Inspection on 04/07/07 for Eastfield Residential Home

This inspection was carried out on 4th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Eastfield Residential Home 05/07/06

Eastfield Residential Home 21/02/06

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Sign Health

Springwood

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

CARE HOME ADULTS 18-65 Eastfield Residential Home Eastfield Residential Home Wawne Road Hull East Yorkshire HU7 5YS Lead Inspector Angela Sizer Key Unannounced Inspection 4th July 2007 09:30 DS0000064775.V345377.R01.S.doc Version 5.2 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 DS0000064775.V345377.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 Adults 18-65. 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. DS0000064775.V345377.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eastfield Residential Home Address Eastfield Residential Home Wawne Road Hull East Yorkshire HU7 5YS 01482 838333 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) Eastfield Residential Home Limited Ms Jane Fenton Care Home 20 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (20), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (20) DS0000064775.V345377.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th July 2006 Brief Description of the Service: Eastfield Residential Home lies to the north of the City of Hull, near to Wawne village. The home is positioned in its own grounds just off the main road on a main bus route leading to the nearby Bransholme shopping centre. Hull city centre is approximately 8 miles away. It is a family run home and the registered provider is also the registered manager. Eastfield Residential home is registered as a care home providing accommodation and personal care for 20 residents who have enduring mental health problems. Recently a new extension has been completed adding a further 6 bedrooms reducing the number of double rooms to three, a small communal lounge, bathroom/shower room and a drinks making area for the residents. In the original part of the building there are three lounges (1designated smoking) and a dining room, an office, kitchen, laundry, toilet and bathroom facilities and the majority of bedrooms. On the first floor there is one bedroom for shared occupancy. This bedroom has an en-suite facility. Access to the first floor is by means of a staircase. All new residents are given a service user guide explaining what the home will provide. The weekly fees range between £295.00 and £327.00, this information was provided by the registered provider during the inspection visit. Additional charges are made for hairdressing, magazines, some toiletries and some transport. DS0000064775.V345377.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit was part of the key inspection process and took place over one day and took a total of 7 hours. Prior to the visit surveys were posted out to 20 of the residents and 12 were returned, 15 to relatives and 9 were returned, 15 were sent to staff members and 2 were returned, of the 6 sent to health care professionals 5 were returned and 7 were sent to care managers and 1was returned. The registered provider returned the Annual Quality Assurance Assessment and this gave some details about the service including the care offered and how needs are assessed and met, staffing, environment and the general management of the home. From this information the decision was made about which staff and resident files would be looked at. A discussion occurred with the manager about the requirements made during the last inspection visit and it was identified that all of them have been met. During the visit several of the residents and two staff members were spoken to this was to find out what it was like for people who live here. A tour of the building was undertaken, some of the records looked at included the 3 resident files, 3 staff files and other paperwork relating to the maintenance of the home and the care of the residents. This was to ensure that the needs of the residents are properly assessed and there are individual plans of care in place for each person. It is also to make sure that the building is run in a safe way. A discussion with the manager occurred regarding diverse needs and in particular how the residents are currently supported to follow their religion of choice and practise their faith. The registered manager was present throughout the inspection and was told how the inspection had gone at the end of the day. The inspector would like to thank the residents, manager and staff for welcoming her into the home and contributing to the content of this report. What the service does well: DS0000064775.V345377.R01.S.doc Version 5.2 Page 6 The home continues to offer a very good standard of accommodation. The environment is clean, hygienic and the atmosphere is friendly and welcoming, which makes Eastfield a very nice place to live. Nine surveys from relatives gave the home excellent reviews and stated how well the home was run, how clean it was and that the staff were excellent. Some comments included, “The staff are pro-active in providing information and advice”, “regularly receive information by phone, letter and on visits to the home”, “the care is very good within the home”, “all of my sister’s needs are met by staff at Eastfield”, “very good support is given, positive approach is used by staff to encourage residents to participate in activities and complete tasks”, “very good for maintaining contact with families”, “I feel the care home looks after my son very well. He seems to be very happy with Jane and the staff who do their best for him at all times”. The ethos of the home is to maintain and promote independence and for the residents to be treated as individuals. Respect and dignity are a high priority for the manager and staff and this was confirmed by speaking to several residents. Residents are supported to carry out activities/hobbies of their choice. From speaking to some of the residents it was clear that they have good relationships with the staff, some comments included; “Good staff”, “I am encouraged to lead an independent life as possible. This