Inspection on 18/01/06 for Eaves Hall

This inspection was carried out on 18th January 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Eaves Hall 08/02/07

Eaves Hall 21/06/05

Eaves Hall 16/12/04

Eaves Hall 30/06/04

Similar services:

Chirnside House

Keer Sands Residential Home

Sunny Bank (P.R.S.) Ltd

Ruskin Lodge

Bushell House

Ashwood Court Unit 1

Langrigg House

Parkside

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

CARE HOMES FOR OLDER PEOPLE Eaves Hall Kiddrow Lane Burnley Lancashire BB12 6LH Lead Inspector Mrs Pat White Unannounced Inspection 18th January 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Eaves Hall DS0000009495.V277450.R01.S.doc Version 5.1 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. Eaves Hall DS0000009495.V277450.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Eaves Hall Address Kiddrow Lane Burnley Lancashire BB12 6LH 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) 01282 772413 01282 771149 Mrs Srebrenka Macintosh Mr Ian Keith Macintosh Mrs Lynn Elizabeth Kendall Care Home 15 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (1), Old age, of places not falling within any other category (14) Eaves Hall DS0000009495.V277450.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The service must, at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. A maximum of 14 service users who fall into the category of OP (Older People) One named service user who falls into the category MD(E). When this person no longer resides in the home, the registered person will notify the Commission so that the registration can revert back to 15 OP. 21st June 2005 Date of last inspection Brief Description of the Service: Eaves Hall is registered to provide care and accommodation for 15 people of either sex over the age of 65, and one named person over the age of 65 with a mental disorder within the overall registration number. The building is of an older type on the outskirts of Burnley town centre. It is situated in its own private grounds that provide a pleasant area for residents to walk and sit. The home consists of two floors linked by a chair lift. There were 9 single rooms, 7 of which were under10 sq ms, and 3 shared rooms, one of which was slightly under 16 sq ms. The home was furnished and decorated to a high standard. Eaves Hall DS0000009495.V277450.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced inspection, the purpose of which was to assess important areas of life in the home that should be inspected over a 12 month period, check the progress of previous legal requirements and good practice recommendations, and check other matters in the home which came to the inspector’s notice. Most of the important matters in the home were assessed at the previous inspection, and as most met legal requirements and National Minimum Standards, there was no need to assess them again at this inspection. The inspection took 6 hours and comprised of, talking to residents, a tour of the premises, looking at resident’s care records and other documents, and discussion with the manager. Ten residents and a relative were spoken with. A member of staff and two district nurses were also spoken with. Comment cards were left in the home for residents and relatives to complete and return to the CSCI. What the service does well: The records of residents’ needs, and how these needs were to be met, were detailed and contained useful information for care staff. Residents are well cared for in the home. All residents spoken with said they were well cared for, that staff were caring and patient. One resident said she “couldn’t wish for a better place” and that she “couldn’t understand anyone who complained”. Two visiting district nurses said that Eaves Hall was an “excellent” home in the way the staff looked after the health care of their patients. The residents praised the food served, and comments such as the “food is very good” were made. Eaves Hall has always been well maintained and decorated with good quality furnishings. There is a high standard of cleanliness in the home. The staff team are well supported and guided by the manager who demonstrates a high level of commitment to the home. Staff working in the home had been recruited in accordance with legal requirements and this helped to protect the residents from unsuitable staff. Eaves Hall DS0000009495.V277450.R01.S.doc Version 5.1 Page 6 The home is a safe place for residents and staff, with staff having appropriate health and safety training, and the environment having appropriate safeguards such as guards on radiators and window restrictors. What has improved since the last inspection? What they could do better: Some aspects of the way medication is managed in the home must be further improved to make sure that staff have accurate and clear instructions for the administration of all medication, and therefore that residents are given the correct medication. Eaves Hall DS0000009495.V277450.R01.S.doc Version 5.1 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. Eaves Hall DS0000009495.V277450.R01.S.doc Version 5.1 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 Eaves Hall