSCI inspections. Consideration should be given to using pictures to accompany menus and also to remind service users what the next meal is. The manager should consider better ways to protect service users from cigarette smoke in their home. The manager should carry out a falls analysis. All care plans should include information relating to a service users social history, past interests and hobbies. 4. OP15 5 6 7 OP8 OP8 OP7 Eardley House DS0000028913.V297357.R01.S.doc Version 5.2 Page 27 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. Extracts may not be used or reproduced without the express permission of CSCI Eardley House DS0000028913.V297357.R01.S.doc Version 5.2 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!