Inspection on 02/08/06 for Eastbrook House

This inspection was carried out on 2nd August 2006.

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 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

Eastbrook House 17/11/09

Eastbrook House 08/12/08

Eastbrook House 18/10/05

Eastbrook House 16/05/05

Eastbrook House 15/02/05

Eastbrook House 04/05/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Eastbrook House 16 Eastbrook Avenue London N9 8DA Lead Inspector Peter Illes Key Unannounced Inspection 2nd August 2006 09:45 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 Eastbrook House DS0000010643.V303266.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. Eastbrook House DS0000010643.V303266.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eastbrook House Address 16 Eastbrook Avenue London N9 8DA 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) 020 8805 6632 020 8805 6637 easterbrookhouse@btopenworld.com Mr Roland Jenkins Beacham Mrs Janet Beacham Mr Johnathan Beacham Care Home 43 Category(ies) of Old age, not falling within any other category registration, with number (43) of places Eastbrook House DS0000010643.V303266.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th October 2005 Brief Description of the Service: The home is owned by Mr & Mrs Roland Beacham and managed by their sons Jonathan and Richard, the former being the registered manager. The Beacham family has run Eastbrook House for over twenty years. The home is registered to provide care for forty three older people. The number of double rooms had been decreased so that there is now only one room used as a double room. The communal space includes three lounges and a dining room. There is a passenger lift and the garden is to the rear of the property. The registered manager stated that the current cost of the service is £400 per week. The home displays the latest CSCI inspection report in the entrance hall of the home for the information of all. The registered manager stated that relevant information is shared with all concerned. Eastbrook House is situated in a quiet part of Edmonton at the end of a short residential road. The home is accessible by public transport and within ten minutes walking distance of the local amenities. The home aims to provide a safe and caring environment for service users. Eastbrook House DS0000010643.V303266.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took approximately seven and a hours, the registered manager was present or available throughout. The home continues to voluntarily limit the maximum number of service users to forty at the present time. There were forty service users accommodated and no vacancies at the time of the inspection. The inspection included: discussion with fifteen service users, nine of them independently; independent discussion with four relatives who were visiting the home at the time of the inspection; discussion with five care staff, three of them independently and independent discussion with the two heads of care and the home’s cook. Further information was obtained from a tour of the premises, and a range of documentation kept at the home. What the service does well: What has improved since the last inspection? What they could do better: Six areas for improvement are made at this inspection in the following areas: medication administration training for staff, maintenance to identified equipment in the kitchen, minimising a potential identified risk, refresher training for staff, notifying the Commission of the death of any service user and two areas relating to health and safety. Eastbrook House DS0000010643.V303266.R01.S.doc Version 5.2 Page 6 A good practice recommendation is also made regarding ventilation in the home, especially in hot weather. 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. Eastbrook House DS0000010643.V303266.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Eastbrook House DS0000010643.V303266.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective and existing service users needs are assessed, including by the home, to assist staff meet their needs when they are first admitted. Their needs continue to be monitored once admitted to the home to ensure that their changing needs can also be effectively addressed. EVIDENCE: Five new long term service users had been admitted to the home since the last inspection. The files for two of these were inspected at random along with the files of two other service users who have lived at the home for a longer period. The files of the two more recently admitted service users contained a current community care assessment and care plan from the respective local authorities that had referred them. Evidence was available that these had been available to the home before the date of admission. The registered manager stated that he also visits service users before they are admitted to the home. He went on to say that this was to meet them and, where there is not a local authority assessment of needs to undertake his own assessment. Following the Eastbrook House DS0000010643.V303266.R01.S.doc Version 5.2 Page 9 admission of these two service users there was evidence of an assessment after six weeks by the referring local authorities to review the service users progress at the home. The files of the two service users who had been accommodated at the home for a longer period both contained clear in-house reassessments of needs, one undertaken in January 2006 and the other in February 2006. Both of the files also contained records of regular key worker sessions with evidence that the service user’s needs were kept under review. The home does not provide intermediate care. Eastbrook House DS0000010643.V303266.