Inspection on 18/10/05 for Eastlake

This inspection was carried out on 18th October 2005.

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 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

Eastlake 11/11/08

Eastlake 14/11/07

Eastlake 14/11/06

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 Deavanand Ramdas Unannounced Inspection 18th October 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Eastlake DS0000013848.V259781.R01.S.doc Version 5.0 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.V259781.R01.S.doc Version 5.0 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) 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.V259781.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Of the 51 persons accommodated up to 24 may fall within the category older people (OP) Of the 51 residents accommodated up to 14 may fall within the category of MD(E) and up to 12 may fall within the category PD(E) Of the 51 residents accommodated up to 20 may fall within the category of DE(E) The age/age range of the persons accommodated will be OVER THE AGE OF 65 YEARS 23rd June 2005 Date of last inspection Brief Description of the Service: Eastlake is a care home providing personal care to older people. It is situated in a quiet residential area in Godalming, Surrey and is close to local shops while the busy shopping centre of Guildford is just a short bus ride away. Eastlake is on two floors split into four independent living units. Each unit is named and has a communal lounge, dining area and kitchen. Rose, Violet and Jasmine units each have 12 single en-suite rooms; Poppy unit has 15 single en-suite rooms. There is a lift for access between the two floors. The home has kitchen, laundry, and adequate bathing and washing facilities. The property is set around a pretty courtyard with shrubs, flowers and seating where you can sit and relax. There are further established gardens to enjoy around the outer perimeter of the home. Private parking is available. Eastlake DS0000013848.V259781.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out by one inspector over a period of six hours. A partial tour of the premises took place and staff, service users, and relatives were spoken to. Documents and care records were inspected. The inspector would like to thank the manager, staff, service users and relatives for their contributions during the inspection. Comment cards, feedback forms and CSCI business cards were left at the home for information. This was a very positive inspection of the service where there were no areas identified as requiring action. What the service does well: What has improved since the last inspection? What they could do better: No requirements or recommendations were made during this inspection. Eastlake DS0000013848.V259781.R01.S.doc Version 5.0 Page 6 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. Eastlake DS0000013848.V259781.R01.S.doc Version 5.0 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 Eastlake DS0000013848.V259781.R01.S.doc Version 5.0 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): 4,5&6. The systems for assessing service users are adequate ensuring the home is able to meet the needs of service users. The home offers trial visits enabling service users and relatives to assess the quality of the home before admission. EVIDENCE: The home had a policy on enquiries, allocation and admissions dated May 2002 and an eligibility criteria for admission dated May 2005. The manager stated assessments were completed prior to admission to ensure the home was able to meet the needs of the service users. The inspector sampled a community care assessment dated 10th September 2005 and noted the service user was happy to be admitted to the home. The manager stated the home offered trial visits to service users. On the day of the inspection it was noted a service user was on a trial visit and stated her assessment was going well, dinner was nice, she met a friend and would like to stay at the home. The manager stated the home did not offer intermediate care and this standard was not assessed. Eastlake DS0000013848.V259781.R01.S.doc Version 5.0 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): 9,10 &11. The medication at this home is well managed promoting good health. Personal support in this home is offered in such a way as to promote and protect service users’ privacy and dignity. The arrangements at the home for handling dying and death are satisfactory. EVIDENCE: The home has a policy on medications dated November 2004. The inspector noted staff were trained in the administration of medications by a senior care officer who is also a trainer. The inspector noted the home had a list with the names of staff deemed competent to give medications. The inspector sampled medication record sheets which were signed and dated by staff. The home had an internal monitoring system and the inspector noted a medications audit was completed on the 20th June 2005 by the deputy manager. Medications were appropriately stored in a locked metal cabinet secured to the wall. The manager stated the home had controlled drugs. The inspector checked the control drugs register and the control drugs stock and noted there were no discrepancies. The inspector noted the room in which control drugs are stored is alarmed for safety reasons. Staff were observed to address service users by their preferred names and the manager and staff knocked on service users Eastlake DS0000013848.V259781.R01.S.doc Version 5.0 Page 10 bedroom doors before entering their rooms. One service user stated, “staff look after us really well here”. The home had a policy on death and dying dated January 2002. The manager stated staff were questioned about death and dying at their interviews. The inspector sampled an interview checklist and noted question 15 related to death and dying. The home had a training manual that covered death and dying, which is discussed during staff induction. The manager stated the home offered facilities for families to stay at the home to be with their relatives during their illness. The inspector noted a room with a bed and shower facilities was available. Eastlake DS0000013848.V259781.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13 &14 The arrangements at the home for activities are adequate ensuring service users social and recreational interests are satisfied. Links with the community are good and support and enrich service users’ social opportunities. The arrangements at the home for making choices are adequate ensuring service users are supported to exercise control over their lives. EVIDENCE: The company had a policy on activities and interests dated 2002. The home employed an activities co-ordinator working 20 hours a week. The inspector noted the home had a Summer 2005 flyer informing service users of activities provided by the home. The manager stated the home had trips to Wisley gardens, Loseley House and Bognor Regis. One service user stated, “staff would do anything to make you happy, we had a BBQ and also went to the seaside”. The manager stated the home is planning a mulled wine, sherry and mince pie evening. The inspector noted this was arranged for the 7th December 2005 and information was available in the foyer for service users to access. The manager stated some service users accessed local amenities and used the local bank, post office and town centre for shopping. The home had visitors and the inspector noted a service user met with her relative in a private area in the foyer. The manager stated service users were able to choose their meals, activities and personal possessions. The inspector noted Eastlake DS0000013848.V259781.R01.S.doc Version 5.0 Page 12 one service user had a display cabinet in her bedroom containing ornate personal possessions. The inspector sampled a menu plan dated 18th October 2005 and noted a service user who did not like the meals on the menu had been offered a cheese omelette for lunch. One service user stated activities are provided by the home but I prefer to be on my own that is respected by staff. Eastlake DS0000013848.V259781.