Inspection on 23/06/05 for Eastlake

This inspection was carried out on 23rd June 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 18/10/05

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 Nightingale Road Godalming Surrey GU7 3AG Lead Inspector Mr Deavanand Ramdas Announced 23 June 2005 rd 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 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 H58_s13848_Eastlake_v220869_230605_stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Eastlake Address Nightingale Road Godalming Surrey Gu7 3AG 01483 413520 Telephone number Fax number Email 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 DE(E) - Dementia over 65 (20) registration, with number of places MD(E) - Mental Dissorder over 65 (14) OP - Old Age (24) PD(E) - Physical Disability (12) Eastlake H58_s13848_Eastlake_v220869_230605_stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Of the 51 persons accommodated up to 24 may fall within the category older people (OP). 2. 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) 3. Of the 51 residents accommodated up to 20 may fall within the category of DE(E) 4. The age/age range of the persons accommodated will be OVER THE AGE OF 65 YEARS Date of last inspection 18th January 2005 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 H58_s13848_Eastlake_v220869_230605_stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection by one inspector carried out over seven hours. A full tour of the premises took place and service users, relatives, staff, and other health care professionals were spoken to. Care records and other documents were inspected. The inspector would like to thank the staff, relatives and service users for their contributions during the inspection. Comment cards and business cards were left at the home. What the service does well: What has improved since the last inspection? What they could do better: Documents at the home must be updated. The complaint section in the Statement of Purpose must be amended to ensure service users have up to date information. Some individual lifestyle agreements and risk assessments Eastlake H58_s13848_Eastlake_v220869_230605_stage4.doc Version 1.30 Page 6 were in need of regular reviews to ensure that service users’ needs were adequately assessed and managed. The home must be regularly checked to ensure kitchen doors are not wedged open so as to maintain a safe environment for service users. A review must be undertaken to assess whether a communal space could be provided for service users to meet for social and leisure activities. The arrangements for induction of staff at the home must be improved to ensure they are allocated a named supervisor for the duration of their induction period. Reporting procedures must be reviewed and updated to ensure hard copies of monthly visits are sent to the Commission and notifiable incidents including cases of MRSA must be reported to the Commission without delay to ensure monitoring of the welfare of service users. 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 H58_s13848_Eastlake_v220869_230605_stage4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Eastlake H58_s13848_Eastlake_v220869_230605_stage4.doc Version 1.30 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 standard(s) 1,2,3. Service users and prospective service users were provided with details of the services the home provides enabling an informed decision about admission to the home. However the complaint section must be updated to ensure service users have up to date and accurate information on which to make decisions. The home offers service users a licence agreement to ensure their rights are protected. Prior to admission an assessment is undertaken to ensure service users needs are identified. EVIDENCE: The home had a Statement of Purpose and a Service User Guide. The information was clearly written and well presented in a glossy brochure. The Resident Information Pack had an introduction to the home and described the facilities and services offered that included, Comfort and Independence, Staff Team, Quality Service, Room, Linen, Toilets, Bathing, Medications, Doctor’s visits, Visitors, Hairdressing, Chiropody, Religious services, Individual Lifestyle Agreement, Key Working and Activities. The inspector noted the complaint section needed updating to reflect that a complaint could be made to the Commission at any stage should a complainant wish to do so. This was discussed with the manager. The manager stated the home had licence agreements. These were sampled. The inspector noted the licence agreements Eastlake H58_s13848_Eastlake_v220869_230605_stage4.doc Version 1.30 Page 9 included the room to be occupied and were dated and signed by the service user. The home had an admission policy and a needs assessment. The needs assessment covered the areas of personal care and physical wellbeing, communication, mobility, medical history, medication, mental health and cognition, diet, foot care, religious observance and activities. Eastlake H58_s13848_Eastlake_v220869_230605_stage4.doc Version 1.30 Page 10 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 standard(s) 7,8,10 Although there is a care planning system in place, this must be regularly reviewed and updated to ensure they adequately reflect the service users’ needs and that cases of MRSA noted in care plans must be reported to the Commission without delay. The health needs of service users are well met with evidence of good working with other health care professionals taking place on a regular basis. Personal support is offered in such a way as to promote service users’ privacy and dignity. EVIDENCE: The manager stated the home had Individual Lifestyle Agreements (ILA). The inspector sampled the ILA’s and found they contained information on aspects of health, personal and social care. Risk assessments were also completed. The inspector noted ILA’s were not regularly reviewed. One ILA dated the 9.3.04 was reviewed on the 15.6.05. Risk assessments were not dated and signed. One risk assessment dated the 7.2.05 was not signed by the key worker. One service user had