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Effective systems are in place to record service users needs on their care plans and give guidance to staff on how to meet these needs. Service users are well supported regarding their health care needs with access to a range of healthcare professionals. Satisfactory medication policies and procedures are in place to safeguard service users although action is needed to ensure that staff knowledge and skills in this area are kept up to date. Service users are treated with respect and dignity by staff at the home, which they appreciate. EVIDENCE: The four service users files inspected all contained good quality care plans and a range of risk assessments. There was evidence that the key worker reviewed the plans and risk assessments monthly. The inspector also noted that the two senior care staff separately reviewed the care plans monthly and used this as a basis for both formal and informal supervision discussions with the key Eastbrook House DS0000010643.V303266.R01.S.doc Version 5.2 Page 11 workers. The inspector spoke to the two senior care staff and was informed that they had completed their National Vocational Qualification (NVQ) level 4 in care since the last inspection and were waiting for their certificates. The inspector was also generally impressed with their overview of service users needs and the way that they described the ways that they monitor the care in the home. The two senior care staff formally supervise all the other care staff in the home. All the service users files are in a modular format with sections including a long term assessment of need that is reviewed on a regular basis, short term goals, and risk assessments including moving and handling, nutrition and skin vulnerability. Other sections include health contacts, personal hygiene needs, social activities, periodic key worker reports and daily reports. The recording in the files seen was up to date. Evidence was seen that care plans had been agreed with service users and or relatives as appropriate. During the tour of the premises the inspector briefly spoke to one of the service users who had recently been admitted to the home and whose file had been inspected earlier. The service user was having a cup of tea with a relative and the inspector was pleased to note that the relative was reading the care plan at the time with the service user to ensure it was correct and the relative understood it. At the last inspection a requirement had been made that a risk assessment for a different service user who smoked was linked more clearly to the care plan and reflected restrictions in that service user’s access to smoking materials. The inspector was pleased to see that this had been complied with. The health needs of service users are recorded in the relevant section of their files along with their contact with healthcare professionals. There was evidence seen that service users had contact with relevant healthcare professional including their GP, dentist, hygienist, chiropodist, district nurse and attended hospital appointments as needed. At the last inspection a requirement had been made that the home make all practical efforts for service users to see their GP in person if circumstances regarding their healthcare needs change. This was because records showed that a GP was sometimes prescribing new medication by phone following a discussion with staff rather that visiting in person. A good practice recommendation was also made that the home should request that GP’s provide an annual health check for all service users. The registered manager stated that contact with GP’s had improved and that service users that had been accommodated for over a year had received an annual health care check. Evidence to support this was seen on some service user files inspected. The homes medication policy was seen with a summary displayed on the wall of the room used to keep medication in for staff’s information. The medication and medication administration record (MAR) charts for four service users were inspected and were satisfactory. It was noted that there was a written covert medication agreement in place for one service user that needed their Eastbrook House DS0000010643.V303266.R01.S.doc Version 5.2 Page 12 medication to be crushed. This was consistent with the home’s medication policy and had been signed by the service user’s next of kin, the prescribing GP and one of the senior carers at the home. The home has a satisfactory controlled drugs cupboard and controlled drugs book that was inspected and was up to date. Satisfactory records were also seen of medication entering and leaving the home. At the last inspection a medication tablet had been found on the floor of one of the lounges. A requirement had been made that the home must ensure that all staff that administer medication must observe service users taking it and report any difficulties. The inspector was informed that all staff had been reminded of the need to do this. It was noted that all staff that administer medication had received training in the safe administration of medication. However, it was also noted that some of these staff needed refresher training to ensure their skills and knowledge remain up to date. A requirement is made regarding this. Staff were seen to interact in a relaxed and appropriately friendly way with service users throughout the inspection. This included when staff undertook such tasks as assisting service users to the toilet and also by staff taking a few minutes to just sit and have a chat. Service users and relatives spoken to were generally complimentary about the staff and the way they worked. It was noted that on the front of each service user’s file there was a separate section next to their name for recording their preferred form of address. Service users asked indicated that they were called by the name they preferred. The home’s double occupancy room was seen to have a screen to aid privacy. The inspector observed the registered manager sorting personal mail to be distributed to service users unopened. The registered manager stated that he had agreements with some relatives that identified mail, such as hospital appointments, could be dealt with directly by the home where to do otherwise may cause distress to the service user. Eastbrook House DS0000010643.V303266.