includes going by bus alone into Hull City centre”, “I get on well with the manager and staff, I can have a joke with staff”, “I am happy with the establishment, I am settled and have a wide range of friends”. The home’s assessment process ensures that new residents are admitted only on the basis that a full assessment of need has been undertaken by people competent to do so, this ensures that the placement is appropriate. People who use the service do have a care plan and risk assessment and these describe what the needs are, therefore residents’ needs are met in full and risk is managed in a way that would ensure the residents are safe. People who live in the home are supported to live their lives as they wish to with regard to partaking in activities, hobbies and interests. The menu continues to be nutritious, wholesome and the choice offered is good. Some comments from residents included; “the food is good”, “excellent meals”, “we talk about the food at our meetings and I said I didn’t like the fry ups”. People who live in the home receive personal care in a way that they prefer, they receive appropriate health care checks ensuring that healthcare needs are met. The medication procedure is adhered to and this ensures the residents’ receive their medication in a safe way. DS0000064775.V345377.R01.S.doc Version 5.2 Page 7 The home has a very good complaints procedure and from speaking to residents and relatives they are confident in the management when dealing with any issues. The home protects the residents from abuse and has clear procedures in place to deal with this, staff receive training and fully understand the needs of the residents. The manager is competent and has dealt with safeguarding issues in an appropriate way ensuring that the safety of the residents has been maintained at all times. Staff are well trained, experienced and competent therefore ensuring that residents’ needs are fully met and understood. People live in a very well run home, there is clear leadership and an open door policy ensures that residents are able to speak to the manager on a regular basis. The home’s quality assurance system ensures that residents and other people who visit the home have their say about how it is run, what is good and what needs changing. What has improved since the last inspection? The care plans and risk assessments have been updated, risk is clearly defined and these are both informative and give direction to staff. This shows that the home has developed a very good care planning and risk management system that identifies needs and risk and what staff need to do to ensure the needs of all residents are fully met. Supervision is held on a regular basis, this was confirmed by speaking to two staff members and from looking at written evidence. One staff member said, “I had a supervision meeting about 2 weeks ago, the manager asks how I am getting on and we discuss personal issues, training and key worker role”, “I have supervision with Jane every 6 weeks. This shows that people who live in the home receive support from staff who are well supported and supervised on a regular basis. Since the last inspection the manager confirmed that she had achieved NVQ level 4 in both care and management. She has also undertaken other training including fire safety, health and safety, general medicines management and risk management. She has a very good understanding of mental health needs and ensures that the staff have access to appropriate training. Since the last inspection the manager explained that a new induction and foundation training programme has been adopted and this now meets the Skills for Care specification, the manager is a qualified assessor. DS0000064775.V345377.R01.S.doc Version 5.2 Page 8 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. The summary of this inspection report can be made available in other formats on request. DS0000064775.V345377.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000064775.V345377.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2,4 & 5 People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home’s assessment process ensures that new residents are admitted only on the basis that a full assessment of need has been undertaken by people competent to do so, this ensures that the placement is appropriate. Prospective residents are enabled to visit and sample the home prior to moving in on a permanent basis and this ensures that they are making an informed choice whether to live there. People who live in the home receive a contract and statement of terms and conditions that clearly describes what they can expect to receive for their fees and also what is not included in the fee. EVIDENCE: An annual quality assurance assessment was received prior to the visit taking place and this stated that the home carries out an initial assessment with the prospective resident and further develops this after admission. This helps tailor the person’s individual care plan and information is sought from other professionals with the resident’s permission. DS0000064775.V345377.R01.S.doc Version 5.2 Page 11 During this inspection visit a discussion occurred with the manager to ascertain what improvements had been made since the previous visit. The manager stated that the home “insists that a community care assessment is received prior to the resident moving in” and also described a recent situation where the Care Management Team had contacted her about an admission for a 97 year old person, she said; “I recently refused an admission from care management as I didn’t feel we could meet the person’s needs”. In some of the surveys received from Health and Social Care professionals it was confirmed that all residents have a suitable assessment in place prior to the admission-taking place. This shows that the manager assesses each person individually and does not take people who she feels the home cannot meet their needs. There was written evidence in place to confirm that prospective residents visit and an assessment undertaken that would show whether the home can meet that person’s needs. On each of the resident’s file was an assessment both from the Social