Inspection on 05/02/07 for Eardley House

This inspection was carried out on 5th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 30/05/06

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 Pam Grace Key Unannounced Inspection 5 February 2007 08:15 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.V329607.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.V329607.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.V329607.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30 May 2006 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. It 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. Current fees range from £328.00 and are reviewed annually. Additional charges are made for newspapers, chiropody, hairdressing, some outings, and personal toiletries. Eardley House DS0000028913.V329607.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection was undertaken by one inspector, over a period of approximately 7.5 hours. The Registered Care Manager Mrs Susan Mountford assisted the inspector throughout the inspection. The inspection had been planned with information gathered from the CSCI database. The key National Minimum Standards for Older People were identified for this inspection and the methods in which the information was gained for this report included case tracking, general observations, document reading, speaking with staff, residents and visiting relatives. A tour of the environment was also undertaken. At the end of the inspection, feedback was given to the care manager, outlining the overall findings of the inspection, and the requirements and recommendations made. Residents and relatives spoken with were very positive about the care they or their relatives were receiving. There were also residents who were unable to communicate, the inspector noted that they appeared well cared for, and were happy in their surroundings. There had been no complaints made to the home, since the last inspection. There were 3 requirements, and 4 recommendations made as a result of this unannounced inspection. What the service does well: The management and staff make the residents’ visitors and relatives welcome, and there are frequent visitors to the home. Health care awareness was evident, with the importance of any changes in health status and mental health, being continually monitored by caring and diligent staff. Eardley House DS0000028913.V329607.R01.S.doc Version 5.2 Page 6 Staff demonstrated great respect for residents, and residents were addressed in an appropriate manner. Discussions with staff were positive, and showed a clear determination that they belong to a committed team. Residents and visitors spoken with were very positive about the care that they and their relatives were receiving. There were also residents who were unable to communicate, the inspector noted that they appeared well cared for, and were happy in their surroundings. The home provides an ongoing programme of activities, The home was clean, warm and comfortable. What has improved since the last inspection? What they could do better: There was a shortfall in relation to residents’ Care Plans. Care plans need to contain a social history of each resident. This is particularly important for residents who have dementia. Staff spoken with confirmed that they had not received dementia care training. The outstanding Fire Compliance/Regulation work, which was identified at the last fire officer’s inspection must be carried out to ensure that service users live in a home that is as safe as it can be. Outstanding repair work identified at the previous inspection must be completed. To ensure that service users live in a home that is safe, and well maintained. It is 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.V329607.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. The summary of this inspection report can be made available in other formats on request. Eardley House DS0000028913.V329607.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.V329607.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives have the information needed to choose a home that will meet their needs. They have their needs assessed and a contract which clearly tells them about the service they will receive. EVIDENCE: A random sample of five individual pre-admission assessments and 5 care plans was examined. These formed part of the case tracking and identified that pre admission assessments are carried out on all individual residents before they are offered a placement at the home. Prospective residents and their relative/representative are provided with information, and given the opportunity to visit and spend time in the home to Eardley House DS0000028913.V329607.R01.S.doc Version 5.2 Page 10 enable them to ask any questions about life in the home. Admission to the home is based upon a full needs assessment, which is undertaken by either the social worker or a member of the management team. The home then confirms in writing to the prospective resident that they can meet their needs. The Statement of Purpose and Service User Guide was available for the inspector to view. These provide information about the home, and are available to the Commission for Social Care Inspection (CSCI), social workers, prospective residents and their families. Contracts and/or Terms and Conditions are held centrally by social services. However, the care manager confirmed that relatives and/or representatives of residents at the home had all received a copy of their contract. The care manager confirmed that Intermediate Care is not provided at this home. Eardley House DS0000028913.V329607.