Inspection on 03/10/06 for Eaton Court Care Home

This inspection was carried out on 3rd October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Eaton Court Care Home 10/11/05

Eaton Court Care Home 23/05/05

Eaton Court Care Home 13/10/04

Eaton Court Care Home 25/05/04

Eaton Court Care Home 16/12/03

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Eaton Court Care Home Eaton Court Grimsby North East Lincs DN34 4UD Lead Inspector Mrs Jane Lyons Unannounced Inspection 3rd October 2006 09:00 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 Eaton Court Care Home DS0000002783.V308334.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. Eaton Court Care Home DS0000002783.V308334.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eaton Court Care Home Address Eaton Court Grimsby North East Lincs DN34 4UD 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 341846 01472 346185 eaton.court@btconnect.com Winnie Care (Eaton Court) Ltd Mrs Beverley Snape Care Home 45 Category(ies) of Old age, not falling within any other category registration, with number (45) of places Eaton Court Care Home DS0000002783.V308334.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the home can accept three persons under the age of 65 years (and no other under that age) That the home can accept three persons under the age of 65 years (and no other under that age) until those persons reach the age of 65 years or terminate their contract with the home. 10th November 2005 Date of last inspection Brief Description of the Service: Eaton Court is a purpose built care home that is situated in a quiet residential area of Grimsby. It is within walking distance of shops and is also on a public transport route. The home is able to support and care for up to forty -five people over the age of sixty five and up to 3 people under 65; the home is registered for the care of people with nursing care needs and up to seventeen places are reserved for people with residential care needs. The home consists of two floors serviced by a passenger lift. There are fortyone single rooms and two shared rooms, and all have the benefit of en-suite facilities. There are six bathrooms, four of these are assisted and two have a jacuzzi facility. The home has two lounges and a large dining room downstairs; there is a further lounge upstairs. There are also easy chairs and occasional tables in the large reception area where people tend to congregate. The home has a pleasant atrium with patio tables and chairs. There are mature gardens to the rear of the building and ample car parking to the front. The whole feel of the home is one of comfort with pleasant, clean and homely surroundings. The home is part of a small group, Winnie Care which in turn is owned by a larger company. The responsible person is Mr Paul Hulbert and the registered manager is Mrs Beverly Snape. Weekly fees are: £336- £510. The home operates a system whereby the fees include a third party contribution. Additional charges are made for the following: toiletries, newspapers/magazines, hairdressing, chiropody, transport to appointments and escort fees. Information on the service is made available to prospective and current service users via the statement of purpose, service user guide and inspection report. Documents are made available prior to and following admission, copies are always held in the reception area. The home currently operates a waiting list. Eaton Court Care Home DS0000002783.V308334.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. • • • • • • The visit lasted from 8.30 a.m. until 6 p.m. Ten residents and five sets of relatives spent some time chatting to the inspector. The visiting hairdresser, administrator, four care staff, the cook, two qualified staff and the manager also talked to the inspector. Records about the care provided, and other records about the running of the home were looked at. Questionnaires about the home were sent to 25 of the residents, 15 staff, 12 relatives and 2 healthcare professionals involved in supporting residents. All of the staff and residents surveys and eight of the relative surveys were returned at the time this report was written. Telephone calls were made to two health care professionals and one relative. The inspector observed how staff and service users worked together throughout the day. People’s views about the home and what was found during the visit have been used to write the report and make judgements about the quality of care. Issues raised in an anonymous concern were investigated during the visit. • What the service does well: Staff spoken to were enthusiastic and liked working at the home, they were keen to ensure that residents receive high standards of care. Observation of staff support and interaction with the residents was seen to be very positive; staff displayed a very good knowledge of the individual resident’s needs, their approach was very patient, kind and supportive at all times. The home provides very good facilities; all areas were decorated and maintained to a high standard, very clean and tidy. There was a relaxed and homely atmosphere in the home, residents were observed to be settled and comfortable in their surroundings. Residents liked the food provided, are well fed and encouraged to eat a healthy diet. The standards of care support were good; comments received from relatives included “I don’t think my mother could be in better care. The staff are lovely, the food is varied and wholesome. The surroundings are warm and comfortable” another relative wrote “I am completely satisfied with all the care provided” Eaton Court Care Home DS0000002783.V308334.R01.S.doc Version 5.2 Page 6 There were good visiting arrangements and visitors were made to feel welcome, discussions with a number of relatives confirmed this. Proper recruitment checks were made before new staff start in the home to ensure they are safe to work there. What has improved since the last inspection? What they could do better: Residents praised the care staff, their skills and attitudes, however