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a wide range of social and recreational activities. These take place both in and outside of the home, which meets their needs and preferences. Relatives and other visitors are made welcome at the home, which they and service users appreciate. Service users are encouraged to exercise as much choice and control over their lives as they can to maximise their independence. Service users also enjoy a range of good quality meals that they enjoy although some maintenance work is required in the kitchen. EVIDENCE: A range of activities is offered to service users both inside the home and outside. Recent visits arranged outside the home have included pub lunches, seaside visits including to Southend and visits to local parks and a zoo. Both service users and relatives spoken to confirmed that these visits outside the home happened on a regular basis and were very popular. Activities inside the home include reminiscence sessions, bingo, arts and crafts and exercise classes. The inspector saw examples of artwork displayed in the corridors and communal spaces that had been undertaken by service users. There was an attractive display of painted, cardboard budgerigars in one corridor that the Eastbrook House DS0000010643.V303266.R01.S.doc Version 5.2 Page 14 inspector was told had been the subject of a recent arts and craft session. During the inspection an external teacher was seen undertaking a passive exercise class with service users including the use of passing and gently playing catch with a soft ball. This was happening in one of the lounges when the inspector was in another. Service users told the inspector that a session earlier that day had also taken place for service users in that lounge. Service users confirmed that they enjoyed these sessions. The registered manager stated that one of the staff acted as an activities coordinator. At the time of the inspection the home was accommodating service users whose first language was not English. The inspector was told that the home currently employs an Italian speaking staff member and an Indian speaking staff member that assists communication with two service users who speak those languages. The inspector was also told that the assistance of relatives is sought for those and other service users whose first language is not English. A number of relatives and friends visited service users during the inspection and the inspector spoke independently to five of them. The feedback about the home and the care it provided was generally positive. One relative told the inspector that their service user had lived at the home for three years and that the staff were very caring. They went on to say that the registered manager and the other manager in the home were always approachable. When asked the relative stated that there had been minor things that went wrong such as misplaced clothing after it had been washed but that this was put right when raised with the managers or staff. Three other relatives also felt the care at the home was good but raised some concern about the temperature in the home during the recent very hot weather. A good practice recommendation is made about this in the Environment section of this report. Another relative was spoken to briefly with their service user in the service users bedroom. This service user had recently been admitted to the home and the relative was pleased with the way the admission process had worked and the care received to date. This was the relative mentioned in the Health and Personal Care section of this report who was going through the service user’s care plan with them. The visitors book showed that the home had regular visitors each day. Relatives spoken to all stated that they were made to feel welcome when they visited. Service users or their relatives are encouraged to handle their own personal finances. The registered manager stated that the home was not appointee for any of the service users. The home did hold personal allowances for some service users and the home had satisfactory procedures for safeguarding this money. Arrangements included a separate service user bank account where money for two service users was being held. A recent bank statement for this account was seen with the corresponding records of the two service user’s monies held in it. Service users are able to bring personal possessions into the home and rooms seen during a tour of the building showed bedrooms personalised to varying degrees. One service user is more independent than the others and is able to travel independently outside of the home. This service Eastbrook House DS0000010643.V303266.R01.S.doc Version 5.2 Page 15 user told the inspector that he has a travel pass for public transport and indicated that he is supported by staff to maintain his independence and appreciates this. The home has a recurring five week menu that was seen and showed a variety of meals and a range of alternatives to the main meals specified should service users request these. The cook was spoken to independently and stated that two of the service users were diagnosed with diabetes and that one service user needed a gluten free diet. The cook stated that these and other special diets could be accommodated as required. The lunch on the day of the inspection was chicken, potatoes and vegetables and was seen to be well presented and appropriately served. Service users spoken told the inspector that they enjoyed the meals that the home provided. Satisfactory health and safety records for the kitchen were seen including daily fridge and freezer temperatures and a record of the temperatures of the main meal ingredients