risk areas identified with no evidence of an action plan to manage the prevention of falls. This was discussed with the manager. Mobility assessments were regularly reviewed and updated. The manager stated the home had one case of negative MRSA. The Commission had not been notified of previous cases of positive MRSA. Service users are allocated a key worker and registered with a GP. On the day of the inspection the GP and the district nurse visited the home. The manager stated that an optician, a chiropodist and Eastlake H58_s13848_Eastlake_v220869_230605_stage4.doc Version 1.30 Page 11 a dentist visited the home. The inspector noted service users were treated with dignity and respect. Staff had been observed to address service users by their preferred names and the manager was observed to seek permission before entering service users’ bedrooms. The inspector interviewed the GP who stated communication between the staff and the surgery is excellent and that ‘his patients are well looked after’. One service user on respite care stated ‘staff look after me well’. Eastlake H58_s13848_Eastlake_v220869_230605_stage4.doc Version 1.30 Page 12 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 standard(s) 15 The meals in this home are good offering both choice and variety and catering for special dietary needs. EVIDENCE: The dining areas were well presented and tables were laid with knife, fork, spoons, napkins and condiments. The home had a written menu plan that reflected variety and choice. Menu sheets are used to order meals the day before. The inspector noted service users had a lunch of gammon, potatoes, green beans and carrots. Dessert was treacle sponge with custard. One service user had jacket potato with butter by choice. Meals were nicely presented and mealtime was relaxed and unhurried. One service user had a glass of red wine with his lunch. Staff were observed to interact with service users during lunch and offered assistance when appropriate. During lunch the inspector noted the chef visited the unit to ask service users whether they were happy with their meals. The staff stated hot and cold drinks were available throughout the day. During discussions staff stated they would like to see a choice of homemade cakes being offered at teatime to service users. This was discussed with the manager who stated a questionaire was recently completed on food and the outcomes would be acted upon. One service user stated the ‘ food is very good, better than I thought and you have a choice’. Eastlake H58_s13848_Eastlake_v220869_230605_stage4.doc Version 1.30 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 standard(s) 16,18. The home has a satisfactory complaints system with some evidence that relatives, staff and service users feel that their views are listened to and acted upon. Policies and procedures were in place in respect of adult protection and training was available for staff to ensure the safety of service users. EVIDENCE: The home had a complaint policy that was in a folder in the office. The manager stated the home kept a record of complaints. The inspector noted the last complaint was made on the 28.5.05 and had been investigated by the Commission. The home had a policy on Rights and Responsibilities that covered abuse. The home had leaflets on complaint freely available in the foyer. Policies on making a complaint were available throughout the home. The kitchen assistant stated he was made aware of the complaint policy and the whistle blowing policy during his induction. The manager pointed out the home had the Surrey Multi-agency Protection of Vulnerable Adults policy and a video Abuse in Care that was used for staff training. The inspector noted service users had a finance file that was kept in the office. It contained receipts and other records of monies spent. During the inspection one service user requested an advance of £10 that was granted by the manager. A relative remarked she was given literature on complaints and stated ‘if I raise an issue it is dealt with immediately’. Staff stated, they are aware of the complaint policy and had used it to address work related issues with management. Eastlake H58_s13848_Eastlake_v220869_230605_stage4.doc Version 1.30 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 standard(s) 19,20,21,22,23,24,25,26 The standard of the environment within this home is good providing service users with an attractive and homely place to live. However, the home should undertake a review to see whether a communal space could be provided for service users to meet and engage in social and leisure activities in the home. The home must undertake frequent and regular checks to ensure doors are not wedged open in order to contain any outbreak of fire and maintain safety. EVIDENCE: The property is well maintained and has a large mature garden with a courtyard that has wheel chair access. The garden is private, safe and secure and has mature trees, plants, shrubs, flowerbeds and seating. On the day of the inspection the home was clean and free of mal odour. Furnishings were of good quality and lighting was adequate. Bathrooms and washing facilities were clean and hygienic. The home was fitted with aids and adaptations such as hoists, assisted baths and toilets and grab rails to help service users maintain their independence. The home had an aid call system. Carpets throughout the home were clean and of good quality. The inspector noted the kitchen door on Rose Unit was wedged open. Bedrooms were well presented and personalised with paintings, photographs, ornaments, flowers, television, and other personal Eastlake H58_s13848_Eastlake_v220869_230605_stage4.doc Version 1.30 Page 15 effects. The home had infection control measures and staff had been observed to wash their hands regularly and to use gloves and aprons as appropriate. The inspector noted portable air conditioning units were supplied to help improve ventilation and comfort for service users. The manager stated, there are plans to install air conditioning in the home. During a meeting staff stated service users would benefit from a communal area where they could meet for activities. A relative remarked activities between staff and service users could be made better. This was discussed with the manager that stated an extra activities co-ordinator would be employed to do activities in each unit. The manager also stated that the home did not have sufficient space for a communal area for activities. Eastlake H58_s13848_Eastlake_v220869_230605_stage4.