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9, and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care, which a resident receives, is based upon their individual needs. The principles of respect, dignity and privacy are put into practice. Care plans are comprehensive, however, they should include a social history of the resident. EVIDENCE: The inspector examined five residents’ care plans. The same care planning system was used for both permanent and short stay residents. This provides a consistent approach to care planning, which in turn provides care staff with the detail they require to meet the care needs of the service users. However, it is recommended that more information should 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. Eardley House DS0000028913.V329607.R01.S.doc Version 5.2 Page 12 There was evidence that regular care plan reviews take place. This ensures that the care plan reflects the changing needs of residents. Care staff spoken with demonstrated a good understanding of the importance of detailed care planning. Care plans examined showed that the mental and physical health needs of residents are being continually monitored, and any changes in wellbeing are reported and acted upon. Involvement by health professionals was documented and recorded. Few residents were able to comment about how the home meets their individual health needs. This is because many residents at the home have dementia. However all residents appeared well cared for, and happy in their surroundings. Two visiting relatives were spoken with. They spoke very positively about the care and the service that their relatives received. One relative said that he was very reassured by the way in which care staff at the home supported his mother. Another relative said that his wife was very well, and had been well looked after by care staff at the home. The care manager stated that the home has a good working relationship with the local community mental health and pharmacist services. The management within the home appropriately notify the Commission for Social Care Inspection (CSCI) about accidents and falls, which happen within the home. The number of falls in relation to recent notifications received about a specific resident was discussed with the care manager. The inspector viewed a falls risk analysis that the care manager had completed. The care manager confirmed that in all instances, residents who fall have their risk assessment reviewed, and are referred to the GP. The GP then refers on to the community occupational therapist or physiotherapist for assessment. The home now has a no smoking policy in place for staff. However, there is a smoking room provided for residents who smoke. The inspector 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. Staff were aware of this problem, and are monitoring and taking action where appropriate. A spot check was undertaken in regard to the administration of medication. Residents are protected by the home’s policies and procedures for dealing with medicines. Medication is appropriately stored, administered and recorded. The care manager confirmed that all staff administering medication had received the relevant training. Medication was appropriately signed for, and amounts held tallied with records kept. Medication is stored safely in locked metal cabinets in a locked medication room. The care manager confirmed that regular medication reviews take place for all residents where appropriate. The inspector spoke with four care staff. Those staff demonstrated a good understanding of how they ensure residents’ privacy and dignity when assisting Eardley House DS0000028913.V329607.R01.S.doc Version 5.2 Page 13 with personal care. 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. The inspector noted that there were locks on all the bathroom and toilet doors. The inspector observed that interactions between staff and residents were undertaken in a courteous, caring and respectful manner. Eardley House DS0000028913.V329607.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14, and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported in choosing their life style, social activity and keep in contact with family and friends. The quality and choice of meals for residents continue to be satisfactory, however changes should be considered in relation to the introduction and use of pictorial menus, which would enable an informed choice for residents with dementia. EVIDENCE: The care manager confirmed that entertainers, sing a longs, videos, knitting, painting and other indoor activities take place on a regular basis. As the majority of residents 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 some residents, and some forms of entertainment requires the ability for residents to concentrate for a long Eardley House DS0000028913.V329607.R01.S.doc Version 5.2 Page 15 period of time. Care staff will often undertake one to one work with a resident, which may entail a staff member talking with, or completing an activity with, a resident or a small group of residents. The home keeps a record of all activities that take place and which residents have taken part in those activities. The care manager confirmed that she has some additional staffing hours that are allocated to staff specifically to carry out social activities with the service users. There was evidence from talking to residents and visiting relatives that contact is maintained with family and friends on a regular basis. There were no restrictions placed on visiting times, and the home provides a relaxed and friendly environment. Two relatives were spoken with. They spoke very positively about the care and the service that their relatives receive. One relative said that he was very reassured by the way in which care staff at the home supported his mother, and that his mother had put on weight, since being at the home she had been eating properly. Another relative said that his wife was very well, and had been well looked after by care staff