CARE HOMES FOR OLDER PEOPLE
Eastbury Manor The Street Compton Guildford, Surrey GU3 1EE Lead Inspector
Janet Daulton Announced 11 May 2005 10:00 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 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. Eastbury Manor H58 s17608 Eastbury Manor v 217699 110505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Eastbury Manor Address The Street Compton Guildford Surrey GU3 1EE 0113 381 6100 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) BUPA Care Homes Limited Srijit Duffadar CRH Care Home 33 Category(ies) of OP Old Age - 33 registration, with number of places Eastbury Manor H58 s17608 Eastbury Manor v 217699 110505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: In respect of up to 5 service users receiving short-term respite or convalescent care the age range may be from 50 years and over. Of the 33 beds in this home, up to 5 beds may be used for short-term respite or short-term convalescent Care. In respect of this service, Service users may be admitted from the age of 60 years. Date of last inspection 20 October 2004 Brief Description of the Service: Eastbury manor is a substantial period detached property that has been adapted to provide accomodation and nursing care for up to thirty three service users. The home is owned by BUPA Care Homes. It is situated in the centre of the small village of Compton, near Guildford, Surrey. The home is arranged on two floors with lift access. 22 of the rooms are for single occupancy, 19 of which have ensuite facilities. There are 2 double rooms with ensuite facilities. Communal facilities include a large lounge, separate dining room,and an activities room. The home is situated in extensive gardens with lawned areas and large lake. Car parking facilities are available within the grounds. Access to public transport is in the village. Eastbury Manor H58 s17608 Eastbury Manor v 217699 110505 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an announced inspection, and the first in the inspection programme for 2005-2006. The inspection took place over 6 hours, and was undertaken by Janet Daulton, lead inspector for the service. She was accompanied for part of the inspection by a student social worker on an observation visit. Mr Srijit Duffadar, the Registered Manager was present throughout the inspection process. A tour of the premises took place. The inspector spoke with eighteen service users during the inspection. The preinspection questionnaire and documentation, four care plans, complaints log, and a sample of safety certificates were examined. Medication records were also examined. This was overall a positive inspection. The inspector wishes to thank the staff and service users for their time, assistance and hospitality during this inspection. What the service does well:
The home provides a good standard of accommodation. The standard of cleanliness was good. Care was provided in a kind and sensitive manner, and individual preferences and wishes were respected. The meals were varied and of good quality. Several service users said how much they looked forward to the mealtimes. Consultation with the service users, through residents’ meetings and residents’ questionnaires, was regularly carried out and the home tried to introduce improvements that the service users had suggested. The feedback from the service users was very positive. They stated that they received good care from the staff, and “nothing was too much trouble.” They stated that they were offered choices in areas such as activities, time for getting up and going to bed, and where to have their meals. Individual preferences were respected wherever possible. For example, one service user only wished to have female carers attending to her for personal care and this was being carried out. The service users also commented that their relatives and friends were welcomed to visit at any reasonable time. There was a relaxed and happy atmosphere within the home. A tour of the premises found the home to be well maintained, clean and bright. The bedrooms had been decorated with the service users own ornaments and pictures to make each room more personal, and the communal areas were well furnished. The care plans gave very detailed information about the needs of the service users and what actions the care staff needed to do to help the service users
Eastbury Manor H58 s17608 Eastbury Manor v 217699 110505 Stage 4.doc Version 1.30 Page 6 There had been no complaints made to the home since the last inspection, and The Commission for Social Care Inspection had not received any complaints about the service. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Eastbury Manor H58 s17608 Eastbury Manor v 217699 110505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Eastbury Manor H58 s17608 Eastbury Manor v 217699 110505 Stage 4.doc Version 1.30 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 standard(s) 3,4,5 The systems in place in the home ensured that all service users were assessed before admission to make certain that the home could meet the needs identified at that assessment. The home reviewed each placement when circumstances changed, to confirm that they were continuing to meet the needs. EVIDENCE: The service user guide stated that pre admission visits were encouraged, and this was confirmed by the service users. The majority of service users were self-funding. The manager or deputy manager completed an assessment prior to admission. These were seen at inspection. Service users were offered a month’s trial stay, following which a review was carried out to ensure that the home could meet the needs. The manager informed the inspector that in one case a trial visit has shown that the service user required a more suitable placement for their specific problems, and this was being actioned. Eastbury Manor H58 s17608 Eastbury Manor v 217699 110505 Stage 4.doc Version 1.30 Page 9 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 standard(s) 7,8,9,10 Care needs identified in the care plans were being met. Care was provided in a dignified, respectful manner. The administration of medication was judged safe. EVIDENCE: Four care plans were randomly selected and the care tracked. All the care plans were detailed, with appropriate risk assessments. Care plans were signed by the service user. All records were kept up to date, and regular reviews of care plans were being made. Weekly visits were made by a local GP, and service users had access to other health professionals, such as the Dentist and chiropodist. The home employed a physiotherapist and reflexologist. There were no service users suffering from pressure sores at the time of the inspection. The home had suitable equipment to prevent pressure sores developing, and for assisting in moving and handling service users. Medication was administered in line with the homes medication policy. The required documentation was in place and all medication records were well maintained. Two service users self medicated, and risk assessments were completed.
