Inspection on 10/07/07 for Eastlands

This inspection was carried out on 10th July 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 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

Eastlands 21/09/06

Eastlands 27/10/05

Eastlands 07/06/05

Eastlands 25/01/05

Eastlands 18/08/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Eastlands Beech Avenue Taverham Norwich Norfolk NR8 6HP Lead Inspector Ruth Hannent Unannounced Inspection 10th July 2007 09:30 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 Eastlands DS0000027462.V345670.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. Eastlands DS0000027462.V345670.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eastlands Address Beech Avenue Taverham Norwich Norfolk NR8 6HP 01603 261281 01603 869995 eastlands@fshc.co.uk None provided County Healthcare Ltd, a wholly owned subsidiary of Four Seasons Health Care Ltd Claire Corrigan Care Home 35 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) Category(ies) of Old age, not falling within any other category registration, with number (35) of places Eastlands DS0000027462.V345670.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Thirty-five (35) Older People, not falling into any other category, may be accommodated. 21st September 2006 Date of last inspection Brief Description of the Service: Eastlands is a care home providing personal care and accommodation for 35 older people. The home is a single storey detached building, situated in the village of Taverham. The accommodation consists of six double and twenty-three single bedrooms, twenty-five of which have en suite facility. Various communal areas are available for service users. A drive way leads to the property with car parking facilities and gardens to front and rear of the premises. Email eastlands@fshc.co.uk Fees £385 - £500 Eastlands DS0000027462.V345670.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection report has been completed following a visit to the Home. To gather all the evidence required information has been taken from an Annual Quality Assurance Assessment (AQAA) sent to the Commission prior to the unannounced inspection. On the day of the visit lots of conversations were held with residents and staff. Records looked at within the Home were care plans, medication records, personnel files, training plans, maintenance files and rota’s. A tour of the building took place and time was spent with the Manager, Deputy Manager, Care staff member and 8 residents. The overall view of this Home is of a happy, well run establishment with residents care needs being met even when those care needs are not always documented appropriately. What the service does well: What has improved since the last inspection? Since the last inspection the Home has recruited a new Activities Coordinator who has lots of energy and enthusiasm that encourages people to take part. The hot water system has been made safe by the addition of thermostatic control valves being added to all sinks. Some flooring and carpet had been replaced. Eastlands DS0000027462.V345670.R01.S.doc Version 5.2 Page 6 The Home now has a comprehensive system to measure the quality of the care service provided. The Home is working hard toward ensuring all staff are fully trained and competent in all aspects of health and safety. The menu’s have again been improved by introducing even more choice than on a previous inspection. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Eastlands DS0000027462.V345670.R01.S.doc Version 5.2 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 Eastlands DS0000027462.V345670.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Potential residents do have an opportunity to visit the home and will have an assessment to ensure their needs could be met. EVIDENCE: The Home has a thorough assessment procedure to ensure that potential residents can have their needs met within the service provided. 2 residents recently admitted had information that was seen with clear details written. One of these residents who has been in the Home for 6 weeks was spoken to. It was her own decision to move into the Home and she decided, after a visit that this was the place she wished to live in. “All the relevant paperwork is dealt with by my son but he is also very happy with my choice of home”. Eastlands DS0000027462.V345670.R01.S.doc Version 5.2 Page 9 Eastlands DS0000027462.V345670.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The outcomes are that resident’s health and personal needs are met although not always documented in the care plans, but robust, safe medication procedures are in place. EVIDENCE: Throughout the site visit three care plans were chosen at random to inspect. The care plan documents are not in clear order due to loose pieces of paper slotted in. To track the care offered to residents was difficult as some pages were out of date order. Missing were fluid charts for a person cared for in bed, weighing of someone who had weight loss but had not been on the scales since April and care plans not reviewed monthly. (Requirement) Although the documentation was not in place the outcome of the residents care, according to the residents comments, gave nothing but praise. “The staff are great”. “I feel so much better now I have such good food”. “I tried one Eastlands DS0000027462.V345670.R01.S.doc Version 5.2 Page 11 Home and did not like it. It is so good here”. “I am cared for by kind, considerate staff who care for me well”. Throughout the whole visit it was very noticeable how everyone was smiling and very willing to have a conversation about the care provided. All residents seen looked very presentable with ladies in clean pressed clothes, make up and jewellery and gentleman clean shaven and smartly dressed. The health care needs of the residents are met well by a team of community health workers working alongside the care staff. The documentation in the Home is held on all aspects of the care support given. The GP arrived during the visit and is obviously a regular visitor who was escorted by the Deputy Manager to see the resident and then the details of the visit recorded on file. The District Nurse had recently commented to Four Seasons Regional Director on how well the Home and the District Nurse team work together. This was very evident in the care offered to residents who are moving towards the end of their life and receiving recognised palliative care. The Deputy Manager takes responsibility for the medication within the Home. The