at the home. There are regular visits to the home by the local church Minister. At the time of this inspection visitors were seen freely entering and leaving the home. Residents were able to bring in small items of furniture and bedrooms were personalised with residents’ possessions. The care manager confirmed that residents had the opportunity and choice to have their hair done. Residents were able to spend time in their rooms or in the communal areas. The kitchen environment was clean and tidy, with up to date daily records kept in regard to cleaning. Recording of Fridge and freezer temperatures had been appropriately documented and recorded. The quality and variety of food served at the home is of a good standard, and the recently reviewed 4 weekly rotational menus reflected the preferences of residents, as well as the changes in season. Residents spoken with confirmed that they enjoyed the meals at the home, and that they are consulted regarding their preferences. The inspector recommended that the home introduce a pictorial menu, this would enable an informed choice for residents who have dementia. The inspector also discussed the need for the care manager to obtain a copy of the CSCI good practice report entitled Highlight of the Day for kitchen and care staff to use. Eardley House DS0000028913.V329607.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are being appropriately documented and recorded. Residents are protected from abuse. EVIDENCE: There was a clear and accessible complaints and protection of vulnerable adults procedure in place at the home. There had been no complaints received by the home or by the Commission for Social Care Inspection since the previous inspection. The care manager stated that she takes all concerns and complaints seriously and addresses them according to the procedure. Complaints are documented and recorded. Residents and relatives spoken with, confirmed that they would know who to approach should they have any concerns or complaints. Staff spoken with confirmed that they had recently received training in relation to the Protection of Vulnerable Adults (POVA). They were aware of the need to monitor the safety of residents and to protect them from any form of abuse. Eardley House DS0000028913.V329607.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24, 25, and 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables residents to live in a wellmaintained and comfortable environment. However, there are still some shortfalls in relation to Fire Compliance, and the replacement/repair of specific windows in the home. EVIDENCE: A Fire Officer inspection last year identified some structural changes, which need to be made to the internal building. CSCI have met with Stoke on Trent Council and the Fire service. Stoke on Trent agreed to address the outstanding work, and a timescale was set for the end of August 2006. That timescale has not been met. Since the previous inspection, the inspector noted that the home has closed 5 bedrooms. This is reportedly due to their being nonEardley House DS0000028913.V329607.R01.S.doc Version 5.2 Page 18 compliant with Fire Regulations. A further two bedrooms are also closed due to repairs being required to both windows. Totalling 7 bedrooms in all. Eardley House is a clean home. Internally, the building is well maintained by a maintenance person and the domestic staff. The residents’ bedrooms, which were seen, were nicely decorated and comfortable. A number of residents had brought in items of their own furniture, which gave each bedroom an individual feel. Externally there has been a number of windows, which are in need of repair or replacement. Some of those windows have been replaced. However, there are still windows that need replacement/repair, i.e. the two bedrooms that have been closed. The inspector requested that an action plan with timescales for both the Fire Compliance/Regulation work, and the repair/replacement of the windows must be forwarded to CSCI. The Fire Officer will reportedly be inspecting the building again in March 2007. This will continue to be monitored. The laundry room was viewed, and was clean and tidy. There is a system in place to ensure soiled and clean laundry is kept separate to avoid potential cross infection. Appropriate hand washing and protective clothing was available for staff use. Eardley House DS0000028913.V329607.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, skilled and in sufficient numbers to fill the aims of the home and meet the changing needs of residents. The staff team is stable and experienced but specific refresher training in Dementia Care must be undertaken to ensure that staff are skilled to meet the specific needs of people with dementia. EVIDENCE: On the day of the inspection the home was suitably staffed with a registered care manager, 3 assistant managers, four care staff, one cook, two kitchen assistants and two domestics on duty. Care staff spoken with by the inspector had worked at Eardley house for some years. They were therefore experienced and familiar with the systems within the home. All care staff spoken with confirmed that they were receiving appropriate and regular supervision, as per the National Minimum Standards (NMS). The care manager confirmed that three night staff and a sleep-in manager staff the home at night, and that there is one qualified first aid person on duty Eardley House DS0000028913.V329607.R01.S.doc Version 5.2 Page 20 for each shift. Records indicate that the home has a consistent staff team and a low staff turnover. This ensures consistency of care for residents. There were 31 residents residing within the home. The majority of residents were permanent, however some residents were also either having a short stay or were having an assessment of their needs. The staffing