Inspection on 31/12/05 for Eastham

This inspection was carried out on 31st December 2005.

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

Eastham 08/08/07

Eastham 13/09/06

Eastham 29/06/05

Eastham 12/01/05

Eastham 19/01/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Eastham Main Road Woodham Ferrers Chelmsford Essex CM3 8RF Lead Inspector Kay Mehrtens Final Unannounced Inspection 12th January 2006 12.00 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 Eastham DS0000028664.V278015.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. Eastham DS0000028664.V278015.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Eastham Address Main Road Woodham Ferrers Chelmsford Essex CM3 8RF 01245 320240 01245 427243 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) Runwood Homes Plc Manager post vacant Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Eastham DS0000028664.V278015.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 25 persons) 29th June 2005 Date of last inspection Brief Description of the Service: Eastham is a detached period property situated in the rural village of Woodham Ferrers, approximately two miles from the town of South Woodham Ferrers with all its main amenities. This home cares for a total of 25 older people with a range of dependency levels from semi-independent to high dependency. The aim of the home is to provide a homely environment where service users are supported and encouraged to exercise their rights by suitably trained staff. The home has been adapted to meet the needs of older people that include the provision of ramps for easy access and a full passenger lift. Bedroom accommodation is on the ground, first and second floors and consists of nineteen single and three shared rooms. The house is set in well-maintained gardens with views over open countryside and has adequate parking facilities at the front. Eastham DS0000028664.V278015.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 that took place on the 12th January 2006. This was the second statutory inspection of the year and focussed on the remaining key standards not inspected at the last inspection, as well as a review of the requirements and recommendations from the last inspection. The inspection process included: discussions with the homes’ acting manager, the providers’ operations manager, care staff, residents, visiting relatives and a district nurse. Information was also provided by the manager, at the request of the Commission, as part of the inspection process. The premises were inspected, including the grounds. Samples of records and residents care plans were inspected. The inspection covered eight standards. One additional requirement was made to those not addressed from the last inspection. The home was clean and well maintained. The manager and staff were very cooperative throughout the inspection. What the service does well: What has improved since the last inspection? Many areas of the home had been redecorated and the home looked much better. The residents and their relatives were pleased with the improvements. Other repairs, stated in the last inspection, with regard to windows and the patio area had been addressed. Staff training with regard to manual handling has been done and the need for refresher training monitored by the manager. Eastham DS0000028664.V278015.R01.S.doc Version 5.1 Page 6 Staff training has improved and the commitment to National Vocational Qualification training is good. 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. Eastham DS0000028664.V278015.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 Eastham DS0000028664.V278015.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): EVIDENCE: These standards were not inspected at this inspection. Eastham DS0000028664.V278015.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): 8 The health care needs of residents were well met. EVIDENCE: The inspector had the opportunity to meet a visiting district nurse. They spoke positively regarding the care provided by the staff at the home. They informed the inspector that they were pleased with the homes approach to seeking advice and training in areas such as diabetes care and incontinence care. The residents have access to four different doctors surgeries. The manager informed the inspector that the home receives a weekly visit from a local practice nurse to review residents’ medication with them and then refers back to the doctor for additional input. This is a positive and proactive approach between the home and one of the local surgeries. There was evidence of positive feedback from a visiting chiropodists impressed with the organisation surrounding their visits. The inspector was also shown a complimentary letter, from a relative, regarding the good health care input and response from the staff at the home for their relative. Eastham DS0000028664.V278015.R01.S.doc Version 5.1 Page 10 The care files for residents were examined. The files contained detailed information regarding the specialist health care needs of the residents. There was good information regarding manual handling and pressure care. The records were well-organised and contained relevant information to assist visiting health specialists. Care plans were reviewed to reflect changes in residents’ health requirements. Appropriate nutritional and monitoring charts were in place and maintained. Additional information, advice and training had been sought to meet the health needs of residents. The residents told the inspector that they were pleased with the health care provided. They felt that the staff contacted appropriate health professional when needed. Several relatives spoken to during the inspection supported this. They felt that staff listened to their relatives concerns and worries about their health and responded appropriately. One resident and their relative told the inspector that their health and mobility had improved since moving into the home. Eastham DS0000028664.V278015.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): EVIDENCE: These standards were not inspected at this inspection. Eastham DS0000028664.V278015.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): 18 Staff training was not sufficient to ensure the protection of residents. EVIDENCE: The home has relevant policies and procedures with regard to Protection of Vulnerable Adults. There was relevant and accessible information for staff with regard to the local Protection of Vulnerable Adults referral process. The staff training records showed that three new members of care staff required Protection of Vulnerable Adults training. The manager was also aware that the catering and domestic staff had not done any Protection of Vulnerable Adults training and this needs to be addressed. Eastham DS0000028664.V278015.