CARE HOMES FOR OLDER PEOPLE
Ebberly House 17/18 Ebberly Lawn Bear Street Barnstaple Devon EX32 7DJ Lead Inspector
Adele Adams Unannounced Inspection 30th November 2005 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 Ebberly House DS0000022086.V269726.R01.S.doc Version 5.0 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. Ebberly House DS0000022086.V269726.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Ebberly House Address 17/18 Ebberly Lawn Bear Street Barnstaple Devon EX32 7DJ 01271 345684 01271 345684 ebberly@tiscali.co.uk 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) Mr Peter Frederick George Allen Mrs Beverly Judith Watton Care Home 19 Category(ies) of Dementia (3), Old age, not falling within any registration, with number other category (16) of places Ebberly House DS0000022086.V269726.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 4th August 2005 Brief Description of the Service: Ebberly House is a large, adapted Victorian property, situated in a residential area close to the centre of Barnstaple. The home is sited on the corner of a private residential square, which provides an attractive outlook from the homes lounge. There is dedicated parking for visitors to Ebberly House in the square. Access to the house is on several levels, the main entrance being approached from Ebberly Lawn. Other entrances have ramped access for wheelchairs. There are stair lifts to facilitate access inside the home. Ebberly House provides long-term accommodation for up to 19 elderly people. There are 17 single bedrooms are of varying sizes and outlook and one double room, all are furnished individually. The communal rooms on the ground floor are spacious and comfortably furnished; the atmosphere is homely and relaxed. Ebberly House DS0000022086.V269726.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection has introduced “Key Standards “ to be inspected over each inspection year. Therefore, unless it is felt necessary by the inspector, some standards will not be inspected. To obtain a full picture of the home it is recommended that all reports written within an inspection year (1st April to 31st March) be taken into consideration. This inspection was unannounced and took place between 8:30 and 12:00. During the inspection, the inspector spent time speaking with residents, relatives, the manager and staff. The inspector toured parts of the home and was invited into the rooms of one resident. The inspector spoke to two residents and two visitors and observed residents and staff. The inspector also read a variety of documentation, which included, staff records, resident records, contractors and maintenance records and policies and procedures. What the service does well: What has improved since the last inspection?
The previous inspection was announced and took place on the 4th August 2005. The improvements identified then continue. Ebberly House DS0000022086.V269726.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ebberly House DS0000022086.V269726.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ebberly House DS0000022086.V269726.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): X These standards were inspected and met at the previous inspection. Intermediate care is not a service provided at Ebberly House. EVIDENCE: N/A Ebberly House DS0000022086.V269726.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 Staff skills need to be developed in the administering of medicines through suitable training and the medicines of residents that self medicate must be secure in the lockable storage provided. EVIDENCE: The inspector spoke with the manager to find out what action had been taken in relation to staff training and the storage of medication for residents that self medicate and was advised that medication training was being looked into and provided evidence of a letter showing this. The registered manager advised that lockable storage was being arranged but was not yet in place. The inspector and manager discussed risk assessment in relation to residents that self medicate. Ebberly House DS0000022086.V269726.R01.S.doc Version 5.0 Page 10 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 and 15. Residents at Ebberly House are able to have a full and varied life depending on their wishes, which shows that their independence is valued and encouraged. Routines and activities within the home are flexible and suited to resident’s needs. Residents’ wide-ranging nutritional needs are well catered for. EVIDENCE: The inspector spoke with 2 residents, 2 visitors, staff and the manager and observed staff working with residents. Staff, the manager, the residents and visitors all confirmed that there are activities in the home which include, movement to music, board games, church services, cards and trips out. Residents are able to receive visitors and are able to go out, as they are able. The Statement of Purpose details the activities available at the home and the 2 resident records inspected detail residents social care needs. The inspector spoke with the cook, saw fridge temperature records, and saw the fridge and freezer and food storage areas. Food in the fridge was appropriately covered and dated. The inspector was told that the owners do the shopping for fresh fruit and vegetables. The inspector read the daily food record diary and saw the menus, which are rotated on a four weekly basis, and individual likes and dislikes are catered for. The residents told the inspector that they enjoy the home cooked traditional food visitors confirmed this. The inspector arrived when residents were eating
Ebberly House DS0000022086.V269726.R01.S.doc Version 5.0 Page 11 breakfast – some were using the dining room whilst others had their breakfast taken to their rooms. The lunch on the day of inspection was a roast lunch being served with 3 vegetables, with a dessert of egg custard; the cook was baking a date and walnut cake for the residents’ afternoon tea. The inspector discussed the approach of 5 fruit and vegetables a day with the cook and the manager. Ebberly House DS0000022086.V269726.R01.S.doc Version 5.0 Page 12 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 There is a clear complaints procedure in place, which is used when necessary, this gives relatives confidence that their concerns are taken seriously and are acted upon. EVIDENCE: The inspector read the complaints procedure, which is also noted in the Service User Guide, the procedure is clearly written and provides timescales and guidance and advice in relation to filling out the complaint form. The home has had no complaints recently. Ebberly House DS0000022086.V269726.R01.S.doc Version 5.0 Page 13 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): 21 and 26 Ebberly House provides its residents with a safe, clean and homely environment in which to live. EVIDENCE: The inspector revisited Standard 21 as at the previous inspection it was noted there is no hand washing facility in a bathroom with a toilet that is in use. The inspector was advised by the manager that the owner was considering removing the toilet, as it is difficult to accommodate a sink – the inspector advised that the manager and owner consider standard 21 before doing so, as there is only one other residents’ toilet on that floor. The manager is to discuss further with the owner. All areas of the home visited were clean – one area did have a smell of urine – the carpet had been shampooed the previous day – the manager said she would look into this. The laundry was clean and tidy, there are 2 washing machines, one has a sluicing facility and both have wash cycles in excess of 65 degrees.
