Inspection on 28/02/06 for Eastfield House

This inspection was carried out on 28th February 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 House 13/03/08

Eastfield House 17/08/06

Eastfield House 21/10/05

Eastfield House 08/12/04

Eastfield House 12/08/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Eastfield House Eastfield Lane Whitchurch on Thames Oxfordshire RG8 7EJ Lead Inspector Annette Miller Unannounced Inspection 28th February 2006 13:45 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 Eastfield House DS0000037997.V285283.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 House DS0000037997.V285283.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Eastfield House Address Eastfield Lane Whitchurch on Thames Oxfordshire RG8 7EJ 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) 01189 842586 01189 842179 eastfieldhouse@majesticare.co.uk Eastfield House Limited Mrs Mary Bayliss Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27), Physical disability (2) of places Eastfield House DS0000037997.V285283.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The total number of persons that may be accommodated at any one time must not exceed 27 The PD category refers to one named resident under the age of 65. Date of last inspection 21st October 2005 Brief Description of the Service: Eastfield House is situated in the village of Whitchurch-on-Thames. The home is registered to provide personal care for 27 male and female service users aged 65 years and over. District nurses visit the home to provide nursing care. Communal space comprising two lounges and a separate dining room is located on the ground floor. Bedroom accommodation is situated on the ground and first floors and there are also five flats for independent living in the grounds of the home. Room sizes and amenities are listed in the home’s Statement of Purpose and Service User Guide. A good range of activities is provided and regular trips to places of interest are arranged. The gardens surrounding the home are well maintained and provide extremely pleasant outdoor amenities. Eastfield House DS0000037997.V285283.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out by one inspector from 1.45pm to 6.15pm. A tour of the building took place and documents were examined. A conversation was held with eight residents in the dining room before and after supper, and with three residents in the lounge during the afternoon. Time was spent with a senior carer during an inspection of the home’s medication procedures. The registered manager was on duty and was present throughout the inspection. The inspector was made to feel welcome by all staff and appreciated their co-operation. In order to gain an overview of the standards inspected during 2005/06 it is recommended that the previous report dated 21st October 2005 is read in conjunction with this report. What the service does well: What has improved since the last inspection? All washbasins accessible to residents are now fitted with thermostatic mixing valves to limit the temperature of hot water to 43ºC for residents’ safety. The advice of the fire service has been sought with regard to fitting approved devices that keep bedroom doors open, but release automatically if the home’s fire alarm sounds. Action has been taken to fit these devices where needed. Eastfield House DS0000037997.V285283.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 House DS0000037997.V285283.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 House DS0000037997.V285283.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): 3 Residents’ needs are fully assessed before moving into the home. EVIDENCE: The manager visits prospective residents in their home, or in hospital if that is their current situation, to determine whether or not the home has the facilities and equipment needed to meet the person’s care needs. The outcome of assessment is recorded on pre-admission assessment forms provided by the company. The assessment for a newly admitted resident showed that a thorough assessment was carried out prior to the person’s admission. Eastfield House DS0000037997.V285283.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 and 9 Care plans provide good information about residents’ care needs. Some aspects of medication record keeping need to be improved to ensure safe systems are in place. EVIDENCE: Three care plans were inspected and the staff action that was needed was outlined clearly and comprehensively, and the care given each day to residents was recorded. Residents are involved in planning their care as much as they wish. Care plans are reviewed monthly. Each resident has his/her own medication administration record sheet where a record is kept of the date and time medicines are administered. However, although the overall standard of record keeping was good, the inspector noted that improvements were needed in some areas. Eastfield House DS0000037997.V285283.R01.S.doc Version 5.1 Page 10 On one medication chart a drug dose was different to the dose shown on an information sheet from the pharmacist, and staff had not checked this inconsistency. The inspector asked for this matter to be clarified and it was established that the dose on the chart was correct. Staff should have checked this situation sooner to confirm the dose. Another medication chart showed that a prescribed medicine had not started and the reason for this was unknown by senior staff in the home on the day of inspection. When this situation was checked it was found the medication was out of stock. A member of staff should have checked this sooner to ensure that the resident involved was kept informed of the reason for the delay. Two charts with handwritten medication instructions were not dated and signed. The inspector established that a carer had written the instructions from a doctor’s previous signed record, but had omitted to sign and date the entries. All handwritten entries must be dated and signed at the time they are written and, to avoid risk of errors, checked by a second person. There was a list of the home’s staff authorised to give medicines, together with a record of their approved initials. This is good practice. The staff responsible for administering medication have attended relevant training. Medication storage facilities are good. Eastfield House DS0000037997.V285283.