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16&17 The complaints process in this home is satisfactory with complaints information available to service users, staff and relatives. The arrangements at the home ensure service users rights are protected. EVIDENCE: The home had a policy on complaints, which was displayed in the foyer for information. The manager stated the home had a complaint and commendation folder and this was sampled. The inspector noted the last complaint was made on the 13th October 2005 and acted on by the senior care officer on duty. A complaint and suggestion box was in the foyer. The manager stated some service users have power of attorney over their finances and she had used Age Concern to act as advocates for some service users. The inspector noted copies of power of attorney were kept at the home for information. The manager stated service users participated in elections using postal voting and one service user stated she watched interesting things on television such as films and Question Time – a political programme. Eastlake DS0000013848.V259781.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 &26 The standard of the environment within this home is good providing service users with an attractive and homely place to live. The arrangements at the home for hygiene are good ensuring the home is clean and pleasant for service users. EVIDENCE: On the day of the inspection the home was clean, well ventilated and free from mal odour. The inspector noted the handyman shampooing the carpet in the bedrooms. The gardens were private, secure and accessible and the courtyard was well maintained. Furnishings and fittings were of good quality. The home had infection control measures. Gloves, aprons and hand wash were available and the inspector noted staff washed their hands regularly. The home have industrial washing machines, dryers and sluicing facilities were available. The inspector noted the home employed a staff to work in the laundry who was appropriately trained in infection control. Eastlake DS0000013848.V259781.R01.S.doc Version 5.0 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 The standard of vetting and recruitment practices are good with appropriate checks being carried out to safeguard the welfare of service users. EVIDENCE: The home had a policy on recruitment and an equal opportunities policy statement dated May 2002, which was displayed in the foyer for information. The manager stated staff had been trained in equal opportunities and the inspector noted this was reflected in the rights and responsibilities induction training for staff. The inspector sampled staff recruitment files and noted it had an application form, two references, a CRB disclosure, terms and conditions of employment and a health questionaire. The manager stated the home is in the process of updating photo identification for staff files. The inspector noted photographs had been taken of staff and the manager stated this matter would be acted upon. A care staff who had been in post for twelve months stated she is enjoying the job and training is very good. Eastlake DS0000013848.V259781.R01.S.doc Version 5.0 Page 16 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): 33,34,35,37&38. The home regularly reviews aspects of its performance through a programme of self-review and consultations with staff, relatives and service users. The arrangements for managing the finances of the home are adequate ensuring service users are safeguarded. The systems for managing service users monies are satisfactory ensuring their interests are protected. The procedures at the home for record keeping are good ensuring service users rights and best interests are safeguarded. The arrangements for managing health and safety are very good ensuring the safety of staff and the service are promoted. EVIDENCE: The manager stated the home had regular quality reviews using questionnaires and comment cards. The inspector noted the home had quarterly resident and family meetings with a recent one held on the 22nd September 2005 which was well attended. The manager stated the company is keen on improving quality and has introduced a service improvement monitoring tool. The inspector Eastlake DS0000013848.V259781.R01.S.doc Version 5.0 Page 17 noted the home had a quality management system manual that was available to staff. The home has introduced flash cards that are available in the foyer to help service users to communicate. The home has liability insurance that expires on the 31st March 2006 and a business plan was available dated 2004. The home has a policy on the management of finances dated May 2002. The manager stated some service users managed their own finances and a lockable drawer was provided in the bedroom. The inspector noted the home had a safe for the safe-keeping of service users monies and valuables. The inspector sampled service users personal accounts and noted the written records were up to date and correct. The inspector noted the personal account of service users were being updated by the administrator at the time of the inspection. The manager stated the home had an archive cupboard to store documents and records. The inspector noted the manager’s office and the administrator co-ordinator’s office had lockable metal cabinets. The inspector sampled documents and care records that were up to date and kept in a locked cabinet. The home has a “Safe Home Award” given by the Anchor Trust that is due to expire in July 2007. The manager stated staff had delegated responsibilities for health and safety and the inspector noted a schedule outlining the name of staff and their specific responsibilities. The inspector sampled service records and these were observed to be up to date. A fire inspection by UK Fire International was carried out on the 2nd September 2005. The inspector noted Waverley Borough Council carried out an Environmental Health inspection on the 6th September 2005 and no recommendations were made. It was positive that Standard 38 was assessed as exceeding the national minimum standards in view of the homes policies and procedures, management arrangements for health and safety, staff practice and ongoing training. Eastlake DS0000013848.V259781.R01.S.doc Version 5.0 Page 18 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 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 3 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 x 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 3 3 X 3 4 Eastlake DS0000013848.V259781.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? No. 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 No requirements were identified as a result of this inspection. 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 Good Practice Recommendations Standard No recommendations were made as a result of this inspection. Eastlake DS0000013848.V259781.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Eastlake DS0000013848.V259781.R01.S.doc Version 5.0 Page 21 - 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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