when cooked. Food was appropriately stored in sufficient quantities and matched the menu. This included a stock of gluten free bread. The main chest freezers for the home are in a building outside of the kitchen and were satisfactory. In addition there is a smaller combined fridge freezer in the main kitchen. It was noted that on fridge freezer the seal on the bottom of the freezer compartment was hanging off and that there was some rust on the bottom of the door. It was also noted that the laminate on the bottoms of the majority of the main work units in the kitchen were raised leaving bare and untreated chip board exposed. A requirement is made regarding both of these potential health and safety hazards. A requirement had been made at the last inspection that staff’s own food must be stored appropriately and separately from service users food. The inspector was pleased to see that this was being complied with. Eastbrook House DS0000010643.V303266.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their relatives can be confident that any concerns they raise with the home will be both taken seriously and be properly dealt with. Service users are also protected by a clear adult protection policy and procedures with managers and staff being aware of how to implement these if needed. EVIDENCE: The home has a satisfactory complaints procedure with a copy displayed on the notice board in the entrance hall. Service users and relatives spoken to all indicated that staff and managers at the home were approachable and that they felt confident that if they raised issues they would be acted on. One relative told the inspector that she had made a complaint the previous year about remarks a staff member made to her about her service user. The relative went on to say that the home had dealt with this appropriately and that she had no further complaint. The inspector fed this back to the registered manager who explained that on investigation he agreed the complaint had been substantiated and explained the action he had taken to deal with the situation. The registered manager stated that no complaints had been received since the last inspection. The home had a copy of the adult protection procedure for the local authority the home is situated in. The registered manager stated that he had been on a one day training course in adult protection run by the authority for homes Eastbrook House DS0000010643.V303266.R01.S.doc Version 5.2 Page 17 located within its area. He showed the inspector the relevant documentation used by the authority including their “alerter form” that is to be used when contacting the authority to notify them of an allegation or disclosure of abuse. The registered manager was clear about actions that should and should not be taken in such circumstances. Evidence was also seen that the home was running a rolling programme of distance learning training in adult protection for care staff. Staff spoken to confirmed this. The two senior care staff spoken to told the inspector that some staff were not keen on distance learning but were clear about the issues involved regarding adult protection. The registered manager stated that no adult protection issues had been raised with the home since the last inspection. Eastbrook House DS0000010643.V303266.R01.S.doc Version 5.2 Page 18 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a home that generally meets their needs although they and staff would benefit from further consideration being given to maximising ventilation in hot weather. An identified potential hazard in one service user’s bedroom needs dealing with. The home was clean and tidy throughout creating a pleasant environment for service users, staff and visitors. EVIDENCE: The home is situated on three floors with the top floor being newer having been added to the building after it was originally built. On a tour of the building the inspector’s general impression was that although adequately decorated and furnished the bedrooms and some of the communal spaces on the first floor in particular were showing signs of their age and had a more institutional feel than other parts of the building. The registered manager acknowledged the limitations inherent in the design and age of the building. He told the inspector Eastbrook House DS0000010643.V303266.R01.S.doc Version 5.2 Page 19 that consideration was being given to an extension to the ground floor accommodation to include an additional lounge and two bedrooms. The bedrooms seen on all floors were adequately decorated and the registered manager told the inspector that a rolling programme of redecoration and maintenance was in place. Bedrooms seen had been personalised to the extent that service users wished. Built-in radiators in bedrooms were satisfactorily covered to prevent accidental injury although there were two mobile radiators seen in one bedroom. The registered manager stated that the service user’s relatives had supplied these as the service user felt the cold, especially in the winter. Although the radiators were not in use at the time of the inspection a requirement is made that they must be suitably guarded at all times when in use in the bedroom to minimise the risk of accidental injury. A requirement had been made at the last inspection to ensure that the central ventilation system to the home’s bathrooms and toilets was working properly. This had been complied with although staff told the inspector that working in the bathrooms and toilets in the hot weather was still difficult, especially on the ground and first floors. This was because these bathrooms and toilets had no windows and because of the temperatures generated when in use. A relative also independently informed the inspector that they were concerned about the temperature in the communal areas of the home for service users in the hot weather. The registered manager stated that the home had acquired some fans