Services Department and one that the home had developed, these clearly define what support is required. From speaking to the residents it was evident that prior to coming to live in the home they were able to visit, enjoy a meal and meet the other residents and staff. This would ensure that prospective residents are able to make an informed decision about whether they would like to move in or not. Several surveys received from residents, relatives and other professionals confirmed that they were able to visit with their family member before the person was offered a place. Some comments made by residents included; “I could testdrive the home before I moved in, I liked it straight away though”, “I came to look around the home with my brother and I liked it”, “I paid 4 daytime visits to Eastfield and stayed overnight before moving in”. All residents’ files looked at included a contract of statement of terms and conditions, these detailed what services are included in the contract price, what is not included, when the fees are due, room to be occupied, termination or breach of contract. During discussion with the manager about meeting diverse needs it was clear that she had a good awareness of the different needs individuals may have and how these could be met. She gave examples about religion and culture and in particular the dietary needs of residents. It was confirmed from speaking to several residents that their religious, cultural and dietary needs were all being fully met. DS0000064775.V345377.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8 & 9 People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People who use the service do have a care plan and risk assessment and these describe what the needs are, therefore residents’ needs are met in full and risk is managed in a way that would ensure the residents are safe. Overall choice and participation is supported by the home, but one area in relation to bathing has not been fully resolved and therefore residents bathing times may be restricted. EVIDENCE: Prior to the inspection visit the Annual Quality Assurance Assessment was received stating that care plans and risk assessments have been updated giving clearer direction to staff, risk identified and more in-depth. DS0000064775.V345377.R01.S.doc Version 5.2 Page 13 Three residents’ files were looked at and it was confirmed that all of the files contained a care plan that the home had develop and updated since the last inspection. The care plans cover areas such as religion, cultural preferences, mobility and physical needs as well as mental health needs. There is a life history and personal profile relating to each resident, this is very good practice and shows that the residents are treated as individuals and their care plans reflect this too. Each care plan included needs, goal, action required and when reviewed and they were signed by the residents, key worker and manager. Prior to the visit-taking place a number of surveys were received from residents, relatives and other social care and health care professionals. The majority of which stated that the home promoted and enabled independence to be achieved. Some comments included; “The staff are pro-active in providing information and advice” “regularly receive information by phone, letter and on visits to the home”, “all of my sister’s needs are met by staff at Eastfield”, “very good support is given, positive approach is used by staff to encourage residents to participate in activities and complete tasks”, “I am encouraged to lead an independent life as possible”. During this visit several of the residents including those who had made the comments were spoken to and they all confirmed that overall the home enables them to take make choices and participate in the day to day running of the home and also that they are consulted about everyday issues such as the menu and the new smoking guidelines. It would appear that there remains some restriction in relation to bathing outside of the rota. From speaking to the manager it was clear that she thought all of these issues had been previously dealt with, but she did state that, “I will discuss this with the staff team and residents and ensure that they are fully aware that the bathing rota is there as a guide and if the bathrooms or shower rooms are free then they can be used by residents at any time”. Staff were observed interacting with residents and it was clear that good relationships had been developed. Two members of staff were spoken to during the visit about what the residents’ needs were, both staff could clearly describe what support the residents required and also described their role as key worker was to support and maintain independence. Risk assessments have been updated since the last inspection and these cover a broad range of areas including mental health, physical health such as epilepsy or the risk of falling. One looked at during the case tracking identified that a person was extremely vulnerable when going into the community and had been targeted in the past. The risk was clearly identified and symptoms and triggers were also stated giving the reader a good idea of what to look for and how to respond. The action required was detailed and how the risk was to be managed and reduced. From speaking to the resident it was confirmed that they had been consulted about the care plan and risk assessment and were in full agreement to the proposed action plan. This shows that the home has DS0000064775.V345377.R01.S.doc Version 5.2 Page 14 developed a very good care planning and risk management system that identifies needs and risk and what staff need to do to ensure the needs of all residents are fully met. DS0000064775.V345377.R01.S.doc Version 5.2 Page 15 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 & 17 People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People who live in the home are supported to live their lives as they wish to with regard to partaking in activities, hobbies and interests. Residents are able to maintain relationships both inside and outside of the home. One area in relation to bathing has not been fully resolved and therefore residents