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): 15 The meals are good, offering both choice and variety and catering for special dietary needs. EVIDENCE: Supper was served at 5.00pm in the pleasant dining room and consisted of soup, a selection of sandwiches or a hot snack. There was a cold dessert or fresh fruit to follow, with hot drinks served afterwards. The inspector spoke to residents sitting at two tables (each table seating four people) and everyone made good comments about the food. The food looked appetising and was nicely served. One resident had supper in the lounge at her request. Eastfield House DS0000037997.V285283.R01.S.doc Version 5.1 Page 12 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 and 18 There are systems in place to protect residents from abuse. EVIDENCE: The home’s complaints policy is included in the Service User Guide and a copy is also displayed prominently in reception. No complaints have been received since the last inspection, either by the home or the Commission for Social Care Inspection. The manager and her deputy have attended training on the protection of vulnerable adults from the Oxfordshire adult protection officer, when a copy of the Oxfordshire multi-agency guidelines on the protection of vulnerable adults was obtained. The manager reported that she has since provided in-house training to staff, with further training from an external trainer planned for April 2006. There are policies on the protection of vulnerable adults and these are discussed with staff during induction. The home’s recruitment procedures include checking new staff against the vulnerable adults list held at the Department of Health to ensure prospective employees are suitable for employment at the home. Eastfield House DS0000037997.V285283.R01.S.doc Version 5.1 Page 13 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): 22 The environment is good and the home’s aids and equipment help residents to stay independent for as long as possible. However, the home does not have a lifting hoist and this should be provided to safeguard residents and staff in the event of a resident becoming unable to move independently. EVIDENCE: Aids and equipment to promote independence are provided, such as grab rails in bathrooms and toilets. A lifting hoist is not provided. The manager explained that residents at this home are mobile and able to move position without assistance. Nevertheless, in the event of a resident needing assistance, for example following a fall, a lifting hoist should be available in the home. A call system with an alarm sound is provided. Eastfield House DS0000037997.V285283.R01.S.doc Version 5.1 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 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 and 29 Staff morale is good resulting in an enthusiastic workforce that works positively with residents to improve their day-to-day lives in the home. Some important information was not obtained during staff recruitment, potentially putting residents at risk. EVIDENCE: A senior carer and two carers were on duty during the afternoon and evening, reducing to one carer overnight with another carer on call within the home. The administrator and the activity organiser were on duty until 4.00pm, and the chef until 5.00pm. This number of staff meets the requirements of the home’s staffing notice agreed with CSCI. Three staff files were inspected and some important information had not been obtained. Two members of staff had only one written reference, instead of the two that are required, gaps in employment for two staff had not been checked and one member of staff had not completed a health declaration. It is a requirement that this information is obtained for all staff prior to appointment. Eastfield House DS0000037997.V285283.R01.S.doc Version 5.1 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 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): 35 There are good systems in place to look after residents’ pocket money. EVIDENCE: The home undertakes to look after residents’ money when they can no longer do this themselves, or prefer not to. The pocket money accounts for three residents were checked and procedures for keeping a check on the money received and spent were good. There is a written procedure for managing residents’ money and a copy was made available for the purposes of inspection. Eastfield House DS0000037997.V285283.R01.S.doc Version 5.1 Page 16 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 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X 3 X X X X STAFFING Standard No Score 27 3 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X X Eastfield House DS0000037997.V285283.R01.S.doc Version 5.1 Page 17 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 The manager must ensure that staff sign and date any information they write on medication administration charts. The manager must not employ a person to work at the care home until all the information required by Schedule 2 of the Care Homes Regulations 2001 is obtained. Timescale for action 28/02/06 2 OP29 19(1) 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 OP22 Good Practice Recommendations A lifting hoist should be available within the home at all times. Eastfield House DS0000037997.V285283.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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 House DS0000037997.V285283.R01.S.doc Version 5.1 Page 19 - 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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