Inspection on 08/02/07 for Eaves Hall

This inspection was carried out on 8th February 2007.

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

The inspector 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 18/01/06

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 Key Unannounced Inspection 8th February 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Eaves Hall DS0000009495.V324018.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. Eaves Hall DS0000009495.V324018.R01.S.doc Version 5.2 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.V324018.R01.S.doc Version 5.2 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 Comission 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. 18th January 2006 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 had a variety of aids and equipment to assist residents with mobility problems. An experienced and qualified person managed the home. The weekly fees ranged from £335 - £375 and were inclusive of hairdressing, chiropody, newspapers and magazines and entertainment. Eaves Hall DS0000009495.V324018.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted at Eaves Hall on the 8th February 2006. The purpose of this inspection was to determine an overall assessment on the quality of the services provided by the home. This included checking important areas of life in the home that should be checked against the National Minimum Standards for Older People, and checking the progress made on a few matters that needed improving from the previous inspection. The inspection included: talking to residents, touring the premises, observation of life in the home, looking at residents’ care records and other documents, and discussion with the manager Mrs Lynn Kendall and the office manager Mrs Ruby Sayle. Written information about the home, the Pre - inspection Questionnaire, (PIQ) was provided to the Commission before the site visit. Survey questionnaires from the Commission were sent to the home for residents and relatives to complete. Twelve residents and ten relatives returned questionnaires. At the site visit six residents were spoken, and gave their views about the home. Some residents, who were unable to give their views about the home, were also spoken with. Two members of staff were spoken with and two visiting district nurses. Some of the views of all these people are included in the report. What the service does well: The way residents were admitted to the home made sure that the needs of people were understood so that a decision could be made about whether or not Eaves Hall was the right place for them to live. Residents are well cared for in the home. All residents spoken with said they were well cared for. 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. A recently admitted resident was very happy with everything in Eaves Hall and preferred it to living at home. Contact with friends and family was encouraged. Visitors appreciated this and felt involved and informed about their relative’s care. Eaves Hall DS0000009495.V324018.R01.S.doc Version 5.2 Page 6 The District Nurses spoken with felt that Eaves Hall were very good at making sure that the residents health care needs were met. Eaves Hall has always been well maintained and decorated with good quality furnishings. Residents appreciated this environment. There is a high standard of cleanliness in the home. One relative said that “cleanliness is a priority” in the home. There were attractive gardens for the residents to enjoy in the warmer weather. The staff team was well supported and guided by the manager who demonstrated a high level of commitment to the home. Staff were able to meet individually with the manager to discuss their work Staff working in the home had been recruited in accordance with legal requirements and this helped to protect the residents from unsuitable staff. Residents and relatives were regularly asked about their views on the home and this information was used to develop the services. The home was a safe place for residents and staff, with staff having appropriate health and safety training and there were measures to protect the residents from water that is too hot and from hot radiators. What has improved since the last inspection? What they could do better: Eaves Hall DS0000009495.V324018.R01.S.doc Version 5.2 Page 7 The care plans should contain up to date information about changing residents’ needs and how they need to be looked after. The care plans should also include detailed information about people’s leisure interests and hobbies. Some aspects of the way medication is managed in the home must be further improved to make sure that residents are given the correct medication at all times including creams and eye drops. The way reports of staff behaving badly towards residents are investigated in the home must be improved, in order to ensure that residents are more protected from potential abuse. Records kept of these types of incidents must be improved. Records kept of staff recruitment and induction training should be improved to show that all necessary procedures have been followed to make sure that staff are suitable and competent for work. 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. Eaves Hall DS0000009495.V324018.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 Eaves Hall DS0000009495.V324018.