Inspection on 14/11/07 for Eastlake

This inspection was carried out on 14th November 2007.

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

Eastlake 11/11/08

Eastlake 14/11/06

Eastlake 18/10/05

Eastlake 23/06/05

Eastlake 18/01/05

Eastlake 15/06/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

1 Marten Road

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Eastlake Eastlake Nightingale Road Godalming Surrey GU7 3AG Lead Inspector Sandra Holland Unannounced Inspection 14th November 2007 10:30 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 Eastlake DS0000013848.V349874.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 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. Eastlake DS0000013848.V349874.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eastlake Address Eastlake Nightingale Road Godalming Surrey GU7 3AG 01483 413520 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) linda.grout@anchor.org.uk sharon.blackwell@anchor.org.uk Anchor Trust Ms Linda Ann Grout Care Home 51 Category(ies) of Dementia - over 65 years of age (20), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (14), Old age, not falling within any other category (24), Physical disability over 65 years of age (12) Eastlake DS0000013848.V349874.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th November 2006 Brief Description of the Service: Eastlake is registered to provide accommodation and care to fifty one older people. The home is located in a residential area in Godalming, Surrey and is close to the post office, local shops and pubs with excellent bus and train routes to nearby towns. Accommodation is on two floors accessed by stairs or a lift and split into four independent living units with a communal lounge, dining area and kitchen. The home has an office, main kitchen, laundry, bathrooms, toilets and bedrooms have en-suite facilities. The home has a courtyard and an attractive garden which is private, secure and accessible. Private parking is available. The fees at the home range from £465.00 per week to £785.00 per week. Eastlake DS0000013848.V349874.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection site visit was carried out by the Commission for Social Care Inspection (CSCI), under the Inspecting for Better Lives process. A full analysis was carried out prior to the visit, of all information held about the home. Mrs Sandra Holland, Regulation Inspector carried out the inspection visit over eight hours. Staff assisted with the inspection initially and Mrs Linda Grout, Registered Manager arrived later. Most areas of the home were seen and a number of records and documents were sampled, including residents’ individual care plans, medication administration records and staff recruitment and training files. Twelve residents, two visitors and nine members of staff were spoken with. An Annual Quality Assurance Assessment (AQAA) was supplied to the home. This was completed and returned and some of the information supplied in the AQAA will be referred to in this report. Information supplied in the AQAA indicated “that diversity is used as an inclusive term to describe the range and breadth of our residents”. It also recorded that “diversity is about respecting and valuing the differences in our residents and staff in a way that improves their well-being” and “equality is about fairness and not discriminating against individuals or groups because of their race, age, gender or disability”. A number of CSCI feedback forms were supplied to residents, relatives of residents and healthcare professionals involved in the support of residents. These are supplied to obtain independent feedback as to how the home is meeting residents’ needs, but at the time of writing this report, none of these had been returned. The people living at the home prefer to be known as residents, so that is the term that will be used throughout this report. What the service does well: Residents’ healthcare needs are well met and appropriate advice is obtained if a change is noted in a resident’s health. The administration of medication in the home appears to be effectively managed, to ensure that residents receive their medication as prescribed. Eastlake DS0000013848.V349874.R01.S.doc Version 5.2 Page 6 Visitors are made very welcome in the home and residents are supported to keep in touch with their families and friends. A number of residents have their own telephone in their room to enable this. Residents are made aware of the home’s complaints procedures, but most residents and visitors said they would speak to the manager or person in charge if they were unhappy about anything, and felt confident that it would be dealt with. The home is very well presented, clean and freshly aired. All areas were attractively decorated and furnished in a homely style to meet residents’ needs. Residents are encouraged to bring their own belongings into the home to personalise their rooms. A full team of staff are employed at the home to meet residents’ needs and over half of the care staff team have been trained to National Vocational Qualification (NVQ) level 2 in care. The home is managed in an open and accessible way, by a stable team of senior staff under the leadership of the manager. What has improved since the last inspection? What they could do better: Contracts or statements of the terms and conditions for living at the home must be supplied to residents before they move into the home, or on the day that they move into the home. The assessment of a prospective residents needs which is carried out before they move into the home, should be signed and dated at the time of the assessment, to show who has carried it out and