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): 19 The home is well maintained but the safety of residents is not ensured. EVIDENCE: There had been several improvements to the décor and maintenance of the home since the last inspection. Several bedrooms and communal areas had been redecorated; sash windows had been repaired, the courtyard patio had a new ramp, brick paving and secure fencing. The home looked much brighter and cosier for residents and their visitors. The provider has been advised, following previous inspections, of the need to repair or replace the driveway gate to ensure the safety of residents, particularly as the home does accommodate some residents that get very confused. Since the last inspection the broken gate has been removed and not replaced. This is a cause of concern to the Commission as the residents’ safety is still at risk. Eastham DS0000028664.V278015.R01.S.doc Version 5.1 Page 14 The provider’s response to these concerns has been to state that residents will not go into the front garden without staff. This is not an acceptable alternative as it infringes the rights of residents and staffing levels would need to increase to ensure that the residents in the home and the garden have sufficient staff to meet their needs and ensure their safety. The providers’ response and the current situation do not meet standard 19.3, which states “grounds are kept tidy, safe, attractive and accessible to service uses, and allow access to sunlight.” The patio area is much improved but it is not big enough to accommodate the number of residents accommodated and the staff to support them. The inspector noted a comment from care staff, on a complaint record, concerning a complaint that the front door was to be kept shut whilst residents were sat in the porch. The carer recorded that they explained to the complainant that having the door open “would put the more vulnerable residents at risk if they wandered out of the home unescorted”. This record of evidence supports the commissions concerns about the risk to residents and the infringement and limitations on their rights. Eastham DS0000028664.V278015.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): 29 and 30 Staff recruitment practices are sufficient to ensure residents’ protection. Staff have a positive attitude towards the care of residents and the training provided. EVIDENCE: The staff recruitment records were well organised and all required checks and paperwork had been undertaken by the manager, prior to any staff starting employment at the home. The manager has ensured that shortfalls, from the last inspection, with regard to checking staff employment histories have been addressed. The staff files sampled contained copies of relevant qualifications and training courses attended by the staff, for example manual handling, health and safety and food hygiene. The staff sat and chatted with residents at different times during the inspection and whenever they were in their company they were friendly and polite. They showed a good understanding of their care and personal needs. Residents and visitors spoke very highly of the manager and staff at the home. The inspector had the opportunity to speak to several residents and visitors during the inspection. Their comments were positive and reflected the good practice observed. Some residents told the inspector that the “staff are polite, supportive and good”. Eastham DS0000028664.V278015.R01.S.doc Version 5.1 Page 16 Relatives were also very complementary about the manager and staff. One relative told the inspector that, “their relative had improved since coming here… it is a lovely home and environment… the staff are so kind and caring”. Shortfalls with regard to the need for Protection of Vulnerable Adults training have been stated under standard 18 of this report. A sample of staff files showed that an induction process had been done with new staff. The inspector advised the manager to investigate the induction training being developed by the “Skills for Care” organisation. The manager had produced a training record that easily identified the training needs of care staff. Supervision sessions are used to discuss training requirements of individual staff. The training records showed that training in dementia care, fire awareness, first aid and manual handling had taken place. Care staff spoken to verified the training opportunities provided. They were positive about the support provided by the manager and senior staff. The number of staff with National Vocational Qualification level 2 has increased since the last inspection. The information provided by the manager states that 32 of staff has this award. Eastham DS0000028664.V278015.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): 37 and 38 Records were generally well maintained. Practices and procedures ensure that the health and safety of residents are generally well protected. EVIDENCE: The inspector did observe that the home was accommodating a resident whose health needs were outside of their registration, that of dementia care. The inspector advised the manager to discuss this with the provider for consideration of an application for variation. The records inspected, as part of the inspection, were well maintained. The manager had ensured that a record of residents’ furniture was now in place. The staff rota was correctly maintained and staff records were well organised. Eastham DS0000028664.V278015.R01.S.doc Version 5.1 Page 18 Health and safety records were well organised. The required checks with regard to electrics, hoists, lift and water temperatures are maintained and monitored. Staff training with regard to manual handling, food hygiene and infection control was recorded and monitored for refresher training. The home had recently had an infection control audit from the Essex Health Protection team. The manager informed the inspector that she is working, with her staff team, to address the areas highlighted as part of the action plan following the audit. Eastham DS0000028664.V278015.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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 1 X X X X X X X STAFFING Standard No Score 27 X 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X 2 X X 3 3 Eastham DS0000028664.V278015.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 OP19 Regulation 23 Requirement Timescale for action 06/03/06 2 OP18 18 3 OP34 25 The registered provider must ensure the homes grounds are secured to protect service users who may wander out to the busy road. This is a repeat requirement for the 4th time. The timescales of March 2004, March 2005 and August 2005 had not been met. The registered provider must 06/03/06 ensure that staff receive training with regard to the Protection of Vulnerable Adults. This includes care staff and domestic staff. The registered provider must 06/03/06 ensure the business plan is available to the home manager and to the Commission for Social Care Inspection. This is a repeat requirement for the 3rd time. The timescales of March 2005 and August 2005 had not been met. Eastham DS0000028664.V278015.R01.S.doc Version 5.1 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Eastham DS0000028664.V278015.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Eastham DS0000028664.V278015.R01.S.doc Version 5.1 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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