records are very thorough with a clear audit trail for all medications. A discussion on the methods used from ordering monthly repeated medication to the one off medication such as antibiotics was clear with records shown of how the process works. The medication held in the controlled drugs cabinet was checked and totals agreed with the amounts recorded in the controlled drugs register. The medication room was clean and tidy and the Home has a new medication fridge. (Temperatures recorded but not always daily!). (Recommendation). The Home staff carry out their tasks ensuring that everyone is treated with respect and privacy. Doors were knocked upon before entrée and conversations overheard were pleasant and respectful. Unfortunately and as mentioned in the pre-inspection information submitted by the home some rooms are shared and only have a curtain divider. This does not offer full privacy with sounds and odours having to be shared. (Recommendation). Eastlands DS0000027462.V345670.R01.S.doc Version 5.2 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. 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. The Daily lives for residents in as active as they want with lots of choice on how they wish to spend their day. EVIDENCE: Since the last inspection the Home has recruited an Activities Coordinator for 15 hours per week. This was written in detail on the AQAA. The programme of group activities is vast with art to knitting to bingo to dressing up days. All residents who take part in activities have a record kept of who and how the person has been involved. The Home is now to progress to offering the residents unable to participate in group activities with some one to one stimulation. The evidence of all the activities occurring is shown in photographs now displayed on the walls and by the enthusiasm of some of the residents when talking about what goes on in the Home from entertainers to the local vicar. Eastlands DS0000027462.V345670.R01.S.doc Version 5.2 Page 13 Visitors come and go all the time with lots of names written in the visitors book. On previous inspections visitors have commented positively on the Manager and staff and how they always feel welcome and involved in the care of their loved one. A recent cheese and wine evening was held but relatives did not attend. Residents enjoyed it so another meeting will be planned. (A fete is due in August and a meeting to discus the event is about to happen). Residents are regularly encouraged to make choices. The Home has just increased the choices available for meals. These are displayed clearly on the notice board and everyone spoken to (eight residents) all commented on the food and how flexible the kitchen staff were to their needs. Some people prefer to eat in their own rooms and some the dining room. The conversation overheard in the dining room was positive and people were obviously enjoying the occasion. Eastlands DS0000027462.V345670.R01.S.doc Version 5.2 Page 14 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): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are listened to with complaints or concerns and are protected from abuse. EVIDENCE: The Home has received one complaint that was dealt with the resident and family straight away. All the records are held in the office. In the entrance to the Home is a notice on how people can voice a complaint and on talking to residents they all said they are happy to talk to the Manager. The Home has carried out some training on the protection of vulnerable adults but is waiting some more dates that have been requested to ensure all staff have received the training. On talking to a staff member she was clearly able to give me examples of abuse and gave a clear description on what is whistle blowing and that she would have no hesitation to report on any concerns of potential abuse. Eastlands DS0000027462.V345670.R01.S.doc Version 5.2 Page 15 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, 21, 23, 25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some areas of the Home are in need of refurbishment and redecoration. EVIDENCE: The Home has the need for a complete redecoration. Many of the areas have had the odd new carpet or flooring and some walls have been painted but as it has been done in patches the rooms, corridors, bathrooms do not look complete. Some of the furniture is old and especially in the lounge contains lots of odd chairs and tables and although the carpet in this room is new it does not look nice and inviting due to the old furniture and poor lighting. The main corridor has very old grey carpet tiles that are stained and make the place look dreary and although the lighting has been improved it still has an appearance of being dark and tired. (Requirement) Eastlands DS0000027462.V345670.R01.S.doc Version 5.2 Page 16 The Homes records for the fire procedures are all in place with weekly fire alarm checks recorded and all fire extinguishers serviced on the 12/06. Some toilets are tatty, dark and have stained carpets. The main bathrooms do appear better decorated but are dark and in need of better lighting. (Recommendation) Very little visual things have changed since the last inspection but the conservatory has had improvements made that includes the removal of a trip hazard and new patio style doors making it easier for people to go in and out of the garden. The residents rooms are individual and have lots of personal possessions to make it their own room. They are cosy and each resident spoken to like the room they have. The Home has just had Thermostatic control valves placed on all the hot water taps that are used by residents, which is much improved. The Home is clean but some difficulty in shampooing carpets that have so many stains over many years makes it difficult for the areas to look completely clean. The laundry is kept busy with two machines that do all the washing. There was noted one area of offensive odour that is at present causing a challenge to the Home and who are in the process of trying various ways to eliminate the problem. Eastlands DS0000027462.V345670.R01.S.doc Version 5.2 Page 17 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. Staffing levels at certain times of the day are not high enough. EVIDENCE: On the day of this visit the Home was short of staff with only three carers on the evening shift. The rotas show 5 care staff in the mornings and 4 care staff in the afternoon. The Home has 32 residents with, at present, some very unwell people who need