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 & 5. Standard 6 was not applicable Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home’s admission procedures, including written information about the home, pre admission assessments and prior visits by prospective residents and relatives to the home, helped to determine whether or not the home could meet people’s needs. Residents and relatives were confident that the home could meet their needs. EVIDENCE: Eaves Hall DS0000009495.V324018.R01.S.doc Version 5.2 Page 10 The Statement of Purpose and the Service User Guide were in accordance with Regulations and the National Minimum Standards and provided useful information about the home to residents and relatives. These documents had been reviewed and updated in 2006 and were due to be updated again this year to include recent developments, particularly with respect to staff training and qualifications. Records showed that an in house assessment was carried out prior to people being admitted to the home. Copies of the social workers’ assessments had been obtained for those residents admitted through “care management” arrangements. These provided more useful information, some of which had not been included in the in house assessments and care plans. After admission the assessment was developed in more detail and a care plan was generated. The inspection indicated that residents and relatives were confident that Eaves Hall could meet residents’ needs. Residents and relatives were given the opportunity of visiting the home prior to making a decision about whether or not it was suitable, and the manager visited them in their place of residence when undertaking the pre admission assessment. Some residents spoken with confirmed that they or their relatives had visited the home prior to admission. One resident stated that she had heard that Eaves Hall was a good home and wanted to live there. Another resident said he “was very happy living in the home” and that “you couldn’t wish for a better place, it’s better than being on your own at home” Eaves Hall DS0000009495.V324018.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care plans contained useful information about the residents’ health, personal and social care needs. However they were not sufficiently up to date on all these matters for all residents. Residents’ health care needs were promoted and maintained. Medication procedures and systems, in general were adequate to ensure the safe handling, storage and administration of medication, but some aspects could be further improved to safe guard residents’ health. Residents’ rights to privacy and dignity in the home were upheld. EVIDENCE: The viewing of records showed that all residents had a written plan of care and that 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. People’s preferred routines and likes and dislikes were Eaves Hall DS0000009495.V324018.R01.S.doc Version 5.2 Page 12 recorded so that staff knew what was important to individuals. The care plans contained appropriate risk assessments, including one for the prevention of falls and pressure areas, and management/preventative measures were recorded on the care plans. Risk assessments on the use of the stair lift without staff assistance had been completed. This gave some residents more independence on moving to and from their bedrooms. However on one care plan viewed the section on medical details had not been completed and some sections could be completed in more detail (see below). In another care plan viewed there was insufficient information about leisure interests and hobbies. The care plans were being reviewed every few months, and there was evidence that residents, and their relatives, were involved in this process. However for one resident who was having all care in bed the care plan had not been sufficiently updated to reflect this recent change, and did not contain sufficient detail about all care needs, such as whether or not she should sit in a chair and for how long and whether or not she needed food supplements. The inspection methods including the records viewed, resident and relative surveys and discussion with two District Nurses, showed that residents had all medical and nursing attention they needed, including psychological care and care towards the end of their lives (see below). As stated above there were risk assessments for pressure areas and appropriate preventative measures, including intervention from the District Nurses. Good nutritional assessments were completed after admission that identified food likes and dislikes and any problems. These risk assessments were reviewed. Continence requirements were also recorded. District Nurses in the home at the time of the site visit praised the home for all the care given to residents, including those nearing the end of their lives and those who were very frail and cared for in bed (see above). They said that staff always carried out their instructions, and communication between the home and themselves was very good. All relatives (10) who completed the comment cards stated that they were satisfied with the care given to the residents. One said “ We are very happy with the care and individual attention given to my mother, she is happy and enjoys the company of the staff and other residents”. Another said, “My aunt is cared for in a professional but very caring manner”. The residents’ survey indicated that residents were satisfied with the care given to them in the home. Eleven out of twelve said they “always” had the care and support they needed and 1 said “usually”. Ten said they “always” get medical attention when needed and 2 said “usually”. Eaves Hall had policies and procedures to assist staff to manage and administer residents’ medication safely, and some areas had improved according to requirements made at the previous inspection. There were some areas of good practice, including the staff training for those administering medication, checking the prescriptions prior to dispensing, the recording of the criteria for “when required medication” (PRN) should be given and the Eaves Hall DS0000009495.V324018.R01.S.doc Version 5.2 Page 13 management and administration of controlled drugs. However practices could be further improved to safeguard residents’ health. One resident was administering her own skin cream but there was no risk assessment for this, and this cream was not being stored at the correct temperature. Another resident’s eye drops were also not being stored at the correct temperature. Whilst medication received into the home, and medication being administered, was being recorded accurately on the Medication Administration Record Sheets (MARs), records of medication being returned to the pharmacist was not being recorded accurately. One resident whose records were viewed had a supply of two types of eye drops, one of which should have been discarded and was not listed on the MAR sheet. Staff were not clear whether or not this medication was being given, and it had not been re ordered when it should have been. Also one resident had unlabelled skin cream in her room that was not listed on the MAR sheet, and it was not clear what this