DS0000009495.V277450.R01.S.doc Version 5.1 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, 3, 4 & 5 Written information about the home is given to residents to help them choose if the home is right for them. Resident’s needs are met by the admission procedure. EVIDENCE: The Statement of Purpose and the Service User Guide were in accordance with Regulations and provided useful information about the home to residents and relatives. Records showed that an in house assessment was carried out prior to people being admitted to the home, including a resident recently admitted as an emergency admission. Copies of the social worker assessment had been obtained for those residents admitted through “care management” arrangements. After admission the assessment was developed in more detail and a care plan was generated. Eaves Hall DS0000009495.V277450.R01.S.doc Version 5.1 Page 10 The inspection demonstrated that peoples’ needs were met at Eaves Hall, including those of a resident who was having all care in bed following a recent stroke. She had requested that she remained at Eaves Hall and all necessary preparations for her care were being made. Residents said that they were well cared for. One resident said she “was very content” and that “you couldn’t wish for a better place”. One relative spoken with said that she “couldn’t fault it”. Residents and relatives were given the opportunity of visiting the home prior to making a decision and the manager visited them in their place of residence when undertaking the pre admission assessment. The admission of the resident as an emergency, and referred to above, had been carried out correctly according to the emergency admission procedures. Eaves Hall DS0000009495.V277450.R01.S.doc Version 5.1 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, 9,10 & 11. Standard 6 was not applicable Residents’ health, social and personal care needs are promoted and maintained to a high standard. This ensures residents rights, privacy and dignity is upheld. Medication procedures and systems had been developed and improved, but further improvements must be made to ensure medication is given safely. EVIDENCE: All residents had a written plan of care and the documentation used included all the matters listed in standard 3.3. In most matters the care plans were completed in sufficient detail to guide staff in caring for individuals. There was a useful section on people’s preferred routine. The care plans contained appropriate risk assessments, including one for the prevention of falls. However for one resident who had a recent history of falling this had not been completed. Since the previous inspection risk assessments on the use of the stair lift without staff assistance had been completed. This had resulted in one resident being able to use the stair lift alone and therefore have the freedom to and from her bedroom at times of her own choosing. Eaves Hall DS0000009495.V277450.R01.S.doc Version 5.1 Page 12 Information on psychological issues and pressure area care was recorded on the care plans. The care plans were being reviewed and updated every few months. There was evidence that residents were involved in the compilation of them. A key worker system operated to make the system of reviews, and the day - to - day care of the residents, more efficient. The residents’ health care, including psychological health, was promoted, and residents had access to all the necessary health care services. Pressure area care was managed appropriately in the home, with advice and support from the district nurse as required. There were good nutrition assessments and residents’ weights were monitored and recorded. The two district nurses spoken with said that their patient’s health care was very well managed by the home and that the standard of care at Eaves Hall was “excellent”. They said that there was good communication and cooperation between the surgery and the care staff, and that staff always carried out their advice and instructions promptly and effectively. They were confident that this would be put into practice for a resident being cared for in bed. Some procedures and systems for the handling and administration of medication had improved since the last inspection. The policies and procedures had been further developed according to the Royal Pharmaceutical Guidelines. The medication of residents admitted to the home was verified with the GP, and GPs were prescribing separate eye drops for each eye to prevent cross infection. The temperature of the medication storage area was being monitored regularly. In addition staff administering medication were undertaking accredited training. However there were some errors in the documentation and procedures that must be rectified with priority. One MAR sheet checked had administration details of a medication but no name for this medication. Hand written details added to, or altered on, the MAR sheets were not signed or dated. One resident was being given a medication that was not listed on the MAR sheet and which was not labelled. Residents stated that their right to privacy was respected, and that staff treated them appropriately when giving