bathing times may be restricted. The food offered is of a good standard, varied and nutritious and therefore residents receive a healthy diet. DS0000064775.V345377.R01.S.doc Version 5.2 Page 16 EVIDENCE: During the inspection visit some of the residents’ were either spoken to or given the opportunity to talk to the inspector about what it was like for them living in the home, some of the comments included; “I am happy with the establishment, I am settled and have a wide range of friends”, “I go out everyday, I go to a community group on Bransholme”, “I like living here”, “there are some activities in the house, but I go out every day in my car”, “we have regular outings which is nice”. From speaking to two staff members and the manager it was confirmed that activities occur on a regular basis and residents are encouraged to attend community groups or event that would promote their daily life skills and also their independence. The manager stated that “we have had lots of outings over the past year, an outing is planned for 26.7.07 to Bridlington and there is a BBQ for a resident’s birthday next week”, “we discuss activities at the residents’ meetings and ask what people would like to do”. Written evidence was seen confirming that residents’ meetings are held and issues such as activities are talked about on a regular basis. The manager also stated that there is a holiday planned for this year. A caravan has been booked for 1 week at Skirlington, which is near to Hornsea. She said, “several residents will go for the first few days and then come home and then another group will go for the latter part of the week”. When speaking to some of the residents it was evident that they feel consulted with and are able to express their views in relation to activities/holidays and outings. Overall the feedback received from the surveys from residents, family and other professionals stated that the level of activities, community links and groups was of a good standard. One relative commented that the activities offered within the home could be improved and one health care professional said the activities could be offered on a more regular basis. The issue of a bathing rota was discussed with the manager and she confirmed that this is only recorded as a minimum of 2 baths per week, this is to promote the self-care to residents and ensure that they maintain their personal hygiene, the manager stated that “no restriction or limit is placed upon the number of baths/showers a resident may take”. One survey received from a resident and one from a health care professional commented about the bathing rota. As mentioned in the previous section the manager confirmed that there is no restriction in place and she will discuss this with the staff team and residents to ensure that they are aware that residents can bathe or shower when they choose to. Surveys received from residents, relatives and other professionals confirmed that the home supports and maintains family links and friendships both inside and outside of the home. Several of the residents were spoken to during the visit also stating that the staff group support them fully in maintaining relationships/friendships. One person said, “I go to Church every week to see DS0000064775.V345377.R01.S.doc Version 5.2 Page 17 my friends”. Another said, “I go out everyday in my car and sometimes I go out with them all at the community centre”. At lunchtime the meal was observed being served and consisted of pizza and salad or salmon sandwiches. The evening meal planned was chicken salad and new potatoes or chicken chasseur with vegetables and potatoes. The sweet was fruit, yoghurt or sponge with custard. The meal was well presented and the dining room is a pleasant bright and homely room. From speaking to the majority of residents it was evident that they enjoy their mealtimes in the home, some comments included; “the food is good”, “excellent meals”. The menu is on a rotating three-week cycle and it was confirmed when speaking to the residents that this is discussed with them on a regular basis. One person said, “we talk about the food at our meetings and I said I didn’t like the fry ups”. The home offers a lighter lunch and a cooked dinner at tea time, supper is also served, drinks are available at set times on a regular basis throughout the day, in addition the residents’ kitchen is now in place and the majority of residents are able to make their own drinks as they choose. All of the staff who either cook or serve food have undertaken the basic food hygiene training. Residents are encouraged to attend education, community centres and local events, written evidence of this was present in residents’ files, but this was also confirmed when speaking to the residents themselves. DS0000064775.V345377.R01.S.doc Version 5.2 Page 18 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People who live in the home receive personal care in a way that they prefer, they receive appropriate health care checks ensuring that healthcare needs are met. The medication procedure is adhered to and this ensures the residents’ receive their medication in a safe way. EVIDENCE: Prior to the visit-taking place an Annual Quality Assurance Assessment was received and had been completed by the registered manager. This stated that all of the health care needs of residents had been maintained since the last inspection visit. During this visit three of the residents’ files were looked at, written evidence was in place confirming what health care checks have been undertaken with the residents and these included optical, dental, chiropody, psychiatrist and DS0000064775.V345377.R01.S.doc Version 5.2 Page 19 other health care and social care professional involvement. From speaking to the residents it was apparent that they have access to all of the healthcare services they need, one person stated; “I am going to the hospital today to get my treatment”, and another person said they were going to the hospital next week for a regular check up. A general discussion occurred with three residents regarding bathing, bedtimes etc, the residents stated that there are no restrictions upon bathing, but the rota