was for. Whilst the criteria for “when required” medication was being recorded, these details had not been updated for the pain relief of one resident. For another resident whose records were viewed the addition of antibiotics to the MAR sheet had not been entered correctly as two people had not signed. One resident had an “oxygen machine” but 3 spare cylinders were stored in the home’s pantry. Some were empty and should be returned, and there was no clear system to identify which were empty and full. Though residents were not at risk from the storage arrangements, the cylinders were not stored securely according to the guidelines. Staff appeared aware of the importance of respecting residents’ privacy and dignity. Staff were observed at the site visit treating people respectfully. Residents spoken with said staff treated them properly but that some were better than others. One resident confirmed that she had been “assessed” for being able to use the stair lift alone, and now had the choice about spending private time in her room. However 2 relatives stated in comment cards that they could not visit residents in private. Eaves Hall DS0000009495.V324018.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Routines were flexible enough to suit individual preferences. There were suitable activities enjoyed by most of the residents. The visiting arrangements encouraged and enabled residents to maintain contact with family, friends and the wider community. Residents were able to have certain choices in their everyday lives, and the meals served suited their preferences and were healthy. EVIDENCE: Discussion with residents and the residents’ survey indicated that routines were flexible enough to suit individual needs and preferences. “Preferred routines” were recorded on the care plans and covered such things as preferred rising and retiring times and food likes and dislikes. Residents confirmed that they could get up and go to bed when they wanted. Some of the residents’ interests and hobbies were recorded on the care plans, but in one care plan looked at this was not in sufficient detail and did not provide useful information about this area of the person’s life (see Standard 7). Some Eaves Hall DS0000009495.V324018.R01.S.doc Version 5.2 Page 15 spoken with appreciated the recent Christmas festivities, and the parties that were held to celebrate residents’ birthdays. In the resident survey 5 said that there were “always” suitable activities, 3 said “usually” and 4 said “sometimes”. Residents were enabled to follow their religious practice and church ministers visited the home. The Pre Inspection Questionnaire (PIQ) and the records kept of activities indicated that various activities were organised such as, dominos, skittles, “cinema afternoons” and birthday parties. Contact with families, friends and the community was encouraged. All ten relatives who completed the comment cards said they were welcome in the home at any reasonable time, were kept informed of important matters and were consulted about residents’ care if relevant. Some residents said that they were able to go out with relatives and friends, and one resident was encouraged to walk to the nearby shops alone. Contact with the local community was encouraged, and church ministers visit and entertainers visited the home. Residents confirmed that they had some choice in certain matters. Residents’ meetings were held, and people were invited to discuss choices about the food served, and the leisure activities, either at these meetings or as individuals with their key worker. There was information about advocacy in the home. Residents’ bedrooms were personalised with small items of furniture and furnishings and residents could manage their finances with help from relatives if needed. The meals served appeared to suit the tastes of the majority of the residents. Menus were planned frequently depending on residents known likes and dislikes and were mainly traditionally English. They appeared healthy and nutritious Three full meals were served each day, with the main, two - course meal served at lunch - time. There was no choice of main meal but residents confirmed that if they did not like what was being served they could have something else. Drinks and snacks were served throughout the day and fresh fruit was available. Different sorts of diet were catered for, such as soft and blended food and food for those with diabetes. Dietary requirements were recorded on the care plan and linked to the nutrition assessments. In the residents’ questionnaire survey 5 said they “always” liked the meals, 6 said “usually” and 1 said “sometimes”. One resident spoken with said she liked the food and that on the whole it was good - “Some people moan about it but I never leave anything”. Another said “ the food was good in general but “you can’t please everyone all the time”. A recently admitted resident said “the food was very good”. Eaves Hall DS0000009495.V324018.R01.S.doc Version 5.2 Page 16 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 adequate. This judgement has been made using available evidence including a visit to this service. Residents and relatives knew who to speak to if they had any concerns. People felt confident that their concerns would be taken seriously. However the home’s, procedures and practices would not guarantee the protection of residents from abuse. EVIDENCE: The home had a complaints procedure that had been previously assessed and found to be in accordance with the Care Homes Regulation and the National Minimum Standard. There had been no complaints made since the previous inspection. Residents spoken with stated that they had no complaints. One resident said that they “had no complaints at all and it was much better than living at home. There was evidence that the residents and relatives knew what to do if they were not happy with something. Of the twelve residents who completed the survey questionnaire, eleven said they “always” knew who to speak to if they were unhappy and one said “sometimes”. Eight said they “always” know how to make a complaint and four said “usually”. One resident in discussion said that if she was not happy about anything, she would sort it out with the manager straight away. All of