some staff still do not get regular formal supervision sessions, therefore the manager cannot demonstrate how she is assessing/ monitoring their continued ability. The quality of the care plan documentation had slipped in that not all residents problems/ needs identified at assessment had been clearly written in the care plans; this is needed to ensure staff have the necessary information to care for residents properly. Not all staff had accessed a recent fire safety training session. This places both residents and staff at risk of potential harm. Residents said that they were happy with the way their concerns are dealt with, however, the manager must ensure that that all relatives know how to make a complaint and records are clearly maintained of all complaints investigations; outcomes and contact with the complainant to demonstrate positive management systems are in place. Eaton Court Care Home DS0000002783.V308334.R01.S.doc Version 5.2 Page 7 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. Eaton Court Care Home DS0000002783.V308334.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Eaton Court Care Home DS0000002783.V308334.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 and 6 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Residents and their relatives were provided with sufficient information to help them decide if the home was right for them. The admission process was thorough with prospective residents having the opportunity to visit the home and the manager carries out needs assessments prior to admission. EVIDENCE: The service user guide and statement of purpose documents had been updated and complied with the Care Homes Regulations, however advice was given to review the wording of the documents in some areas to ensure they fully reflected the current service provision. Since the last visit the home has varied their registration category to accept up to three persons under the age of 65 years. Eaton Court Care Home DS0000002783.V308334.R01.S.doc Version 5.2 Page 10 The inspector case tracked four resident’s care files which demonstrated that the format of the homes needs assessment covers all required areas; copies of completed assessments were detailed and appropriate. Copies of the Local Authority assessment and care plans are obtained prior to admission for those residents referred through the local Social Services care management teams. In addition to the pre admission assessment the home undertakes a further assessment of strengths and needs once the resident has arrived. It is on the basis of both these assessments that the residents plan of care is formalised. The written contract/statement of terms and conditions documents were agreed with residents and held on file. Copies of the letter written to potential service users following the manager’s assessment visits to confirm that the home can meet their needs were also held on file. Residents and their families told the inspector that they had had the opportunity to visit the home prior to admission. The inspector spoke to two residents who had recently moved into the home for respite care; they both confirmed that they had chosen Eaton Court because of it’s reputation and had been very pleased with the care and support they had received. Staff spoken to were aware of residents’ personal care needs. Visiting relatives were also happy with the care being provided. There was good evidence to demonstrate that care staff were accessing a range of service specific training which will help ensure that they have the skills to enable them to deliver up to date care methods and have a better understanding of the varied conditions common to the elderly. The home does not provide intermediate care support. Eaton Court Care Home DS0000002783.V308334.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. 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 from evidence gathered both during and before the visit to this service. The quality of a number of the care plans was inconsistent however there was clear evidence that the health and personal care needs of the residents were well met. Improvements have been made to the management of the medication systems which will better ensure that residents receive the medicine they need. EVIDENCE: Case tracking took place for four service users, which included examination of care records and discussions with service users and staff; written surveys were also sent to service users, relatives and health care professionals. Residents told the inspector during the visit that they were very satisfied with the standards of care provided; that the staff were always very kind, listened to them and treated them with dignity and respect. Relatives also commented on the kindness of the staff; they confirmed that communication was good and that they were always informed of any changes when these occurred. Eaton Court Care Home DS0000002783.V308334.R01.S.doc Version 5.2 Page 12 In general, the format of the care plans remains the same although advice given at the previous inspection, to develop the evaluation section of the record had been taken and implemented with good effect; all plans had been reviewed regularly with evidence of documented changes to care provision where necessary. A number of inconsistencies were identified in the quality of the care plans; two of the care plans were very detailed with all problems identified from assessment. However, a number gaps were identified with the two other plans; one service user has a PEG feed and the oral care required had not been detailed on the care plan. Another service users’ daily records evidenced that “thick and easy” powder was being used to support the service users’ swallowing difficulties yet this had not been identified on the care plan neither had the problem of the service user lowering herself to the floor on a regular basis. Risk assessments were in place for nutrition, mobility, tissue viability, falls, use of bed rails and general issues. These had been reviewed regularly and all high risk areas had