is there to make sure that they receive at least two per week. One person stated, “I think it is a good idea because when I am not well I tend not to bother taking care of myself”. All of the residents spoken to could confirm who their key worker was and that they spent time with them on a regular basis. Some comments included, “high standard of care”, “the staff are friendly and approachable”, “the staff are very hard working, organised, polite, welcoming, smart and friendly. They empathise with people”. Staff spoken to could describe the needs of the residents who they were key worker to and what support was required from them, it was obvious that the staff had developed a good understanding of what the residents needs were and residents were treated with respect and their dignity maintained at all times. During the visit the medication procedure was looked at and the records were in very good order, no gaps or errors in recording were found. The pharmacist had recently undertaken an audit of the procedure and any areas requiring attention have been attended to. Staff who administer have all undertaken joint Health and Social Services training that consists of a workbook modular file and covers safely managing medicines. Two staff members were spoken to about the training confirming that they felt better equipped to administer medication since completing the training course. DS0000064775.V345377.R01.S.doc Version 5.2 Page 20 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People who use the service experience excellent outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home has a complaints procedure that ensures resident’s views are listened to. A well-trained staff group and policies ensure that people who live in the home are protected from harm or abuse. EVIDENCE: The home has not had any complaints since the last inspection. The complaints procedure is clear and residents’ confirmed that if they have any problems they can go to the staff or manager. All of the surveys received stated that the management respond to complaints or concerns in an appropriate manner. Two staff members were spoken to and this confirmed their knowledge about what the Protection of Vulnerable Adults procedure entailed. All staff have undertaken safeguarding adults training and written evidence confirming this was seen. Staff were able to talk about different types of abuse, signs and symptoms and what they would need to do about it. A discussion occurred with the manager about diverse needs and she was able to describe some different needs residents may have and how the home aimed to include all residents. During the visit a resident disclosed some information, this was dealt with by the manager immediately and a safeguarding referral was made DS0000064775.V345377.R01.S.doc Version 5.2 Page 21 to the local Care Management Team. This showed that the home has a knowledgeable and well-trained manager who acted very quickly and in an empathic and understanding way ensuring that all residents were protected. DS0000064775.V345377.R01.S.doc Version 5.2 Page 22 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The standard of the environment is very good and equipment is maintained. The home is clean, hygienic and domestic in style; this ensures that people live in a well-maintained, safe and homely place. EVIDENCE: A tour of the building was undertaken confirming that the previous high standards of cleanliness have been maintained. Overall the standard of the environment is very good, but there is one area that will require attention in the near future and that is the hallway at the rear of the building, although the carpet is cleaned on a regular basis it is worn and stained. There were no offensive smells throughout the building and during the visit the domestic staff were observed to be very hard working and conscientious about their job. The home has a separate laundry room and there are good infection control procedures in place, all staff have received infection control training. During a DS0000064775.V345377.R01.S.doc Version 5.2 Page 23 walk around the building several residents were spoken to confirming that they had everything they needed in their individual rooms, some comments included, “I am happy with my room”, “I like my room”. Surveys returned from relatives indicated that the home was very clean and hygienic and some comments included; “provides a clean, well maintained home”, “ has a good atmosphere whenever you visit”. Surveys from social and health care professionals also commented about the cleanliness of the home, “the home environment is homely, clean and tidy”, “provides a supportive and caring environment for people who experience a wide range of illness and problems”, “I have always found Eastfield to be a very homely and friendly establishment with a good quality of care. It really feels like a “home” and the people I have placed have settled well and their quality of life is good”. DS0000064775.V345377.R01.S.doc Version 5.2 Page 24 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 & 36 People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People who use the service receive support from a well-trained and experienced staff group. The home operates a robust recruitment procedure that ensures residents are supported by appropriately vetted staff. EVIDENCE: During the inspection visit three staff files were looked at confirming that the recruitment procedure is adhered to, all files contained a photograph and identification for the individual, two references and a current Criminal Records Bureau check. Evidence that staff have undertaken training in relation to the mandatory courses including moving and handling, first aid, infection control, protection of vulnerable adults, health and safety and food hygiene. All staff received induction and foundation training that meets the Skills for Care specification. Two staff members were spoken to about their role and responsibilities and they could give clear information about what the people who lived in the home needs were. The home also has a written record/year planner for the courses undertaken. Some comments included; “I