assistance. The member of staff spoken with demonstrated a good understanding of the importance of privacy and dignity to residents. All the necessary preparations were being made to look after a resident who was thought at that time to be at the end of her life. In this way her wish to remain at Eaves Hall was upheld and she was able to remain comfortable in the familiar surroundings in her own room with familiar staff around her. The services of the district nurses had been agreed and extra care staff had been organised. Eaves Hall DS0000009495.V277450.R01.S.doc Version 5.1 Page 13 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 & 14 Routines were flexible enough to suit individual preferences. EVIDENCE: Routines were flexible enough to suit individual needs and preferences. “Preferred routines” were recorded on the care plans. Residents had choices in rising and retiring times and were asked about what meals they would like. Residents’ interests and hobbies were recorded on the care plans. Some spoken with appreciated the recent Christmas festivities and the parties that were held to celebrate residents’ birthdays. Residents were enabled to follow their religious practice and church ministers visited the home. A Religious Sister visited the home to give Holy Communion to Roman Catholics. Since the previous inspection the leisure activities in the home had been reviewed with a view to organising trips out. This will be kept under review. Residents confirmed that residents’ meetings were held and people were invited to make choices about the food served and the leisure activities. There was information about advocacy in the home. Residents’ bedrooms were personalised with small items of furniture and furnishings. Eaves Hall DS0000009495.V277450.R01.S.doc Version 5.1 Page 14 Though the standard on meals and mealtimes was not fully assessed, the main (cooked) meal at lunch time was appetising and nutritious. Residents said they had enjoyed the meal and that the food served in general was very good Eaves Hall DS0000009495.V277450.R01.S.doc Version 5.1 Page 15 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 & 18 Residents are protected by a clear and accessible complaints and abuse procedures. EVIDENCE: There had been no complaints made since the previous inspection and the home’s complaints procedure had been previously assessed and found to be in accordance with the Care Homes Regulation and the National Minimum Standard. Residents spoken with stated that they had no complaints. One resident said that she “couldn’t wish for a better place” and that she “couldn’t understand anyone who complained”. A relative said that she “had no complaints at all” and that her mother would tell her if she was unhappy. Though standard 18 was not fully assessed, it was previously established that the home had appropriate policies and procedures to assist in the protection of residents from abuse, and guidelines to protect staff from aggression from residents. There had been no recent allegations or suspicion of abuse. Eaves Hall DS0000009495.V277450.R01.S.doc Version 5.1 Page 16 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, 20, 22, 24, 25 & 26 The home provides a safe, clean, well maintained, well furnished and comfortable accommodation for the residents. EVIDENCE: The tour of the premises confirmed that the home was well maintained and furnished and decorated to a high standard. It provided safe and pleasant accommodation. Furnishings and carpets were of a good quality, comfortable and homely. Audits of the property were carried out regularly to ensure that renewals and repairs were carried out rapidly. The grounds were accessible to residents in wheelchairs and were a pleasant area in which residents could sit and walk. Eaves Hall DS0000009495.V277450.R01.S.doc Version 5.1 Page 17 Communal space consisted of 2 lounge / dining areas and a sitting area between the two. This allowed each service user approximately 4.0 sq m of communal space, which for a home registered before April 1st 2002, complies with standard 20.4. The home was bright, and lighting in the communal areas facilitated reading and other activities. Following a recent audit of disability equipment and adaptations, more equipment had been purchased. Individuals had equipment for walking and mobility, and there was one assisted bath and one assisted shower in the home. Risk assessments had been carried out to determine whether or not residents can use the stair lift without staff assistance, and so increase the choice and independence of some residents with respect to moving to and from their bedrooms upstairs. The bedrooms were pleasantly decorated and furnished and personalised. The residents spoken with stated that they were satisfied with their private accommodation, though some were smaller than the recommended National Minimum Standards for older people. Key workers were responsible for checking the contents of the bedrooms and the beds and bed linen to ensure comfort and good quality. The home was comfortably warm on the day of the inspection and the central heating radiators were fitted with safety guards. Hot water