an associated care plan in place. Evidence in records demonstrated that the health needs of residents are monitored closely and appropriate support accessed; of the files case tracked the home had accessed support from care management, occupational therapy, G.P., dietician, physiotherapist and palliative care team. Following the visit the inspector spoke to one of the community matrons and a health and social care co-ordinator, both of whom are regularly involved with the home; the feedback was very positive with both parties confirming their satisfaction with the standards of care, management and levels of communication in the home. The community matron said that the home was particularly good in providing care for service users with palliative care needs and she herself had received very positive feedback from the G.P. team she works in association with about the manager and the nursing team. There were no service users with any pressure sores at the time of the visit; tissue viability/ continence needs and support were identified on care plans. Service users appeared well cared for and well groomed. Observation, records and discussions with staff and service users evidenced that a good standard of personal care support was provided. There was evidence in the care records that service users funded by the local authority had completed review surveys. Advice was given to provide all privately/ publicly funded residents with the opportunity to access an annual review meeting; where staff at the home could meet with the resident and next of kin to discuss the current care needs and any issues arising at the time. Eaton Court Care Home DS0000002783.V308334.R01.S.doc Version 5.2 Page 13 Medication storage and recording was checked. Storage of general medications was satisfactory, the home continues to utilise the Nomad monitored dosage system. The ordering systems have been reviewed and updated by the senior nurse with improvements to the overall management of the systems. Improvements had been made to the recording of medications; two sets of administration charts were checked and no gaps with signatures or codes were found. Controlled medication storage and administration was checked and found to be satisfactory. There was evidence that the staff are proactive in ensuring that service user’s medication is reviewed by the G.P. Temperature recordings of the medication storage room and refrigerator are taken daily which were satisfactory. There was evidence that service users are supported to self – administer their medications; risk assessments were used to support the practise. Eaton Court Care Home DS0000002783.V308334.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. 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 from evidence gathered both during and before the visit to this service. The arrangements for providing activities, visiting, meals and supporting residents to make choices met with the expectations of the residents. EVIDENCE: Residents and visitors were happy with the visiting arrangements and it was clear that residents are supported to keep in touch with friends and family. Many of the residents access trips out with their friends and family, one resident told the inspector that she regularly went out to her daughter’s house or out for lunch to a local restaurant which she really enjoyed. There was a large number of visitors to the home throughout the day; a number commented on how friendly and welcoming the staff were and that they were always offered tea or coffee. One resident was due to celebrate her birthday the following day and staff were organising the tea- party. Residents commented on the lovely cakes that the cook bakes. Eaton Court Care Home DS0000002783.V308334.R01.S.doc Version 5.2 Page 15 In recent months the activity programme had not been fully implemented due to the activity organiser leaving however a new organiser had recently been appointed and the programme was back on track. The organiser is employed for two/ three days per week and has developed a formal programme which includes in – house activities such as Bingo, manicures, quizzes, dominoes and games; trips out to the boating lake, garden centre and local pubs for lunch have also been arranged. The new activity organiser was previously employed as a carer and is well known to many of the residents, she is a popular member of staff and reported that she was enjoying her new role. The home provides a trolley shop and one resident told the inspector that she found it very useful as she could make her own choices without having to bother the staff or her relatives. Records demonstrated that the social and recreational needs of the more dependent residents were met generally through one- to one sessions. Residents’ social, recreational and psychological needs were identified in assessments, care plans and daily records; advice was given to review a number of the long-term residents needs. Religious needs were identified on admission; staff reported that residents have the opportunity to attend services held in the community or the home hosts ecumenical services each month. Residents said that they felt able to make their own choices about how they spend their time. They can rise and retire to bed at times to suit themselves, choose where to have their meals, what clothes they wanted to wear and how they wanted to spend their day. One resident said that she had enjoyed a lie in that morning and staff had brought her breakfast up at 10 a.m. which she liked to do a couple of times per week. There was evidence from observation and interview that residents have the opportunity to speak to staff and management on a one –to –one basis; records evidenced that formal meetings are also held where activities and meal choices are the most popular agenda items. Very positive comments were received from the residents and relatives about the quality of the meals provided at the home, these included:” lovely food” and “the meals are always very good”. The meal served during the visit looked