and air coolers for use in the recent hot weather. The inspector does acknowledge that the weather had been exceptional for the weeks preceding this inspection and that there are limitations to the building because of its age and design. However, a good practice recommendation is made to review the ventilation requirements for the communal lounges and internal toilets and bathrooms and to maximise the use of fans and air coolers in hot weather for the benefit of service users and staff. The home was clean and generally tidy throughout the inspection although a requirement is made in the Management and Administration section of this report for the stairwells to be cleared for health and safety reasons. The home’s laundry facilities were inspected and were satisfactory as were the infection control procedures. Eastbrook House DS0000010643.V303266.R01.S.doc Version 5.2 Page 20 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a staff team with sufficient numbers to effectively support the service users accommodated. Service users are protected by staff having access to relevant qualification training. Service users are also protected by the home’s recruitment policy and procedures. Service users benefit from a staff group that have access to a range of training opportunities although further attention is needed to ensure that staff skills in key areas are kept up to date. EVIDENCE: A satisfactory and up to date staffing rota was seen. The rota indicated the following numbers of staff on duty in the home at any one time: seven care staff and a senior working on the early shift, five care staff and senior working in the afternoon up until 6 pm, four staff working from 6 pm until 9 pm with the senior on duty until 7 pm, 3 care staff working between 9 pm and 10 pm and two waking night staff. Domestic staff and a cook are employed in addition to the above. Staff on duty during the inspection matched those recorded on the rota. The registered manager confirmed that the home continues to run a rolling programme of staff training for them to achieve the national vocational qualification (NVQ) level two in care. This was so that the home continues to Eastbrook House DS0000010643.V303266.R01.S.doc Version 5.2 Page 21 employ a minimum of fifty percent of care staff with this qualification. Evidence from staff files sampled and discussion with care staff supported this. The two senior care staff told the inspector that they have now completed their NVQ level 4 in care and are awaiting their certificates. The files of three care staff that had been appointed since the last inspection were inspected. These showed that an appropriate recruitment procedure was being operated with the staff files sampled containing copies of satisfactory proof of identity, satisfactory criminal records bureau (CRB) checks that included a protection of vulnerable adults (POVA) clearance and appropriate references. A requirement had been made at the last inspection that all staff employed had satisfactory enhanced CRB/ POVA checks, the registered manager confirmed that this was being complied with and evidence from the staff files inspected confirmed this. At the last inspection a requirement was made regarding the qualification of the person who was then providing parctical moving and handling training for care staff. This requirement had been complied with although the registered manager stated that the home was now using the training resources from a neighbouring local authority to provide staff training in moving and handling. Staff spoken to independently confirmed this. The inspector was given a copy of a staff training matrix that showed all staff employed, the training that they had undertaken and when refresher training was due. This showed that the home remained committed to staff training including using distance learning where appropriate. It was noted however that some staff were overdue for refresher training in fire safety, health and safety and infection control. A requirement is made that all staff undertake refresher training in all core areas including the above. Eastbrook House DS0000010643.V303266.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, 35, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from the home being run by a competent manager. Service users and other stakeholders views are actively sought to assist develop further the quality of care the home offers although the home needs to ensure that the Commission is kept informed of all significant events. Service users are protected by effective procedures to safeguard their financial interests. Staff receive regular supervision to assist them meet service users needs and to assist their own development. The home has effective health and safety procedures in place to protect service users and others that work or visit the home although further attention is needed to identified areas to maximise this protection. EVIDENCE: The registered manager presents as being competent, experienced and has passed his registered managers award. A second manager who was not on duty on the day of the inspection shares the management responsibility for the Eastbrook House DS0000010643.V303266.R01.S.doc Version 5.2 Page 23 home with the registered manager. All the requirements from the last inspection had been complied with. Service users, relatives and staff were complimentary about the overall management of the home and the care that it provides. The home completes an annual service user satisfaction survey and individual responses were sampled. The registered manager stated that these were analysed and any particular themes addressed as appropriate. He gave an example of comments made regarding further improving the meals in the home. He went on to say that these were discussed with the cook in supervision and improvements agreed through this process. The home also has a satisfactory business plan for 