when. Eastlake DS0000013848.V349874.R01.S.doc Version 5.2 Page 7 Residents’ individual plans of care must be drawn up, must be kept under review and must contain enough information to guide staff to the care and support needs of each resident. Any risks to residents must be assessed and must be kept up to date, to reflect changes in the residents’ needs or changes to the level of the risk. The home’s programme of social and leisure activities must be made available in a way that is understandable by all residents. The hours worked by activities staff should be reviewed to ensure they these are enough to meet the residents’ needs. A person must not be employed to work in the home unless the specified information and documents have been obtained in relation to that person. Staff must receive training appropriate to their role, including food hygiene. A system of assessing the quality of the service provided must be set up and maintained and this must include consultation with residents and their representatives. 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. Eastlake DS0000013848.V349874.R01.S.doc Version 5.2 Page 8 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 Eastlake DS0000013848.V349874.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all residents have been supplied with a contract or a statement of the terms and conditions for living at the home, so residents may not be aware of these. The needs of prospective residents have been assessed to ensure that these could be met by the home. EVIDENCE: The files of a number of residents were sampled, including those of recently admitted residents. It was noted that the required information regarding the terms and conditions for living at the home, which is usually supplied in a contract between the resident and the home, had not been supplied to all residents. A contract had been supplied to one resident who had recently moved into the home, and this made reference to “most of the weekly charge” being paid for Eastlake DS0000013848.V349874.R01.S.doc Version 5.2 Page 10 by a local authority, but did not state how much this amounted to or what contribution the resident, or anyone else, was required to make. No information was available regarding the fees payable for another resident who had moved into the home very recently, although it is required that this information is supplied to residents before they move in, or on the day they move in. This is to ensure that residents are fully aware of the terms they are agreeing to live under. A detailed assessment had been carried out of the needs of prospective residents, as these enable the home to know if they can meet the needs of each individual. These were seen to include reference to risks to the safety and welfare of residents, such as the risks of falls. Some residents had visited the home for an assessment day and other residents had been visited at their home or previous place of residence. It is important that assessments are carried out before admission, so that residents are not admitted inappropriately, but it was not clear from a number of the assessments, exactly when these had been carried out. For three residents, the assessment form stated that the date of assessment was before their admission to the home. These forms had been dated and signed by senior staff however, at varying times after the admission. The manager stated that this was when the senior staff had checked through the assessments. It is recommended that the assessment form is dated and signed at the time of the assessment to ensure accuracy. A number of residents are supported financially by a local authority, and where this was the case, an assessment had been carried out under the care management process and a copy of the assessment had been obtained. The manager advised that intermediate care is not provided at the home, so Standard 6 does not apply and has not been assessed. A requirement has been made regarding Standard 2, that a contract or a statement of the terms and conditions for living at the home must be supplied to residents, before they move into the home or on the day that they move in. Eastlake DS0000013848.V349874.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements need to be made to individual care plans and risk assessments, to ensure staff are fully aware of the care and support needs of residents. Residents’ healthcare needs are well met, medication appears to be administered appropriately and residents are treated with respect. EVIDENCE: The manager advised that the system of care planning in the home was in the process of being changed and the care plans in the home were gradually being transferred to the new style. Information in the AQAA stated “all residents have an individual plan of care and residents’ needs are monitored and recorded and action is taken if required”. The AQAA also stated under the “what we could do better” section, “develop the implementation of the service user plans”. Eastlake DS0000013848.V349874.R01.S.doc Version 5.2 Page 12 As previously mentioned, the files of recently admitted residents were sampled, including the individual care plans. It was noted that the care plans did not appear to be used as designed, were not always reviewed as regularly as required, and for one resident, the care plan had not been drawn up, although the resident had been living at the home for a week. A one page, “residents’ summary sheet” had been completed for this resident, but this provided very minimal information about the resident’s needs. It is not clear how staff would have known all the care and support needs of this resident, or what action was required to ensure that these