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,30 Staffing levels are adequate ensuring service users receive consistent care. The arrangements for the induction of staff are good, however the home must nominate a named staff to supervise a new employee for the duration of their induction. The home has an ongoing NVQ training programme to ensure staff have the appropriate skills to satisfactorily meet service users needs. EVIDENCE: On the day of the inspection the numbers of staff on duty were adequate. The inspector noted the manager was on duty, one senior care officer, eight care assistants, one administrative staff, one agency chef, one kitchen assistant, one handyman and two cleaners. Three of the care assistants on duty had the NVQ in Care award. The duty rota reflected the numbers of staff on duty. During a meeting staff stated that the staffing levels were adequately maintained. The home had an NVQ tracking sheet dated May 2005 that indicated seven staff had achieved the NVQ in Care award and fourteen staff were working towards the award. The home had an induction policy dated May 2002. The inspector sampled staff induction files that had evidence of TOPSS standards. Induction topics included role definition, safety at work, role of the key worker and service user groups. Induction checklists were dated and signed by the supervisee and supervisor. Staff stated they were happy with the level of training. The inspector noted new staff did not have a named supervisor for the duration of their induction period. This was discussed with the manager. Eastlake H58_s13848_Eastlake_v220869_230605_stage4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,36 The manager is supported well by the senior staff in providing clear leadership throughout the home. The process for managing the home is open and transparent enabling staff and service users to affect the way in which the home is run. The supervision of staff is adequate ensuring they have the opportunity to discuss all aspects of their work. EVIDENCE: The home has a qualified and experienced manager that has the NVQ Level 4 in Management, Registered Manager Award, NVQ Assessors Award and is an internal verifier for the NVQ training programme. The manager has implemented clear lines of accountability within the home. The home has regular meetings. There are senior care officer meetings, care staff meetings and night staff meetings. The inspector sampled minutes of meetings and noted they were well attended. The care staff meeting on the 7th February 05 had been attended by 21 members of staff. The inspector had a meeting with care staff that stated the manager is approachable and that communication has improved. One staff stated ‘ I feel I can go to the manager with a problem’. One service user stated ‘the management is very good, very Eastlake H58_s13848_Eastlake_v220869_230605_stage4.doc Version 1.30 Page 18 friendly’. A senior care officer commented ‘the manager is fair and get things done’ and ‘training has improved’. The manager stated staff had regular supervision. The inspector noted a monitoring sheet on staff supervision was in the office and had the names of staff and dates of supervision. Staff commented they had regular supervision and were able to identify their supervisors. The manager supervised senior care officers and the chef manager and senior care officers supervised other staff. The inspector noted hard copies of Regulation 26 visits had not sent to the Commission. (These are visits that must be completed monthly by the responsible individual or their representative). Eastlake H58_s13848_Eastlake_v220869_230605_stage4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 2 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 x x x 3 x x Eastlake H58_s13848_Eastlake_v220869_230605_stage4.doc Version 1.30 Page 20 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard NMS 1 Regulation 4(1)(c) Schedule 1(14) Requirement The registered person must update the Statement of Purpose to reflect that a complaint can be made to the Commission at any stage should a complainant wish to do so. The registered person must ensure Individual Lifestyle Agreements are regularly reviewed and updated at least monthly. Risk assessments must be dated and signed and where a risk is identified the manager must ensure there is a written care plan on how the risk would be managed by staff. The registered person must ensure that fire doors are not wedged open including kitchen doors so as to adequately contain the outbreak of fires. The registered person must ensure that hard copies of Regulation 26 visits are sent to the Commission. The registered person must ensure notifiable incidents including MRSA must be reported to the Commission without delay. The registered person must Timescale for action 01.08.05 2. NMS 7 14(2)(a) (b) 15(2)(a) 01.08.05 3. NMS 38 23(4)(a) (c)(i) 26.06.05 4. NMS 37 26(5)(a) 01.07.05 5. NMS 38 37(1)(b) 01.07.05 6. Eastlake NMS 36 18(2)(b) 01.07.05 Page 21 Version 1.30 H58_s13848_Eastlake_v220869_230605_stage4.doc (i) ensure that a member of staff is appointed to supervise new employees for the duration of their induction period. 7. 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 NMS 20 Good Practice Recommendations The registered person should undertake a review to assess whether a communal space could be provided at the home for service to meet and participate in social and leisure activities. Eastlake H58_s13848_Eastlake_v220869_230605_stage4.doc Version 1.30 Page 22 Commission for Social Care Inspection 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 H58_s13848_Eastlake_v220869_230605_stage4.doc Version 1.30 Page 23 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!