the ten relatives who completed the questionnaires said they had never had to make a complaint and were satisfied with the overall care. Nine said they were aware of complaints procedure and one wasn’t. Eaves Hall DS0000009495.V324018.R01.S.doc Version 5.2 Page 17 Since the last inspection there had been an anonymous allegation of abuse against a member of staff in the home. This was made through Social Services and concerned some alleged injuries to a resident’s legs and an alleged “bullying and aggressive manner” towards residents. The Social Services ensured that the home followed the correct procedures to safeguard residents whilst investigations were undertaken. These investigations indicated that the allegations were not substantiated and the member of staff was reinstated to work in the home. However looking at records and discussion with the manager and the office manager at the site visit confirmed that full and detailed records of the alleged incidents and investigations, including discussions with the people concerned, had not been made. It was therefore unclear as to what subsequent action had been taken to ensure residents continued to be protected. Some recommended action had not been taken the member of staff had not been more rigorously supervised and staff had not undertaken appropriate training. Also in the light of this experience, the written abuse procedures did not give sufficient clarity of guidance to the manager and staff and these should be reviewed and amended if necessary. Eaves Hall DS0000009495.V324018.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24, 25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Eaves Hall provided pleasant, comfortable well - maintained and clean and safe, private and communal accommodation that suited the residents’ needs. Refurbishment and renewal tasks were carried out in a planned and prioritised way. 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 Eaves Hall DS0000009495.V324018.R01.S.doc Version 5.2 Page 19 and walk. According to the PIQ several rooms had been decorated and new dining room chairs had been purchased since the previous inspection. A fire safety inspection of the premises had been undertaken early in 2006 and subsequent action ensured that the home met the fire regulations. Residents in conversation stated that they appreciated the environment and one said “see for yourself how nice it is”. Communal space consisted of 2 lounge / dining areas and a sitting area between the two. For a home registered before April 1st 2002, this was classed as sufficient communal space for the number of residents in the home. The home was bright, and lighting in the communal areas facilitated reading and other activities. The bedrooms were pleasantly decorated and furnished and personalised with small personal possessions. 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, and some were shared. 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. The water system was safe from the spread of Legionella. 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. All residents who completed the questionnaire survey stated that the home was “always” fresh and clean. Eaves Hall DS0000009495.V324018.R01.S.doc Version 5.2 Page 20 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 good. This judgement has been made using available evidence including a visit to this service. The home had sufficient staff on duty to meet the needs of the residents. The staff - training programme was being developed according to the needs of the residents and staff to ensure that staff were qualified and competent. Staff recruitment procedures helped to protect residents from unsuitable staff but records could be improved to further safeguard residents. EVIDENCE: The rotas supplied and observations on the day of the inspection showed that there were sufficient members of staff on duty to meet the needs of the residents and enable good standards of cleanliness and hygiene to be maintained. Nine out of ten relatives who completed comment cards said they felt there was always enough staff on duty, one said there was not always enough staff on duty. The District Nurses stated they felt there were enough staff on duty. Each resident had a key worker which facilitated communication with residents and the understanding of their needs. The PIQ stated that 7/14 care staff, that is 50 , were qualified to at least NVQ level 2, and that 5 more were undertaking the training. Staff members spoken with confirmed that they were completing NVQ courses. Eaves Hall DS0000009495.V324018.R01.S.doc Version 5.2 Page 21 The records of two members of staff, recruited since the previous inspection, were looked at. These records, and discussion with the manager and office manager showed that the way staff were recruited to work in the home helped to protect residents from unsuitable staff. Staff did not start work until the Protection of Vulnerable Adults check and two satisfactory employment based references had been obtained. They did not work without supervision until the full police checks had been received and Induction training had been undertaken. The manager stated that the Induction programme was in accordance with Government guidance, but on the files looked at there were no records of the induction. Also for one member of staff a relevant reference from the home care agency where she was working at the time of her appointment had not been sought, and there was no written explanation of why not. Staff records looked at, and discussion with staff, showed that staff were undertaking training in accordance with their own needs and those of the residents. This training included: looking after people with dementia to help them understand the needs of those residents who were confused or had memory loss; medication; diabetes and external fire training. Eaves Hall DS0000009495.V324018.