were met. One part of the care plan is called a baseline assessment and is printed with the statement “you need to fill this in within 24 hours of a person coming into the home”. Three of these seen and one was dated five days after the resident moved into the home, one was dated a month after and one was dated nearly three months after. The National Minimum Standards (NMS) for Older People recommends that care plans are reviewed each month, to ensure that any changes in residents’ needs and any change in the care of support required are recorded. It was noted that the care plan for one resident had only been reviewed once since they had been admitted five months previously. The manager advised in writing before this report was written, that a staff meeting had been arranged to discuss care planning and service user plans. Assessments had been carried out of some risks to residents, but not all. The pre-admission assessment of one prospective resident identified that they were at risk of falling, but this risk had not been assessed when the resident moved into the home. Another resident had been identified as having a history of weight loss and had been prescribed nutritional supplements, but the risks associated with this had not been assessed and the resident’s weight had only been recorded twice over a period of five months. From the records seen and speaking to staff, it was clear that residents’ healthcare needs are well met. Information in the AQAA stated that residents’ benefit from “good support form general practitioners (GP’s), district nurses and have regular input from chiropodist, optician, dentist, dietician and community psychiatric nurse (CPN)”. Records indicated that a referral was made promptly to healthcare professionals if a change was noted in a residents’ health. Medication is supplied to the home by a national pharmacy chain, in a monitored dosage, “blister-pack” system. Individual doses of each medication are contained in each blister, to help ensure medication is administered safely, as prescribed, and for ease of monitoring. The stocks of medication were randomly checked with the records held and these were found to accurately match. Eastlake DS0000013848.V349874.R01.S.doc Version 5.2 Page 13 A member of the senior staff advised that they take the lead in overseeing, ordering and receiving medication. Medication was seen to be stored appropriately and a secure medication fridge was available for any items requiring chilled storage. Medication record keeping was in good order and no gaps were observed in the MAR charts. It was positive to see that if a handwritten entry is made onto the medication administration record (MAR) chart, this is signed by the person making the entry and checked and countersigned by a second member of staff. Medication that is no longer required is returned to the pharmacy and records of this are maintained. Staff were observed to treat residents with respect, speaking to them in a friendly and informal, but appropriate way. Resident’s privacy was respected and maintained. Staff were seen to knock on residents’ bedroom doors before entering and assistance with personal care was offered and given discreetly. Two requirements have been made regarding Standard 7, that care plans must be drawn up and kept up to date, to guide staff to the needs of residents, and that assessments must be carried out of any known risks to residents, to ensure they are safeguarded. Eastlake DS0000013848.V349874.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A range of activities are offered to residents, but residents need to be informed about these in a way that they can understand. Residents are supported to keep in touch with their families and friends and to make their own choices. A well-balanced and varied diet is offered to residents, which is adapted to meet their needs. EVIDENCE: The home has a programme of social and leisure activities for residents and this was seen to be displayed in a written format on the notice board in each unit. A separate notice informed residents’ about regular bingo sessions, but this was also in a written form, with a small picture on it. A requirement was made following the last inspection, that information about activities must be provided in a way that is understandable by residents. This requirement was made because a high proportion of the home’s residents may have dementia or a mental disorder, and may need the activities programme to be presented in a different form, such as pictorial, in order to understand it. Eastlake DS0000013848.V349874.R01.S.doc Version 5.2 Page 15 A timescale of 1st February 2007 was given, but this has only been partially met. The manager advised that she had met with the two activity co-ordinators who are employed in the home, to discuss ideas, and a large, pictorial activities calendar was being developed. The manager advised that staff are also being encouraged to understand that residents’ everyday activities, such as having a bath, can be developed into a leisure activity. Information supplied in the AQAA stated that trips out are organised and a “minibus was hired to enable this” and that there are “social events in the home and group activities”. An attractive display of photographs in the entrance hall show residents taking part in a number of events and trips out. A group of residents were seen enjoying indoor ball games in one of the lounges during the course of the inspection visit. The activities co-ordinator advised that although the activity programme is planned, this can be varied “on the day”, if another activity is requested or preferred by residents. The manager advised that it is planned to