rotas were seen and indicated that the home is appropriately staffed at all times. The care manager confirmed that two staff had just completed their NVQ level 2 awards. Two more staff had just commenced NVQ level 3 awards. This brings the total percentage to 40 of care staff having achieved their NVQ awards. The care manager is aware that this is still below the 50 target for 2005 as set out within the National Minimum Standards for older people. The residents spoken with were unable to give feedback about the experience and training of staff because of their dementia. Staff were observed to interact positively with residents. Residents looked well cared for and happy. The atmosphere in the home was relaxed and staff spoken with demonstrated an understanding of the needs of individual residents. The feedback from relatives was positive about the experience and skills of the work force. Four staff members were spoken with about the training they had received to enable them to do their jobs. Staff spoken with confirmed that they had received Moving & Handling, Protection of Vulnerable Adults POVA, and Fire training. However, staff had not received refresher/general training in Dementia Care. It is a requirement of this report that all staff must receive Dementia Care training. This is considered by the inspector to be particularly relevant as many residents at the home have dementia. The cook confirmed that she and the kitchen staff have up to date Food Hygiene certificates, and the care manager confirmed that all assistant managers have now received first aid training. It is recommended that the manager consider implementing a staff training matrix in order to identify and monitor training undertaken, and any gaps in training. The inspector examined 5 staff recruitment files. These were found to be satisfactory. There was evidence that all 5 staff had appropriate police clearances and references. There was also evidence that an application form had been completed by each of those staff members and therefore details about previous work history and experience was recorded. Proof of identification was also on the files. Eardley House DS0000028913.V329607.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,36, and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents live in a home which is well managed and where there are systems in place to protect their health and safety. Care Staff are appropriately supervised. 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.V329607.R01.S.doc Version 5.2 Page 22 The manager demonstrated a commitment to ensuring that the home is run in the best interests of the residents 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 and residents spoken with during the inspection stated that the manager is ‘very approachable’. All the comments received from residents, 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. However, this information needs to be analysed, acted upon, and used to inform the future planning of the home. It was recommended that the care manager considers how the outcomes from CSCI inspections and their own internal quality assurance systems are shared with prospective residents, their representatives and other interested parties. The inspector spoke with 5 care staff about supervision. They all confirmed that they received supervision on a regular basis, as per the National Minimum Standard (NMS). The fire records indicated that regular fire drills and testing takes place. 5 care staff confirmed that they had received recent fire training. A fire risk assessment for the home, and for each individual resident was in place. The care manager confirmed that first aid training was recently undertaken by all assistant managers, this ensures that a first aid person is always on duty over a 24 hour period. 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.V329607.R01.S.doc Version 5.2 Page 23 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 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 X X X X 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X X 3 X 3 Eardley House DS0000028913.V329607.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP19 Regulation 23(4) Requirement Outstanding Fire compliance works as stated in the fire report must be completed. (previous time scale of 31/08/06 not met) A timescale for the completion of the outstanding repair/replacement work to identified windows must be forwarded to the CSCI. ( previous time scale of 31/08/06 not met) The registered person must ensure that the persons employed to work at the care home receive training appropriate to the work they are to perform. This is in relation to Dementia Care training. Timescale for action 30/05/07 2. OP19 23(2)(b) 30/05/07 3. OP30 18(1)(c) (i) 30/05/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000028913.V329607.R01.S.doc Version 5.2 Page 25 Eardley House 1. 2. 3. 4. Standard OP7 OP15 OP30 OP33 All care plans should include information relating to a service users social history, past interests and hobbies. Consideration should be given to using pictures to accompany menus and also to remind service users what the next meal is. The care manager should consider a training matrix to enable monitoring of training and to identify any gaps in training undertaken by staff at the home. Feedback from quality assurance surveys should be analysed and used to inform any future plans for the home. The manager should consider ways of sharing feedback information from quality assurance surveys with residents, relatives and stakeholders. Eardley House DS0000028913.V329607.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Eardley House DS0000028913.V329607.R01.S.doc Version 5.2 Page 27 - 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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