Eastbury Manor H58 s17608 Eastbury Manor v 217699 110505 Stage 4.doc Version 1.30 Page 10 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 standard(s) 13,14,15 The service users were enabled to maintain their independence as much as possible. Catering arrangements were good, and service users received varied and nutritious food, which was appropriately served. EVIDENCE: The full time chef oversees the catering arrangements. The choice of food offered was varied and appeared nutritious. A menu was displayed. All service users spoken with were satisfied with the quality of the food served. Visitors were able to call on the service users at any reasonable time. Several of the service users had regular visitors. Local information about events happening in the village were displayed in the entrance area. The service users stated that the home encourages them to be as independent as possible. They retain control over their financial matters as long as they are able, otherwise their families or advocates acts on their behalf. The service users are encouraged to personalise their rooms, and several service users had brought in their own small furniture items. Eastbury Manor H58 s17608 Eastbury Manor v 217699 110505 Stage 4.doc Version 1.30 Page 11 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 standard(s) 16,18 The home has a simple and accessible complaints procedure, which includes timescales for the process. Training for all staff in abuse awareness must be implemented to protect service users. EVIDENCE: The complaints file was examined at inspection. A record was kept of all complaints, with the action taken to address the areas of concern. There had been no complaints logged since the last inspection, and there have been no complaints made to the Commission for Social Care Inspection. Several service users spoken to during the inspection were aware of the complaints procedure, and felt confident about using the process. The complaints procedure was available in the home’s service user guide. From records examined, only 2 members of staff had had abuse awareness training. Eastbury Manor H58 s17608 Eastbury Manor v 217699 110505 Stage 4.doc Version 1.30 Page 12 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 standard(s) 19,25,26 The location and layout of the home was suitable for its stated purpose. The accommodation for the service users was of a satisfactory standard, and comfortable and well maintained. EVIDENCE: The Service users rooms were comfortable and well furnished and decorated. Rooms were normally decorated when vacated, and the maintenance man had a programme of routine upkeep and maintenance. The grounds were well kept, and accessible for service users. Heating and lighting were satisfactory, and radiators were guarded. Water was delivered at a safe temperature, and checks were made regularly by the maintenance man. The premises were clean. One room was identified as having a malodour, and this was discussed with the manager. The carpet shampooer was awaiting repair. Staff were observed to carry out their procedures with good infection control measures, and wore gloves and aprons where appropriate.
Eastbury Manor H58 s17608 Eastbury Manor v 217699 110505 Stage 4.doc Version 1.30 Page 13 Laundry facilities were available, and the washing machines had the specified programming facilities to meet disinfection standards. Eastbury Manor H58 s17608 Eastbury Manor v 217699 110505 Stage 4.doc Version 1.30 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 The number of staff on duty during the inspection was sufficient to meet the needs of the service users. The recruitment procedure in the home did not meet the National Minimum Standard. Training for the staff in specific areas needs further development. EVIDENCE: The staff rota was examined. The staff complement on the day of the inspection included the manager, deputy manager, 2 trained nurses and 4 carers There was always a qualified nurse on duty. There were sufficient ancillary staff on duty, including 2 housekeepers, chef, and laundry assistant. The employment records for four members of staff were examined. There were two references on file for all these staff , however two staff files did not contain Criminal Records Bureau checks. Service users were generally very complimentary about the staff at the home, Interactions observed between staff and service users were seen to be caring and respectful. Training files were examined. The staff training needs further development to ensure that more staff attend the various courses offered. From records seen at inspection, only 4 staff had attended infection control training, 2 staff attended stroke care training, and management of falls only 2 staff attended. Eastbury Manor H58 s17608 Eastbury Manor v 217699 110505 Stage 4.doc Version 1.30 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,38 The home had an effective quality assurance and monitoring system in place that was based on seeking the views of the service users. . EVIDENCE: The home had completed a survey of service users views about the home, and these had been collated into a report. The inspector commends the management for their ongoing efforts in looking for ways to further improve care and services offered to those living in the home. During this inspection a sample of safety certificates were examined, and were found to be in order. The Fire officer had visited on 240105. All recommendations apart from 1 had been actioned. A Fire risk assessment had been completed on 23rd January 2005. Eastbury Manor H58 s17608 Eastbury Manor v 217699 110505 Stage 4.doc Version 1.30 Page 16 From records examined 13 staff had not attended the Moving and handling update last year. Staff were observed to be following appropriate health and safety practices as they went about their work. Policies and procedures were in place to ensure, so far as was reasonably practicable, the health, safety and well being of the service users, however during the tour of the home a bottle of cleaning fluid was found in an unlocked area of the home. Action was taken to remove this during the inspection. Eastbury Manor H58 s17608 Eastbury Manor v 217699 110505 Stage 4.doc Version 1.30 Page 17 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 3 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 x 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 3 x x x x x 3 2 STAFFING Standard No Score 27 3 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x 3 x x x x 2 Eastbury Manor H58 s17608 Eastbury Manor v 217699 110505 Stage 4.doc Version 1.30 Page 18 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. Standard 18 29.3 30.1 Regulation 12(1)(5) 19(4)(c ) 18(1)(a) Requirement All staff must have abuse awareness training All staff must have a criminal records bureau check before being employed. More staff attend the training courses offered to ensure ongoing training and updating of the staff working in the home The 1 outstanding recommendation from the fire officers visit is actioned All staff must have the moving and handling update training Harzardous chemicals must be stored securely The carpet shampooer must be repaired Timescale for action August 31st 2005 July 31st 2005 August 31st 2005 July 31st 2005 August 31st 2005 Immediate. Actioned at time of inspection. May 31st 2005 4. 5. 6. .38.2 38.2 38.3 23(4) 13(5) 13(4)(a) 7. 26.1 21(1)(a) 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.
Eastbury Manor H58 s17608 Eastbury Manor v 217699 110505 Stage 4.doc Version 1.30 Page 19 Refer to Standard Good Practice Recommendations Eastbury Manor H58 s17608 Eastbury Manor v 217699 110505 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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