recruit further activity co-ordinator staff to enable more social and leisure activities to be carried out. This is strongly recommended as only twelve hours each week are currently worked regularly by activity staff, and this does not include any allocated activity time at weekends. From speaking to residents, it was clear that they are actively encouraged to maintain contact with their families and friends. Residents spoke of their visitors coming to the home and being made very welcome. One resident spoke of meeting with their partner at a day centre and another resident was observed going out for the morning with a visitor. Visitors who were spoken with, made positive comments about the home and one referred to their relative having their own telephone to enable them to keep in touch with family and friends. During the tour of the home, staff were observed offering residents choice, such as where they would like to sit, whether they would like to join in the activity taking place, and a choice of drinks and snacks mid morning. The lunch-time meal was seen being served and it was positive to note that residents are offered a choice of two main courses and two desserts. These are both freely available at the time of serving, so residents do not have to make a choice the day before, or try and remember what meal was ordered. Staff were available to assist residents if required, although residents were encouraged to be independent as possible. The cook was spoken with and advised that specialist diets are provided for residents as required. Vegetarian, diabetic and fortified diets were currently been prepared for those residents needing them, the cook stated. Eastlake DS0000013848.V349874.R01.S.doc Version 5.2 Page 16 Meals are served in the individual dining rooms in each of the four units of the home. These were equipped with dining tables for small numbers of residents and each table was attractively set with tablecloths, napkins, glasses and flowers. Staff advised that residents could also have their meals in their rooms if preferred or needed. The previously made requirement regarding Standard 12, that information about the activities in the home must be supplied to residents in a format they can understand, has been made again. A recommendation has been made, that the hours worked by activity co-ordinator staff are reviewed to ensure these are sufficient to meet residents’ needs. Eastlake DS0000013848.V349874.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Many compliments have been received and the few complaints that have been received have been appropriately managed. Staff are aware of their responsibilities in the protection of residents. EVIDENCE: The complaints procedure is displayed in the entrance hall and information supplied in the AQAA stated that only three complaints had been received in the last year. The AQAA also stated that the home “acts on complaints with a positive attitude” and there is an “open culture and we listen to what we are told”. The complaints received had been responded to within the specified timescales, had been upheld and the manager was able to advise on the issues involved and any action taken in response. No information has been passed to CSCI about any complaint made to the home. It was positive to note that over twelve letters or cards of compliment had been received by the home, so far this year. These included comments such as “I think the home and staff are wonderful and provide Mum with excellent care”, “all staff are most helpful and considerate” and “no complaints about anything”. Another letter received included positive comments from a healthcare professional, about the standard of care that had been taken with an aspect of a residents’ health. Eastlake DS0000013848.V349874.R01.S.doc Version 5.2 Page 18 Residents and visitors stated that they would speak to the manager or person in charge if they were unhappy about anything, and felt sure that this would be dealt with without having to make a formal complaint. The manager stated that in the event of an incident or allegation of abuse, the home would follow the Surrey Multi-agency procedure. An up to date copy of the procedure is held in the home for staff to refer to if needed. The manager advised that she and nine other staff have received training in the Surrey safeguarding adults procedures this year. Other staff have received training on rights and responsibilities, which includes abuse awareness and links with other policies and procedures in the home, such as whistle-blowing. Staff who were spoken with stated that they would report any concerns about residents to the manager or the person in charge. Staff were aware that they could report their concerns outside the home, to other people in the Anchor management team for example, if this was needed. Eastlake DS0000013848.V349874.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 24. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is attractively decorated and furnished to meet residents’ needs. It presents as a comfortable place in which to live, is well maintained, clean and freshly aired. EVIDENCE: Information supplied in the AQAA stated that the home was “ purpose built, clean and odour free” and this was confirmed during the tour of the home. All areas that were seen were decorated and furnished to a high standard, in attractive colours with co-ordinating soft furnishings. The AQAA also stated that air-conditioning had been installed in the upstairs units to prevent overheating, and there are plans to decorate and re-carpet further areas of the home. Eastlake DS0000013848.V349874.R01.S.doc Version 5.2 Page 20 It was positive to note how clean and freshly presented the home was, given the high level of needs of some residents. Housekeeping staff were spoken with and took evident pride in their work to ensure it was a pleasant place for residents to live. Residents can enjoy outdoor space in the courtyard or the enclosed garden, and two new summerhouses have been provided at the request of residents. The garden and grounds of the home were observed to be neat, tidy and well maintained. An allocated laundry room is provided, which is well equipped with appropriate washing and drying machines. Staff advised that residents’ personal laundry is carried out by their key-workers or the care staff on the individual units, to ensure this is carried out in a suitable manner and to promote the link between residents and staff. Wash hand basins are provided in all appropriate places and are equipped with liquid soap and paper towels to maintain hygiene. Staff were observed to use personal protective equipment including gloves and aprons, to prevent infection and the spread of infection. The manager stated that the home has a contractual arrangement for the collection of clinical waste and a policy and procedure regarding infection control. No details were supplied in the AQAA about the number of staff who have received training in infection control, but the manager stated that this is being arranged. Eastlake DS0000013848.V349874.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A full team of well-trained staff are employed to meet residents’ needs. Recruitment practices must be more robust to ensure residents are fully safeguarded. EVIDENCE: From the information supplied in the AQAA and from speaking to staff and residents, it was clear that a full team of staff are employed to meet residents’ needs. The majority of the team are care staff, but residents are also supported by housekeeping staff, catering staff, activities co-ordinators, an administrator, a receptionist, a gardener / maintenance worker and a team of senior staff. Staff advised that a number of members of the team have worked at the home for many years, creating stability and continuity for residents. Information in the AQAA indicated that the cultural background and gender of the staff group reflects that of the resident group, which enables staff to have a good understanding of these needs in relation to residents. Many staff have achieved a National Vocational Qualification (NVQ) in care to level 2 or above, and more staff are undertaking this. The home exceeds the recommended 50 of staff trained to this level, and information in the AQAA Eastlake DS0000013848.V349874.R01.S.doc Version 5.2 Page 22 indicated that the home is aiming for 70 of care staff to be trained to this level. The home also plans to ensure that all team leader staff have achieved an NVQ to level 3 in care. Although information in the AQAA stated that “stringent CRB (Criminal Record Bureau), POVA (Protection Of Vulnerable Adults) and reference checks” are carried out, this was not fully borne out at the inspection visit. The files of a number of recently recruited staff were seen and it was noted that for two of these staff, a full employment history had not been obtained, as required. One of the staff mentioned above had not included their last place of employment, which involved working with vulnerable people, and had therefore not provided any written reason as to why they stopped working there. It was also noted that no reference had been obtained from the last employer. The manager stated that efforts had been made to obtain a reference from the last employer, but they had not been willing to provide one. The manager advised that this member of staff was being closely supervised whilst they undertake their induction period. It was positive to note that all staff working in the home are encouraged and supported to undertake training which is suited to their role. A training plan is maintained in the main office and individual training records are held for each member of staff. From these and speaking to staff, it was clear that staff have received most, but not all, of the required training. Staff have received training required by law (mandatory training), in fire safety, first aid, moving and handling, but it was noted that many care staff need to receive food hygiene training. This is required because care staff are involved on a daily basis, in serving food and assisting residents with their meals. Staff have received other training to develop their knowledge and skills, such as NVQ’s, dementia, rights and responsibilities and communication. As mentioned at Standard 26 which relates to hygiene, staff need to receive training in infection control. Requirements have been made regarding Standard 29, that a person must not be employed to work in the home unless the specified information and documents have been obtained in relation to that person and regarding Standard 30, that staff must receive mandatory training, including food hygiene training. Eastlake DS0000013848.V349874.