outlets were fitted with pre set valves to ensure that residents were protected from the hazards of water that is too hot. Since the previous inspection the water system was tested for Legionella, and preventative treatment undertaken, every few months. All parts of the home were clean and fresh with no offensive odours. The laundry procedures ensured that the residents’ standards with respect to personal dress were maintained Eaves Hall DS0000009495.V277450.R01.S.doc Version 5.1 Page 18 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 & 30 The home had sufficient staff on duty to meet the needs of the residents and these were adjusted according to the changing needs. The staff training programme had been improved and developed according to the needs of the residents and staff. EVIDENCE: There were sufficient members of staff on duty to meet the needs of the residents and extra care was being arranged to meet the needs of a resident who was having care in bed towards the end of her life. A cleaner was also working in the home, and good standards of cleanliness and hygiene were maintained. No members of staff had been recruited since the previous inspection, but at that time procedures were found to be thorough. The member of staff spoken with confirmed that she had not commenced work until the CRB/POVA checks had been returned. The home has a low turnover of staff, which enabled residents to benefit from continuity of care. The staff training programme was being developed in accordance with the needs of the staff and the residents. Previous viewing of staff records showed that staff had completed courses in dementia, challenging behaviour, palliative care, diabetes, medications management and abuse of vulnerable adults. The in house Induction training programme had been developed according to the Skills for Care (the former TOPSS) specifications. There was a rolling Eaves Hall DS0000009495.V277450.R01.S.doc Version 5.1 Page 19 programme of moving and handling training, and 7 care staff had recently completed up dated training. The member of staff spoken with confirmed the training opportunities available. Eaves Hall DS0000009495.V277450.R01.S.doc Version 5.1 Page 20 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, 32 & 36 The management and administration of the home ensures staff are well supervised and supported for the benefit of both residents and staff. EVIDENCE: The current registered manager is experienced and competent to run the home, with over 12 years experience in managing a care home. She demonstrated a clear commitment to Eaves Hall and that she had knowledge and skills for the resident group. Mrs Kendall had finished the NVQ level 4 in “Management” and will complete NVQ level 4 in “Care” in the next few weeks. She had attended numerous other courses relevant to her post. There were clear lines of accountability within the home and also with the registered provider and responsible individual, Mr Macintosh, who visits the home on a regular basis. Eaves Hall DS0000009495.V277450.R01.S.doc Version 5.1 Page 21 Mrs Kendall worked along side the care staff and was described as being approachable, supportive and committed to her job. She was praised for her hard work. She communicated a clear sense of direction and leadership. Since the previous inspection Mrs Kendall had begun to carry out formal one to one supervision sessions with the care staff. The member of staff spoken with confirmed this and said that she found these sessions useful. Eaves Hall DS0000009495.V277450.R01.S.doc Version 5.1 Page 22 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 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 3 X 3 X X X X STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X 3 X x Eaves Hall DS0000009495.V277450.R01.S.doc Version 5.1 Page 23 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(1) &3 (4)(b)(c) Requirement A risk assessment in relation to the risk of falling must be completed as part of the care plan for all vulnerable residents and especially for the resident identified. The MAR sheets must be completed correctly and all medication must be named. All hand written entries on the MAR sheets (additions and alterations) must be double signed and dated. The medication listed on the MAR sheets must correspond to that being prescribed. Only medication listed on the MAR sheets must be given All prescribed medication must have an appropriate label The criteria for PRN and variable dose medication should be clearly defined and recorded on or with the MAR sheets (Previous timescale of 31/07/05 not met) Timescale for action 04/02/06 2. 3. OP9 OP9 13 (2) 13 (2) 18/01/06 18/01/06 4. OP9 13 (2) 18/01/06 5 6. OP9 OP9 13 (2) 13 (2) 18/01/06 04/02/06 Eaves Hall DS0000009495.V277450.R01.S.doc Version 5.1 Page 24 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 Eaves Hall DS0000009495.V277450.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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 Eaves Hall DS0000009495.V277450.R01.S.doc Version 5.1 Page 26 - 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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