Inspection on 11/01/06 for Eastfield Care Home

This inspection was carried out on 11th January 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Eastfield Care Home 28/07/08

Eastfield Care Home 14/03/07

Eastfield Care Home 08/03/06

Similar services:

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Snydale Care Home

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

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

CARE HOMES FOR OLDER PEOPLE Eastfield Care Home Moss Road Askern Doncaster DN6 OJZ Lead Inspector Janet McBride Unannounced Inspection 11th January 2006 10:00 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 Eastfield Care Home DS0000065778.V274866.R01.S.doc Version 5.1 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. Eastfield Care Home DS0000065778.V274866.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Eastfield Care Home Address Moss Road Askern Doncaster DN6 OJZ 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) 01302 700810 01302 707009 Ashbourne (Eton) Limited Mrs Alison Nicholls Care Home 59 Category(ies) of Dementia (25), Old age, not falling within any registration, with number other category (34), Physical disability over 65 of places years of age (34) Eastfield Care Home DS0000065778.V274866.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service may admit four persons 60 years of age and over. Date of last inspection Brief Description of the Service: Eastfield Care Home provides Nursing and Residential care to older people, the home is registered for 59 beds, 34 beds offer nursing and residential care this includes 4 beds to accommodate people aged 60 years, also separate unit with 25 beds offering residential EMI care. The home is situated in the village of Askern and is within walking distance of shops, churches and other community facilities. All the homes bedrooms are single and three new bedrooms have ensuite facility. Eastfield Care Home DS0000065778.V274866.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Since the last Inspection Ashbourne (Eaton) Ltd applied to the Commission for Social Care Inspection to register as proprietor of Eastfield Care Home which is an existing care home providing a service for 59 service users. One Inspector from the Commission for Social Care Inspection carried out this unannounced inspection at Eastfield Care Home, on the 11th of January 2006, commencing at 10:00 and finished at 17:15 During the Inspection we looked at a number of standards, a chosen number of documents, sampling of records, tour of the premises and direct and indirect observation of staff interaction with residents, this Inspection also included individual and group discussions with staff, residents, and comments from visitors on the day. Any issues or concerns that were raised were discussed with the Manager during and at the end of the Inspection. What the service does well: What has improved since the last inspection? The manager has addressed all the requirements that are within her control made in the last inspection report. The home has exceeded in providing care staff with NVQ qualifications. Eastfield Care Home DS0000065778.V274866.R01.S.doc Version 5.1 Page 6 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. Eastfield Care Home DS0000065778.V274866.R01.S.doc Version 5.1 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 Eastfield Care Home DS0000065778.V274866.R01.S.doc Version 5.1 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): 3456 All residents are fully assessed prior to being admitted to the home, this ensures that the home will meet their individual care needs. EVIDENCE: Evidence was seen that prospective residents that are referred via social services or privately funded had a completed assessment prior to admission, to ensure that resident’s needs and objectives for the placement can be met. Various risk assessments, dependent on their needs including residents who smoke are risk assessed prior to using the smoke room alone. Discussed with the manager what happens if residents and families want to come to the home to have a look around, she stated that she and her staff encourage families to visit and look around the home, they are invited to stay at the home on a trial basis before their decision to stay permanently. Eastfield Care Home DS0000065778.V274866.R01.S.doc Version 5.1 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 the following standard(s): 7 8 9 10 The care planning systems are sufficiently detailed to enable staff to deliver care; this ensures residents health care needs are fully met, including arrangements for dealing with resident’s health issues are adequately met by staff at the home, with support from health professionals. EVIDENCE: The home as two units one unit offers residential and nursing care, the other unit is for EMI residential. Care plans were examined and two care plans were case tracked, these were cross-referenced with medication and accident records. The resident’s health, personal and social care needs are set out in an individual plan of care, baseline assessments on admission and risk assessment dependant on the individual needs. Records show that residents have access to health care services including chiropodist, optician and dental services, with some residents being referred to specialist services including tissue viability and continence advisors. Eastfield Care Home DS0000065778.V274866.R01.S.doc Version 5.1 Page 10 Medicines in the custody of the home are handled according to the requirements of the Medicines Act; random MAR sheets were examined and found satisfactory. Storage and receipt of drugs was satisfactory, with the exception of some medicines not having a date when opened. Both units within the home are using a domestic fridge for the storage of medicines, when the temperature was checked it was higher than the normal range, this requires addressing as it may have an impact on prescribed medicines. The home must have a separate fridge exclusively for the storing of medicines, ensuring that the temperature is checked on a daily basis and record kept. Controlled drugs were checked and evidence was seen that they are administered correctly with the required records kept. During the day staff were observed directly and indirectly, conversing with residents, and attending to care needs it was noted that they explained to the residents any tasks they were going to carry out. Staff spoken to on the day were well informed of residents likes and dislikes aware of those residents who are able to make choices and those who needed either prompting or help with tasks. Eastfield Care Home DS0000065778.V274866.R01.S.doc Version 5.1 Page 11 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 The home ensures that dietary needs of residents are well catered for with a balanced and varied selection of food available. Social activities are organised to provide stimulation and interest for those residents living in the home and wishing to take part. EVIDENCE: The home has two activities coordinators in post one works 18 hours and the other person works 12 hours this is for both units. On the day of Inspection no activities were taking place as one activity coordinator was off sick and the other person works does some administrative hours within the home. A varied activity within the home for example, quizzes, sing-along and bingo. Religious needs are catered for; residents can visit church or chapel every Sunday. Relatives were in and out of the home most of the day, some were spoken too they confirmed, they can visit at any