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed in an open and accessible way by a person who is fit to be in charge, and a team of senior staff. A quality survey has been supplied to residents and those involved in their support, to obtain feedback on the service provided. The health and safety of residents and staff is promoted and protected. EVIDENCE: Information supplied in the AQAA stated that the manager has achieved the NVQ Registered Manager’s Award (RMA), a certificate in management and is an NVQ assessor and verifier. The manager has many years experience of working with older people, and managed another home in the Anchor organisation prior to being appointed to Eastlake three years ago. Eastlake DS0000013848.V349874.R01.S.doc Version 5.2 Page 24 A senior team of two deputy managers and five team leaders provide additional management support. It was clear that the management team have an open door policy, are accessible to residents and staff, and work effectively together. The AQAA stated that one deputy manager has achieved NVQ level 4 in care, the RMA and the NVQ assessor’s award and the other deputy manager is working towards the assessors award. This enables the senior team to provide effective support to staff undertaking their NVQ courses. The manager stated at the time of the inspection, that a quality assurance survey had not been supplied to residents or those involved in their support during the last year. Before this report was written however, the manager sent confirmation that a questionnaire had been sent out to residents and their relatives. As mentioned previously, feedback on the quality of the service provided has been obtained, in the many cards and letters of appreciation which have been received at the home. Visits to the home have also been carried out as required under Regulation 26 of The Care Homes Regulations. This regulation requires organisations, such as Anchor Homes, to appoint a person to make unannounced visits to the home on a monthly basis, to monitor the quality of the service. During the visits, the person should speak to residents and staff, look around the premises and write a short report on their findings. A copy of the report must be left in the home. The reports of recent Regulation 26 visits were seen and these made positive comments on their findings. The visit in October, for example, recorded that three staff were training to assist with the new care planning process and there was a superb Halloween display on one unit. The administrator advised that monies are held for safekeeping on behalf of residents. These are stored securely and only senior staff and the administrator have access to these, to safeguard residents. Written records and computer-based records are maintained of residents’ monies and two signatures are recorded for each transaction. The computer-based records were checked against the written records and these accurately matched. The amount of money held was initially found to be incorrect by a small amount, but this was immediately rectified when the amount was found to have been placed elsewhere in error. Information supplied in the AQAA indicated the equipment and systems in the home are maintained and serviced appropriately, to safeguard all those living and working in the home. Signs on the notice boards in each unit advised residents and staff of the regular, weekly fire alarm testing that takes place. The home’s up to date insurance certificate was displayed as required, in the entrance hall, along with the home’s health and safety policy statement. Eastlake DS0000013848.V349874.R01.S.doc Version 5.2 Page 25 Only one potential hazard to residents’ health and safety was noted. In one area of the home, a number of portable heaters were seen in the corridor. Staff stated that there had been a problem with the heating, but this had now been dealt with. It is recommended that the heaters are removed as they may present a risk to residents if they are switched on and become hot, or as a tripping hazard. Eastlake DS0000013848.V349874.R01.S.doc Version 5.2 Page 26 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 2 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Eastlake DS0000013848.V349874.R01.S.doc Version 5.2 Page 27 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 OP2 Regulation Requirement Timescale for action 12/12/07 5A (2 & 3) Each person who became a resident after 1st September 2006, must be supplied with a statement specifying the fees payable by, or in respect of the resident, for the provision of any of the following services – (i) accommodation, including the provision of food; (ii) nursing; and (iii) personal care. 15 2 OP7 A written plan must be drawn up 12/12/07 in consultation with the resident, as to how the resident’s health and welfare needs are to be met. The plan must be made available to the resident and kept under review. Any activities which residents take part in must, so far as reasonably practicable, be free from avoidable risks. Unnecessary risks to the health or safety of residents must be identified and so far as possible eliminated. The registered person must DS0000013848.V349874.R01.S.doc 3 OP7 13 (4) (b & c) 12/12/07 4 Eastlake OP12 16 (m) 12/12/07 Version 5.2 Page 28 (n) ensure information about activities is in a format which is understandable by service users. Timescale of 01/02/07 not met. 12/12/07 5 OP29 19 & Sch. A person must not be employed 2 to work in the care home unless the information and documents specified in Schedule 2 have been obtained in respect of that person. 18 Persons employed to work at the care home must receive mandatory and other training appropriate to their role, to include food hygiene training. 6 OP30 06/02/08 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 OP3 Good Practice Recommendations It is good practice for the person carrying out the preadmission assessment to date and sign the assessment, so that it is clear who carried it out and when. It is recommended that the hours worked by activity coordinator staff are reviewed, to ensure these are sufficient to meet residents’ needs. 2 OP12 Eastlake DS0000013848.V349874.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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. 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