Inspection on 19/10/06 for Eastwood House

This inspection was carried out on 19th October 2006.

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

Eastwood House 30/05/08

Eastwood House 06/12/07

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

CARE HOMES FOR OLDER PEOPLE Eastwood House 7 Eastwood Avenue Grimsby North East Lincs DN34 5BE Lead Inspector George Skinn Key Unannounced Inspection 19th October 2006 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 Eastwood House DS0000067250.V317157.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. Eastwood House DS0000067250.V317157.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eastwood House Address 7 Eastwood Avenue Grimsby North East Lincs DN34 5BE 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) 01472 278073 Mrs Christine Lyte Care Home 16 Category(ies) of Dementia - over 65 years of age (8), Old age, registration, with number not falling within any other category (8) of places Eastwood House DS0000067250.V317157.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th October 2005 Brief Description of the Service: The home is situated in a residential area of Grimsby. It is a converted domestic house and has been extended; there is large conservatory to the rear of the house and a small garden. The home is easily accessible and is on a bus route. The home provides care for 16 elderly people some with dementia. Bedrooms are provided on both the ground and first floor; there is a lounge and the conservatory is used as a dinning room. Eastwood House DS0000067250.V317157.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced site visit lasted for 7 hours, during that time service users staff and visiting relatives were spoken with; some records were looked at and the building was inspected. Prior to the site visit service user and staff surveys were sent to the home, comments from these were positive. The service users were happy within the care they received and this was echoed during the site visit. One service user said that this was now his home and he had settled very well. What the service does well: What has improved since the last inspection? What they could do better: The records which are kept about the service users need to have risk assessments included in them. The home need to look at the medication procedures. Activities need to be made available for service users to participate in. The home must be aware of and cater for Service users cultural and religious needs. The right amount of bathing facilities must be provided fro the service users. Service users must be able to lock their bedroom door if they want to. The registered person must provide the right amount of staff and make sure they are trained properly. Eastwood House DS0000067250.V317157.R01.S.doc Version 5.2 Page 6 The manager must be registered with the CSCI and the owners must make sure that the proper reports are kept about the service users and the running of the business. 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. Eastwood House DS0000067250.V317157.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 Eastwood House DS0000067250.V317157.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All residents including those who are self-funding are assessed prior to their stay at the home. EVIDENCE: Those files seen contained assessments undertaken by the local Authority and by the home prior to residents moving in. Eastwood House DS0000067250.V317157.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have care plans but these need development. Service users health needs are fully met The homes policy and procedures for the administration of medication protected the service users Service users fell they are treated with respect and their right to privacy is upheld. EVIDENCE: Evidence seen during the site visited indicated that all the service users have a plan of care which has been devised with them or a representative, these did not include any risk assessments. Eastwood House DS0000067250.V317157.R01.S.doc Version 5.2 Page 10 Files looked at indicated that the service users receive regular visits from their GP and district nurses when required or requested, this was confirmed by the service users who said they could see their doctor at any time and the staff would request this for them. The home have good procedures in place for the administration of medication, however the mar sheets were hand written. This could put the service users at risk if the information is copied wrongly. The service users commented on the staff treat them with respect and dignity at all times. This is an integral part of the induction training; staff were seen to be polite to the service users and addressed them appropriately. There are no locks on the doors to service users rooms. Eastwood House DS0000067250.V317157.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service user are not stimulated in any meaningful way, their religious and cultural needs re not being met. Service users are helped to maintain contact with relatives and friends. Service users can exercise choice in their daily lives. Service users receive a well balanced diet in pleasant surroundings. EVIDENCE: Evidence seen during the site visit indicates that the service user opportunity to participate in any meaningful activities is limited; there is no structured activities program or individual 1:1 time. Service users were seen to be sat for long periods of in the lounge with the TV on. Many service users and relatives commented on the lack of activities and how there should be ore opportunity for stimulation. Eastwood House DS0000067250.V317157.R01.S.doc Version 5.2 Page 12 During the site visit there were many visitors to the home, they were made welcome and could see their relatives in private or in the lounge area. During the site visit the service users were seen to be exercising choice about when to get to get up and what food they wanted, their choice of activities is severely limited, but staff were seen to be chatting with them and interacted well. The service users receive a well-balanced and wholesome diet. The cook commented that she was able to provide a varied diet due to the amount of food that is supplied for her to use. The home have one Jewish service user and there was no evidence that the staff had asked her whether she followed a kosher diet. The staff had received no training in this area and were unaware of any religious or cultural needs the service user may have other than arrangements for her death. Eastwood House DS0000067250.V317157.