have received a lot of training since I started working here”, “it is like my second DS0000064775.V345377.R01.S.doc Version 5.2 Page 25 home the residents are part of our extended family”, “everyone is treated as an individual, and we ensure that the residents have choice eg what time they go to bed, choice of food or if they want to go out”. It was clear from observing staff interact with residents that positive relationships have been developed and staff spoke to residents with respect at all times. All of the surveys returned contained positive comments about the staff; “The staff are very hard working, organised, polite, welcoming, smart and friendly. They empathise with people”, “they do a great job already”, “good staff”, “I have always found them to be excellent”. There was written evidence confirming that 56 of staff have now achieved NVQ level 2, which exceeds the minimum required amount of 50 , it also ensures that residents receive support from a well-trained, knowledgeable and qualified staff group. There are two staff on duty at all times and the majority of the manager’s hours are in addition to the care hours. The home’s current staffing level is appropriate and meets the needs of the people who live there. Supervision is held on a regular basis, this was confirmed by speaking to two staff members and from looking at written evidence. One staff member said, “I had a supervision meeting about 2 weeks ago, the manager asks how I am getting on and we discuss personal issues, training and key worker role”, “I have supervision with Jane every 6 weeks. This shows that people who live in the home receive support from staff who are well supported and supervised on a regular basis. DS0000064775.V345377.R01.S.doc Version 5.2 Page 26 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39 & 42 People who use the service experience excellent outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The management of the home is excellent, compliance is achieved and appropriate guidance is offered; ensuring residents receive a good quality of care and a resident centred ethos is promoted within the home. People live in a very well run home, there is clear leadership and an open door policy ensures that residents are able to speak to the manager on a regular basis. The home has developed a good quality assurance system and residents are involved in this process ensuring that their views are listened to and acted upon. DS0000064775.V345377.R01.S.doc Version 5.2 Page 27 EVIDENCE: Since the last inspection the manager confirmed that she had achieved NVQ level 4 in both care and management. She has also undertaken other training including fire safety, health and safety, general medicines management and risk management. She has a very good understanding of mental health needs and ensures that the staff have access to appropriate training. There is clear leadership and direction given to staff and this means that people live in a home that is well run. Some comments received on surveys from residents, relatives and other professionals included; “The care home manager in particular is very approachable and understanding”, “the manager is diligent in making sure that she has all the relevant information to plan the right care for her residents”. The training records for three staff were looked at confirming that all of the mandatory courses required are either undertaken or a place has been booked, these include health and safety, first aid, infection control, moving and handling, food hygiene and the protection of vulnerable adults. Since the last inspection the manager explained that a new induction and foundation training programme has been adopted and this now meets the Skills for Care specification, the manager is a qualified assessor. The home has developed a quality assurance system, residents are involved in this process and this was confirmed by speaking to them about it. Surveys are sent to various people who either live in the home or visit the home in order to gain their views about the service. During discussion with the manager diversity and equality was discussed, the manager feels that all of the residents’ receive equal treatment and that the home takes seriously their role in enabling residents to become part of the local community. She explained that she is aware that the home will need to offer training in this area and has stated that she will be looking into this over the coming weeks. Some residents have physical difficulties too and staff have undertaken courses in Epilepsy and Dementia to attempt to gain a better understanding of the residents’ needs. The health and safety of the residents is ensured by having all of the appropriate maintenance certificates in place, regular checks on these take place and evidence was seen confirming this. Staff undertake all health and safety courses within the first 6 months of employment ensuring that the staff are knowledgeable and have the necessary skills to deal with emergencies. All accidents and incidents are reported and recorded appropriately; regulation 37 notices are forwarded to the Commission for Social Care Inspection DS0000064775.V345377.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 4 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 2 4 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 4 16 2 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 4 4 3 X X 3 X DS0000064775.V345377.R01.S.doc Version 5.2 Page 29 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. Standard Regulation Requirement Timescale for action 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 YA16 YA7 Good Practice Recommendations People who live in the home should be able to take a bath or shower when they choose to, unless there was a risk management plan that indicated this was a problem. This would ensure that residents are able to make choices about their everyday routines and increase independence. DS0000064775.V345377.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000064775.V345377.R01.S.doc Version 5.2 Page 31 - 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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