tasty and well presented. The majority of residents use the dining room and the mealtime was seen to be a relaxed and social occasion with the staff interacting well with the residents; individual support was provided patiently and discreetly. The cook visits the residents daily to discuss menu choices; the staff demonstrated a good knowledge of the individual service users’ nutritional needs and preferences. A number of specialist diets were being provided, resident’s weights are monitored regularly and any concerns are referred to community health services for support. The cook told the inspector that she was keen to access a course on specialist diet provision which the manager was currently arranging. Eaton Court Care Home DS0000002783.V308334.R01.S.doc Version 5.2 Page 16 The environmental health officer had visited the home in November 2005 and made a number of requirements and recommendations; these areas were checked and compliance had been achieved. Records to support HACCP management in the kitchen were maintained and satisfactory; the kitchen areas appeared tidy, clean and well managed. Eaton Court Care Home DS0000002783.V308334.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are confident that their concerns will be listened to, however, documentation and recording of complaints needs to improve to demonstrate that the home takes complaints seriously and issues are investigated appropriately. Procedures are in place to ensure a proper response to any suspicion or allegation of abuse. EVIDENCE: The homes complaints procedure was clear, appropriately worded and displayed in the in the entrance area. Three of the surveys returned from relatives detailed that they were not aware of the home’s complaint procedure therefore the management need to address this. All service users and relatives spoken to felt able to make any complaints they may have either to the manager or staff members. The home had received one complaint since the previous inspection which had been partly substantiated. Although the manager could verbally account for the investigation she had carried out and had written to the complainant, there were no written records in place to support the investigation and any outcome action taken. Eaton Court Care Home DS0000002783.V308334.R01.S.doc Version 5.2 Page 18 An anonymous complaint was made to the Adult Protection Team at the Local Authority in March and the issues passed on to the Commission; the decision was taken due to the homes positive quality rating, the anonymity of the complaint and lack of detail around the issues to investigate the concerns at this key inspection visit. Issues raised were: poor moving/ handling practises, staff shortages, staff taking their breaks at the same time, staff swearing in the dining area, no call bells in a number of areas accessed by residents and residents left wet or soiled for long periods. All the above issues were investigated and the findings are detailed in the relevant sections of the report. None of the issues were substantiated. The home has policies and procedures to cover adult protection and prevention of abuse, whistle blowing, aggression, physical intervention and restraint in place. There was evidence that the staff had accessed training in adult abuse; when asked about abuse, what it was and what they would do if they saw a service user being abused, the staff answered correctly. The inspector found that recruitment practices were satisfactory; examination of staff files demonstrated that CRB checks/ POVA First checks had been obtained for new staff prior to employment. Eaton Court Care Home DS0000002783.V308334.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22 and 26 Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the visit to this service. The standard of the environment in this home remains high, providing service users with a very safe, comfortable and homely place to live. EVIDENCE: The home provides and maintains very comfortable and safe facilities. All areas of the home are decorated and furbished to a high standard. There is a maintenance programme in place; redecoration and refurbishment is carried out where needed. The manager reported that the new carpet cleaner had significantly improved the condition of a number of the communal carpets especially the ones in the first floor corridors. All areas were seen to be very clean and tidy; residents told the inspector during the visit and had written on surveys that the home was always kept Eaton Court Care Home DS0000002783.V308334.R01.S.doc Version 5.2 Page 20 very clean. One resident had also written how much she liked her cleaner and looked forward to having a chat with her every day. Equipment provision is reviewed regularly; the home had recently purchased four profiling beds a new syringe driver. Discussion with staff evidenced that the number of service users needing mobility support with the hoist had increased in recent times, none of the current service users could use the Stand Aid type of hoist therefore another standard type of hoist would be beneficial; this was passed on to the manager who confirmed that she would review the provision. Eaton Court Care Home DS0000002783.V308334.