reasonable time, and were happy with the care and the home. Eastfield Care Home DS0000065778.V274866.R01.S.doc Version 5.1 Page 12 It can be difficult to provide choice and independence in the lives of residents who require ongoing supervision especially on the EMI unit; therefore discussion with both the manager and staff and observation during the visit. Those staff spoken to stated they encourage choice and independence, and this was evident when observing care staff interaction with residents. Some changes to catering facilities within the home since Ashbourne became the registered provider, but this, as had no impact one residents. Most residents have a nutritional assessment when first admitted this is monitored on a regular basis, ensuring that resident’s weights are also monitored. Lunchtime was observed on the nursing unit, food looked well presented, with tables having place mats and condiments were available if required. Menus are over an eight-week period, and residents stated that the food was good with plenty of choice being available. Eastfield Care Home DS0000065778.V274866.R01.S.doc Version 5.1 Page 13 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 Residents and relatives are provided with information to enable them to raise concerns or complaints about the home and their care. Staff had knowledge and understanding of adult protection issues, which promotes protection of residents from abuse. EVIDENCE: The complaints procedure was discussed with the registered manager and records checked, which provided evidence that the home has a clear and accessible complaints procedure, which includes the stages and time-scales for the process records show that any complaint received are dealt with promptly and effectively, it also makes reference to the CSCI if the complaints are not happy with the investigation or outcome. The home has policies and procedure to ensure the protection of vulnerable adults and whistle blowing. Discussion with staff seen on the day, which confirmed they were aware of these policies and procedures and would use them if necessary. Other procedures in place ensure that staff have CRB and POVA checks completed before commencing employment. Eastfield Care Home DS0000065778.V274866.R01.S.doc Version 5.1 Page 14 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): Not assessed at this Inspection. EVIDENCE: Eastfield Care Home DS0000065778.V274866.R01.S.doc Version 5.1 Page 15 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 Sufficient staff numbers ensure that the home meets the care needs of the residents, and robust recruitment procedures offers protection for those residents that live in the home. EVIDENCE: Staffing and skill mix was discussed with the manager, who could produce an duty rota showing which staff are on duty at all times. The manager is totally supernummary, but her deputy is on long-term sickness and nurses at the home are covering her shifts. The home has a very stable staff group and employs nurses, care staff, activity staff, administrator, maintenance domestic and laundry staff in sufficient numbers. The ratios of nurses and care staff to residents is calculated according to residents assessed needs, and additional staff are on duty at peak times for example on the EMI unit staff have assessed that residents needs are more dependent in the afternoons. Staff can access NVQ training and have two NVQ assessors within the home. The home has exceeded the 50 ratio as they have 61 of care staff that has completed NVQ level 2 or 3,and further staff is committed to complete NVQ training. Eastfield Care Home DS0000065778.V274866.R01.S.doc Version 5.1 Page 16 Recruitment files were checked and evidence was seen that the manager operates a thorough recruitment procedures based on equal opportunities and ensures that all staff is CRB checked for the protection of residents within the home. Pin numbers of all nurses are checked and confirmed with the NMC and documented. Eastfield Care Home DS0000065778.V274866.R01.S.doc Version 5.1 Page 17 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 The manager provides leadership; guidance and direction to staff this ensures the home is well managed and that residents within the home receive consistent quality care. These practices promote and safeguard the health, safety and welfare of residents within the home. EVIDENCE: The registered manager has been at the home a number of years, she his a registered nurse and holds an NVQ level 5 in management. Very experienced manager, aware of her responsibilities and aims to run the home in the best interest of the residents in her charge, and provides leadership, guidance and direction to staff within the home. Staff spoken to confirmed that the manager his very approachable and supportive. Eastfield Care Home DS0000065778.V274866.R01.S.doc Version 5.1 Page 18 The manager completes various monthly audits, e.g medication; pressure sore, accident and care plan audits all these were available to examine. Feedback from relatives and residents surveys is due to be sent out before the 1st march 2006. Residents finances were discussed with the homes administrator and records checked. All residents money is kept in a Halifax umbrella account, any pocket money left over is kept in individual wallets, four of these were checked and found correct. The home had written records of all transactions that have taken place. Secure facilities is provided and evidence seen that the home keep a record of any valuables that they have been given for safekeeping. Supervision was discussion with the manager, who stated that staff receiving supervision but since her deputy as been on long term sick this as created a problem and not all have received this on a regular basis, however all staff has received their yearly appraisals. Some staff interviewed confirmed that they receive supervision but not on a regular basis. Heath and safety was discussed with the manager, staff and records checked. The registered manager ensures so far as is reasonably practicable the health, safety and welfare of residents and staff. It was evident from the number of records that were examined and observation of staff; that the home implement all policies and procedures to ensure the safety of residents. Eastfield Care Home DS0000065778.V274866.R01.S.doc Version 5.1 Page 19 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 3 3 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 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 3 28 4 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Eastfield Care Home DS0000065778.V274866.R01.S.doc Version 5.1 Page 20 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 OP9 Regulation 13(2) Requirement Medicines in the custody of the home must be handled according to the requirements of the Medicines Act; The home must have a separate fridge exclusively for the storing of medicines. Staff must ensure that Medicines have dates when opened. All staff must have supervision on a regular basis. Timescale for action 28/02/06 2 3 OP9 OP36 13(2) 18(2) 01/02/06 28/02/06 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 OP12 Good Practice Recommendations Look at developing the activities role with an increase in hours. Eastfield Care Home DS0000065778.V274866.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ 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 Eastfield Care Home DS0000065778.V274866.R01.S.doc Version 5.1 Page 22 - 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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