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was well managed by an experienced qualified manager and a stable staff team. The home had quality assurance measures that took into account the views of residents and relatives. The health and safety of the residents and staff were promoted. EVIDENCE: The current registered manager is qualified, experienced and competent to run the home, with over 13 years experience in managing a care home. She demonstrated a clear commitment to Eaves Hall. Mrs Kendall had successfully completed NVQ level 4 in “Management” and “Care” and had attended Eaves Hall DS0000009495.V324018.R01.S.doc Version 5.2 Page 23 numerous other courses relevant to her post, such as looking after people with dementia, risk assessments and palliative care. Mrs Kendall worked along side the care staff and was praised for her hard work. There were clear lines of accountability within the home and also with the registered provider and responsible individual, Mr Macintosh, who visited the home on a regular basis and made unannounced visits under Regulation 26 of the Care Homes Regulations. The home carried out annual quality monitoring exercises involving residents’ questionnaires and the views of relatives. The last survey showed that in general residents were satisfied with life in the home. There were residents meetings about twice yearly to try and involve residents in the running of the home. There was no residents’ money kept in the home, and the record of the fees charged and paid indicated that fees were managed efficiently and safely in the home. Appropriate (computer) records were kept of fees charged and paid, and the respective contribution of residents and Social Services. The computer records for two residents viewed balanced with the paper records from the Social Services and the written information given to the residents and families. The home was a safe place for residents and staff to live and work. The PIQ indicated that all maintenance and servicing of installations, appliances and equipment had been carried out appropriately. Residents were also protected from the hazards of hot water and hot surface temperatures. Nearly all staff had undertaken appropriate health and safety training, such as first aid training, moving and handling, infection control and food hygiene. However some staff were due to attend up dated moving and handling training. The fire precautions were satisfactory. All staff had attended an external fire safety course and there had been a fire safety inspection on in Feb 2006. Some recommendations had been complied with and the fire risk assessment was satisfactory. Records showed that the fire equipment was tested and maintained sufficiently and that fire drills were held at appropriate intervals. However the names of the staff attending the fire drills were not recorded, so it was not known who needed to attend. Accidents were recorded appropriately according to Data Protection so residents’ rights to confidentiality were respected. Eaves Hall DS0000009495.V324018.R01.S.doc Version 5.2 Page 24 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 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 X X X 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Eaves Hall DS0000009495.V324018.R01.S.doc Version 5.2 Page 25 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) & 2 (c) Requirement Timescale for action 28/02/07 2. OP9 13 (2) 3. OP9 13 (2) The registered person must ensure that all the care plans contain up to date detailed information on all aspects of health, personal and social care needed, including medical information, information about those who have to spend most of their time in bed, including food requirements and information about leisure interests. All medication must be stored at 23/02/07 the correct temperature, including creams and eye drops that require storage below room temperature in a fridge. All hand written entries on the 23/02/07 MAR sheets (additions and alterations) must be double signed (witnessed) and dated (Previous timescale of 18/01/06 not met) Records of medication leaving the home and returned to the pharmacist should be recorded accurately. The medication listed on the MAR sheets must correspond to DS0000009495.V324018.R01.S.doc 4. OP9 13 (2) & 17(1)(a) (i) 13 (2) 23/02/07 5. OP9 23/02/07 Eaves Hall Version 5.2 Page 26 that being prescribed. Only medication listed on the MAR sheets must be given, including creams and eye drops (Previous timescale of 19/01/06 not met) 6. OP9 13 (2) All medication, including eye drops, must be ordered correctly so that residents receive all the required medication The registered person must ensure that all correct procedures are followed, including detailed written records of all incidents, discussions and investigations, affecting residents and staff, following an allegation of abuse Staff must undertake appropriate training in the protection of vulnerable adults The registered person must ensure that the home’s policies and procedures for the protection of vulnerable adults give clear step by step directions to staff and the person in charge according to the Department of Health guidance “No Secrets” Records of the contents of the staff Induction and the dates of commencement and finishing, must be kept in the care homes’ staff records. 23/02/07 7. OP18 13(6) & 17(1)(a) (3)(j) & 17(2), (6)(f) 23/02/07 8 9 OP18 OP18 13(6) 13(6) 30/06/07 23/02/07 10 OP29 19 (5)(d) Amended schedule 2 23/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP1 Good Practice Recommendations It is recommended that details from the social work DS0000009495.V324018.R01.S.doc Version 5.2 Page 27 Eaves Hall 2 3 4 OP9 OP9 OP29 5 OP38 assessment are transferred to the in house documentation so that staff have easier access to more information. The written criteria for PRN medication should be reviewed and updated Oxygen cylinders should be secured securely and should be clearly identified as full or empty. References from places of employment in care should always be sought unless there are good reasons for not doing so and these reasons should always be documented properly. It is recommended that the members of staff attending fire drills be recorded as a way if identifying staff who need to attend Eaves Hall DS0000009495.V324018.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Unit 1 Tustin Court Port Way Preston Lancashire PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Eaves Hall DS0000009495.V324018.R01.S.doc Version 5.2 Page 29 - 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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