two staff members for each transfer. Both staff and residents stated that first thing in the morning people are kept waiting with the buzzers sometimes ringing non stop, this happens again in the evening when everyone wants help to bed. The Home needs to look more at the times the care is needed and adjust the numbers of staff on duty to meet the demands of the busier times. With limited staff residents may be put at risk so staff on duty must be in high enough numbers to ensure residents are cared for correctly and safely. (Requirement). The Home has some qualified staff at present but does need to increase the numbers of qualified to ensure 50 is reached. The Manager was able to show Eastlands DS0000027462.V345670.R01.S.doc Version 5.2 Page 18 the appeal to get more places for NVQ and hopes this will improve over this next year. (Recommendation) The Home has clear guidance on how to recruit new staff. The two personnel files seen show all relevant paperwork is in place. Each one has a CRB, 2 references, contract, application, two forms of I.D. and health declaration. Staff do not work unsupervised until the CRB has been returned. This year the Home has worked hard in ensuring the staff are trained. The Deputy Manager (who recently attended a trainers update) was able to show the recent update in moving and handling, which is about to be cascaded to the staff team. (3 dates offered on the notice board alongside COSHH and care planning). On talking to staff the recent training has been first aid, moving and handling, fire awareness and medication. Eastlands DS0000027462.V345670.R01.S.doc Version 5.2 Page 19 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, 32, 33, 35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The overall management of the Home is carried out well. EVIDENCE: The Manager has been in post for a number of years and is qualified. She has recently completed a course and is now able to lead disciplinary hearings. On talking to residents and staff it is clear that as a Manager she is approachable and acts on what is said. A requirement last year was to establish a form of quality assurance. The Home has worked hard on this and a comprehensive folder of the results of Eastlands DS0000027462.V345670.R01.S.doc Version 5.2 Page 20 the quality checks carried out were seen. The next step still to be done is a action/development plan that will begin the cycle of assess, plan, develop and review of the quality delivered. The records of any money transactions on behalf or with the residents was not looked at on this occasion but was seen fully at the last inspection and also checked with the shared Administrator from another home who works in both Homes using the same system. Staff supervision is taking time to establish. This was a requirement at the last inspection and some staff have received one to one with their line Manager. What is not apparent is the regularity of these sessions and the value/understanding of these meetings. Some ideas were shared on the way these sessions can be conducted. It was noted that some dates for future supervision was in the diary and ideas discussed will be carried out. (Recommendation) As mentioned in staffing the training for staff is in place and all equipment used as service dates on the side of each piece. The Four Seasons company are about to train all the Managers in all areas of health and safety that an then be cascaded to the staff. The Hot water as mentioned previously is now thermostatically controlled. Four taps in total were tested and although they did not run too hot the Maintenance Officer should do his monthly check soon and test each one to see if a slight adjustment is required. A concern was shared with the Manager of the security of the building. ON the day of the inspection the front door was wide open and although the front door bell was pressed no one came and I was walking right through the Home until I found a staff member. Residents do like to sit in the entrance with the door open but without someone being in the office to oversee the front door this does present a risk. (Recommendation). The Manager does send through appropriate notifications on accidents, injuries or deaths to the Commission and will discus any relevant issues that give concern by contacting the office. The Estates Manager has just completed a fire risk assessment for the building. (Seen). Staff do have a comprehensive booklet on starting employment that is the induction to the job. Only a blank one could be seen on the day as any new staff had their booklets at home. A responsible individual within the company does now visit monthly and completes a report that is sent through to the Commission on a regular basis. Eastlands DS0000027462.V345670.R01.S.doc Version 5.2 Page 21 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 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x 2 x 3 x 3 2 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 x 3 2 x 2 Eastlands DS0000027462.V345670.R01.S.doc Version 5.2 Page 22 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 OP7 Regulation 12.2 a Requirement Timescale for action 01/09/07 2 3 4 OP7 OP19 OP27 12.2b 23.2d 18.1a The Home must ensure that all relevant documents are in the residents care plan to make up their person centred requirements. Residents care plans must be 01/09/07 under regular review. The Home must be kept in good 01/12/07 decorative order. The Manager must ensure that 01/09/07 there are enough staff on duty at busy times of the day, taking into consideration the high level of needs of some of the residents. 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 OP9 Good Practice Recommendations The Manager should find ways of reducing the room temperature in the medication store room. DS0000027462.V345670.R01.S.doc Version 5.2 Page 23 Eastlands 2 3 4 4 OP10 OP21 OP36 OP38 The Home must consider the privacy of each resident and stop having shared rooms. The bathrooms need to have better lighting as they have no natural light. The staff need to have some form of training in the understanding and value of constructive supervision sessions. The manager needs to find a way to ensure the Home is secure at all times and not leave the front door open and unmanned. Eastlands DS0000027462.V345670.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Eastlands DS0000027462.V345670.R01.S.doc Version 5.2 Page 25 - 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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