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home provides sufficient numbers of staff on each shift to meet the care needs of service users. Staff are generally trained and competent to carry out their work, although improvements in the provision of fire safety training must be achieved. Recruitment practices afford sufficient protection for service users. EVIDENCE: The home had 42 residents at the time of the visit; the manager and staff reported that the dependency levels in the home remained stable. Part of the anonymous complaint received earlier in the year identified poor staffing levels as an issue and two of the relative surveys returned detailed that they did not consider that there was always enough staff on duty, however all 14 staff surveys returned and all 26 residents surveys detailed that they considered there was enough staff on duty. This was also borne out by observation during the day and with staff and service user interviews. The staff rotas identify that seven care staff are rostered on the morning shift, six care staff on the evening shift and three care staff on night duty; there is one qualified nurse rostered on each shift. The deputy manager has been on long- term sick leave in recent months; the shifts have been covered by the home’s staff and regular bank nurses. Eaton Court Care Home DS0000002783.V308334.R01.S.doc Version 5.2 Page 22 The workforce has continued to be very stable; this has supported positive moral amongst staff and provided continuity of care for the service users. All service users spoken to commented very positively about the staff; specifically about how kind and lovely they are. All service users spoken to commented that they considered the staff had time to provide care in a timely fashion and did not feel they were unduly rushed or had to wait long for their call bells to be answered. One resident told the inspector “The staff always have time to sit and have a chat”. None of the service users reported any issues with staff attitude, language or behaviours. An anonymous complaint made earlier in the year, raised an issue regarding staff taking their breaks together; through observation and discussion with staff and service users during the visit there was no evidence to support that this takes place. Staff breaks are arranged to fit in with the routines of the home with no more than four staff off the floor at any one time; staff reported that they are expected to provide support for residents at all times. Three new staff had been appointed since the previous inspection; the recruitment files were examined and found to be in good order. They contained all the relevant documentation to comply with Schedule 2 of the Care Homes Regulations and there was evidence that POVA First and CRB checks had been obtained prior to employment. The home has not yet met the standard for having at least 50 of its workforce trained at level 2 NVQ; currently this figure stands at 20 . The manager reported recent problems with the training provider however the programme continues and five staff are currently working towards qualification and further staff are waiting to enrol on the course. There was evidence that the home provides a structured approach to the induction of new staff and would be implementing the new common induction standards programme in October. Records evidenced that there had been a slip in the number of staff accessing fire safety training updates; although fifteen care staff had accessed the course this year this left twenty remaining and a number of those had not accessed the course since 2002/03. Records evidenced that twenty care staff currently hold basic food hygiene certificates; care staff do not have any responsibility in the home for meal preparation and support the kitchen staff to serve the meals. Staff were up to date with moving and handling training; they confirmed at interview that hoist provision was used for service users who could not weight Eaton Court Care Home DS0000002783.V308334.R01.S.doc Version 5.2 Page 23 bear; appropriate handling techniques were observed during the visit. One resident confirmed that staff had to use the hoist to help her transfer, she said that although she did not really like it she understood that the hoist was for her and the staffs’ safety. Staff have accessed first aid training. Staff have accessed a range of general and service specific courses such as; infection control, adult abuse, optical awareness, palliative care, dementia, feeding and swallowing, stroke awareness, diabetes and COSHH. Two of the senior care staff have recently enrolled on the Safe Handling of Medicines course and the activity organiser is to access a course on meaningful activities for residents. Staff at interview were very complimentary about the training they received and said that the home supports them to access relevant courses. Eaton Court Care Home DS0000002783.V308334.R01.S.doc Version 5.2 Page 24 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): 31,33,35,36 and 38 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Improvements have been made to the staff supervision programme and significant progress has been made towards the implementation of a formal quality assurance system which will better demonstrate how the home ensures continuous improvements are made. The residents were satisfied that they lived in a home that was well managed and they were provided with appropriate opportunities. EVIDENCE: The manager is a qualified nurse, has many years experience in providing care for the elderly and demonstrates sound management practices. Service users and staff were very complimentary about how the home was run and health Eaton Court Care Home DS0000002783.V308334.R01.S.doc Version 5.2 Page 25 and social care professionals surveyed during the inspection also made very positive comments about the overall management of the home. Staff confirmed that moral was good and commented that there was a good team approach to the care delivery at the home. Evidence from interviews with and surveys from care staff indicate that they consider the manager and nursing staff to be very approachable and supportive, they take all issues raised seriously and prompt action to resolve matters. Staff and service user meetings were held regularly; there was evidence that requests and suggestions made at these meetings were discussed and actioned where possible. Improvements had been made to the implementation of the staff supervision programme however there remained inconsistencies in that some staff had accessed regular sessions which would meet the annual targets whilst other staff had accessed few sessions. The quality of the supervision sessions was also inconsistent depending of the supervisor; records evidenced that some sessions were thorough complying with the standards whilst other sessions were more minimal; concerns