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users knew who to complain to Service users are protected from abuse. EVIDENCE: The complaints procedure is on display in the main entrance. It is also included in the service user guide. The complaints log was seen and all records appeared to be in order. Staff and service users, when questioned, all could explain the process for complaints reporting and were confident that these would be dealt with appropriately. One complaint has been received at the CSCI about the home since the last inspection and this has been resolved. Eastwood House DS0000067250.V317157.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is maintained to very high standard and it is clean pleasant and hygienic. The home do not have the required amount of bathing facilities for the service users to use. EVIDENCE: The home was very co-ordinated in each area, with matching curtains and other items in each individual section of the home. The new owners do have a program of refurbishment. The grounds and garden were generally very neat and tidy and well maintained. Eastwood House DS0000067250.V317157.R01.S.doc Version 5.2 Page 15 There were no malodours and the home has policies and procedures to help the staff to eliminate cross infection, protective clothing is provided for the staff to use. There are no locks on service users bedroom doors. At the time of the inspection the bathing facilities for the service users had been removed. The registered person has been written to separately as a mater of urgency as to the replacement of this. Eastwood House DS0000067250.V317157.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users needs are met by the number of staff, and are protected by the homes recruitment practises. EVIDENCE: The home has recently changed ownership therefore it must now comply with the Residential Staffing Forum Guidelines. From the information gathered during the site the home must provide a minimum of 336 care hours per week. The home provides training for the staff and this need to be kept up to date, especially with regard to mandatory training. The acting manager comment that there been a problem with retaining of staff following the change of ownership, but there was a main core of workers who had worked there for many years. The home undertake the correct recruitment procedures, staff file looked did not contain all of the relevant information. The home needs to make sure that at least 50 of the care workers are trained to NVQ level 2. Eastwood House DS0000067250.V317157.R01.S.doc Version 5.2 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is currently being managed by an acting manager. The home are still developing a quality assurance system, the resident money is handled safely and the health safety and well fare of the staff and residents is promoted. EVIDENCE: The home is currently managed by an acting manager who has worked at the home for a number of years in the role of deputy. An application needs to be made for her to be registered with the CSCI as a fit person to manage. Eastwood House DS0000067250.V317157.R01.S.doc Version 5.2 Page 18 The home has developed a quality assurance system but this still requires development to fully meet the requirements of the standard to include all stakeholders in the service. The home have in place safe working polices and procedure for the handling of resident money. The health and safety of the residents and staff is promoted as far possible. Eastwood House DS0000067250.V317157.R01.S.doc Version 5.2 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 1 X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Eastwood House DS0000067250.V317157.R01.S.doc Version 5.2 Page 20 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 2 Standard OP7 OP9 Regulation 15 Requirement Timescale for action 01/02/07 01/02/07 3 4 5 OP12 OP12 OP21 6 OP24 7 8 9 OP27 OP28 OP27 Service users care plans must include a comprehensive risk assessment. 13, 18, 19 Consultation must be undertaken with the supplying pharmacist as to the use of hand written MAR sheets 5, 12, 16, Service users must be given the 23 opportunity to partake in meaningful activities 5, 12, 16, Service user cultural and 23 religious need must be catered for. 23 There must be the right amount of bathing facilities for the service users to use. Letter sent separately to owner. 16, 23 Locks must be fitted to all service users bedroom doors; key should only be available for service users following a thorough risk assessment 18 There must be at least 336 care hours provided. 18 50 of the care staff must be trained to NVQ level 2. 18 Mandatory training must be up dated within required time scales. DS0000067250.V317157.R01.S.doc 01/02/07 01/12/06 28/10/06 01/02/07 01/02/07 01/03/07 01/03/07 Eastwood House Version 5.2 Page 21 10 11 OP29 OP33 18, 19 4, 5, 6, 14, 15, 17, 21, 22, 24 4, 12, 24, 26 26 12 13 OP31 OP37 14 OP37 37 Staff files must contain all the required information. A quality assurance system must be developed which includes consultation with all stakeholders. A report must be produced and made available to all interested parties. An application must be submitted for the registration of the acting manager. The registered person must undertake visits in accordance with regulation 26 of the Care Homes Regulations 2001 The home must make notifications in accordance with regulation 37 of the Care Homes regulations 2001 01/02/07 01/12/06 01/12/06 01/11/06 01/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Eastwood House DS0000067250.V317157.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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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