2006/ 07 that was seen. This outlined a range of targets for further improvements for the home including further feasibility work on the proposed extension to the ground floor accommodation. The home notifies the CSCI of significant events but it was noted that the home had not notified the Commission since the last inspection when service users died of natural causes. Once this was clarified with the registered manager he filled out notification forms and gave them to the inspector at the time. The home does not act as an appointee for any of the service users. The home has a resident’s bank account that currently holds money for two service users. A recent bank statement and satisfactory related records for the two service users were seen. The home holds the personal allowances for those service users that are unable to do so themselves. Records and related individual cash purses were sampled and were satisfactory. The home has a satisfactory staff supervision procedure. The two senior care staff formally supervise the other care staff every two months. A supervision matrix was seen to evidence this along with supervision records sampled. These showed clear records of issues discussed and had been signed by supervisor and supervisee. Care staff spoken to independently confirmed the above and that they found the process useful. The two senior care staff are supervised by one of the two managers and indicated to the inspector that they felt comfortable in raising issues in their supervision. The registered manager stated that he also supervised the cook. A range of satisfactory health and safety documentation was seen. This included an electrical installation, servicing of the home’s lift and hoists, waste disposal contract and records of regular hot water temperature checks. The home’s gas safety certificate, portable appliance testing certificate and annual test regarding minimising the risk of legionella had just expired and all need renewing. A requirement is made regarding this. Evidence was seen that fire-fighting equipment has been serviced in the last twelve months, the home’s fire risk assessment had been reviewed in the past twelve months and that fire drills were taking place. However, it was noted that a fire door was propped open at the entrance to one of the ground floor Eastbrook House DS0000010643.V303266.R01.S.doc Version 5.2 Page 24 lounges, there were wheelchairs and other equipment stored under both the home’s stairwells and there was a gap in a pair of fire doors on a first floor corridor. A requirement is made that no fire doors must be held open when not in use unless by a device approved by the fire officer, that the stairwells must be kept clear at all times and that a person competent to do so examines all the home’s fire doors to ensure that they are properly fitted and minimise the spread of smoke in the event of the fire. The home is also required to consult with the fire officer for advice on approved door closures and for guidance regarding smoke seals on all of the fire doors. Eastbrook House DS0000010643.V303266.R01.S.doc Version 5.2 Page 25 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 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 3 X 2 X 3 3 X 2 Eastbrook House DS0000010643.V303266.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13(2) Requirement Timescale for action 30/09/06 2 OP15 13(4) 3 OP19 13(4) 3 OP30 18(1) The registered persons must ensure that all staff that administer medication have regular updated training regarding this to keep their skills and knowledge up to date. The registered persons must 15/09/06 ensure that the faulty seal on the bottom of the fridge/ freezer in the kitchen that is a potential health and safety hazard is replaced and that the doors that are damaged on the main work units in the kitchen and are a potential health and safety hazard are also repaired or replaced. The registered persons must 15/09/06 ensure that two mobile heaters in an identified service user’s bedroom are suitably guarded at all times when in use in the room to minimise the risk of accidental injury. The registered persons must 30/09/06 ensure that all staff receive regular and updated training in fire safety, health and safety and infection control to keep their skills and knowledge up to date. DS0000010643.V303266.R01.S.doc Version 5.2 Eastbrook House Page 27 4 OP33 37(1) 5 OP38 13(4) 6 OP38 23(4) The registered persons must 15/09/06 ensure that the CSCI is notified of the death of any service user no matter what the circumstances of that death. The registered persons must 15/09/06 ensure that the home has a current gas safety certificate, portable appliance test certificate and evidence of an annual check to the home’s water supply system relating to minimising the risk of legionella. The registered persons must 15/09/06 ensure that; no fire doors are held open when not in use unless by a device approved by the fire officer, that the stairwells are kept clear at all times and that a person competent to do so examines all the home’s fire doors to ensure that they are properly fitted and minimise the spread of smoke in the event of a fire. The home is also required to consult with the fire officer for advice on approved door closures and for guidance regarding smoke seals on all of the fire doors. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP19 Good Practice Recommendations The registered persons should review the ventilation requirements for both the communal lounges and the internal toilets and bathrooms and to maximise the use of fans and air coolers in hot weather for the benefit of service users and staff. Eastbrook House DS0000010643.V303266.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Eastbrook House DS0000010643.V303266.R01.S.doc Version 5.2 Page 29 - 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. 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