about practice and disciplinary issues were not clearly followed up. The manager and records confirmed that she had started this years appraisal programme. There were accurate and up to date records relating to any personal allowances the home keeps on behalf of residents. The home has a good range of policies and procedures to support equality and diversity in the home, these include: dietary and religious needs, sexuality/ relationships, hearing/sight needs, dementia and challenging behaviour needs. Significant progress has been made to implement a formal quality assurance system; the manager has carried out regular audits and surveys in areas such as care plans, meals, laundry, bedrooms, bathrooms and lavatories, standards of cleaning, staff attitudes, response to call bells and the building/ grounds. She has begun to develop action plans where deficiencies have been identified and advice was given to ensure these are simply defined to enable clear identification of improvements made; progress has also been made on producing a format to publish the findings of the audits/ surveys. Areas which still need addressing within the programme are the inclusion of the views of key stakeholders on service delivery arrangements and the production of an annual development plan. The fire safety equipment and checks were all in place and up to date. A fire drill had been carried out in September. Records evidenced that service checks had been completed for all installations and equipment. Eaton Court Care Home DS0000002783.V308334.R01.S.doc Version 5.2 Page 26 Risk assessments were undertaken for all safe working practices; an external audit has taken place for all the health and safety measures/ practices within the home. Safe working practices are maintained by the provision of training to staff in the form of moving and handling, basic food hygiene, first aid at work, infection control and fire safety; as described in the previous section further fire safety training needs to be provided for staff to ensure that all the staff meet the annual statutory target. Accident reports were maintained, the manager audited the incidence monthly; and now provides detailed reports on all further action taken to further reduce risks especially with regard to falls. A newly admitted service user has significant problems in this area and although a referral had been made to the Community Occupational Therapist advice was given to also consult with the community falls co-ordinator to ensure appropriate management systems and equipment are in place. The maintenance man keeps up to date records on equipment checks; water temperatures are monitored weekly; records showed that the hot water temperature at the outlet in the first floor tea room regularly records temperatures above 50degC; the manager confirmed that although few residents use the facility she would ensure a thermostatic valve was fitted. All other hot water temperatures were satisfactory. Bed rails are also checked weekly in line with guidance issued from the Medical Devices Agency. One of the issues raised in the anonymous complaint was a concern that a number of the residents call bells were not working; the engineer was at the home during the visit checking the system and ensuring all points were in working order. Discussions with staff and service users did not identify any issues with the call bells not working. One of the surveys returned from relatives detailed a concern that the call bell in the T.V. lounge area had not been in working order for sometime and that this had caused difficulty for service users in that area; further discussion with staff identified that the call bell had been in working order and that access for service users using that area would be secured. Eaton Court Care Home DS0000002783.V308334.R01.S.doc Version 5.2 Page 27 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 4 X X 3 X X X 4 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 2 Eaton Court Care Home DS0000002783.V308334.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement Timescale for action 31/10/06 2. OP33 24 3. OP36 18(2) 4 OP16 22 The registered person must ensure that all individual service users’ problems/ needs identified on assessment are clearly detailed in the care plans. The registered person must 15/12/06 ensure the quality assurance programme is fully implemented; views of stakeholders to the service need to be sought, action plans need to be completed where deficiencies have been identified and an annual development plan needs to be produced. Previous timescale 28/02/06 not met. 15/12/06 The registered person must ensure that all staff including herself receives regular documented supervision and that care staff receive at least six sessions per year. Previous timescale 31/12/05 not met. The registered person must 15/11/06 ensure that records are clearly maintained of all complaints investigations and any outcome DS0000002783.V308334.R01.S.doc Version 5.2 Eaton Court Care Home Page 29 5 OP30 OP38 23(4)d action taken. The registered person must ensure that all staff working in the home access annual fire prevention training. Dates for outstanding staff to be arranged by: 31/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP28 OP1 Good Practice Recommendations The registered person should ensure that 50 of care staff are qualified at level 2 NVQ. The registered person should consider revising the statement of purpose and service user guide documents to ensure they fully reflect the home’s current aims/ objectives, philosophy and service provision. The registered person should ensure all residents have access to an annual review meeting. The registered person should review the current provision of hoists to ensure adequacy. 3. 4 OP7 OP22 Eaton Court Care Home DS0000002783.V308334.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Eaton Court Care Home DS0000002783.V308334.R01.S.doc Version 5.2 Page 31 - 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. 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