Ebberly House DS0000022086.V269726.R01.S.doc Version 5.0 Page 14 The risk assessment for cross infection was read and the home had the hospital infection control guidelines for care homes. Hazardous materials such as disinfectant and bleach were being stored on a shelf in the laundry, which is not currently locked – the inspector pointed this out as an area for action with the manager. Ebberly House DS0000022086.V269726.R01.S.doc Version 5.0 Page 15 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 and 29 Staff are busy but respond in a timely caring manner to residents needs. Current recruitment practices do not ensure residents are protected from unsuitable staff, as not all staff at Ebberly House have had the necessary recruitment checks undertaken. EVIDENCE: The inspector observed the staff working with residents, read the staff rota and spoke with the manager and visitors. All indicate that currently residents’ needs are met by the staff. The inspector spoke with staff and the manager and found that the home will soon have 50 percent of its staff trained to NVQ Level 2. The inspector revisited Standard 29 following the requirement made at the previous inspection and after talking with the manager and inspecting the staff file of a member of staff that had recently started working as a carer at the home found that only one written reference had been obtained and that a CRB, POVA or POCA check had not been undertaken. An immediate requirement was issued and assurances were given by the manager that the member of staff would not work unsupervised and that a CRB, POVA and POCA check would be undertaken immediately. Ebberly House DS0000022086.V269726.R01.S.doc Version 5.0 Page 16 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): 33, 35 and 38 Residents do not currently benefit from positive approach to quality assurance. Residents manage their finances if they are able to and suitable resident finance records are in place. Residents’ safety may be compromised as some Health and Safety checks at Ebberly House remain outstanding. EVIDENCE: The inspector spoke with the manager in relation to quality assurance and quality systems at Ebberly House. The manager advised the inspector that the last resident questionnaire was undertaken in January 2004 and that she was aware that this is an area to be improved. The registered manager confirmed she does not act as an agent for any of the residents. Families or a named person such as a solicitor manages residents’ finances. The registered manager oversees the residents’ day to day money for payment for services such as the chiropodist and hairdresser.
Ebberly House DS0000022086.V269726.R01.S.doc Version 5.0 Page 17 An inventory of residents’ possessions is held in each residents record – 2 of these were seen. Standard 38 was revisited in respect of the five yearly electrical testing at the home which was found to be six months overdue at the previous inspection – the manager confirmed in writing the day following the inspection that this had not been done and that the owner is arranging for this to take place. The hoist and stair lifts were maintained in June 2005 and certificates were produced to verify this. The PAT testing has not yet been done. Ebberly House DS0000022086.V269726.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X X 1 X X X X 1 STAFFING Standard No Score 27 3 28 3 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X 1 Ebberly House DS0000022086.V269726.R01.S.doc Version 5.0 Page 19 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 OP9 Regulation 13(2) Timescale for action The registered person shall make 31/12/05 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. All medication in the home must be securely stored - this relates to medicines in resident’s rooms. Staff should receive suitable training in the administration of medicines. (2) The registered person shall having regard to the number and needs of the service users ensure that (j) there are provided at appropriate places in the premises sufficient numbers of lavatories, and of wash-basins, baths and showers fitted with a hot and cold water supply. This refers to the lack of a wash hand basin in a resident’s bathroom / toilet. 28/02/06 Requirement 2. OP21 23(2)(j) Ebberly House DS0000022086.V269726.R01.S.doc Version 5.0 Page 20 3 OP26 13(4)(a)( b)(c) (4) The registered person shall ensure that (a) all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety; (b) any activities in which service users participate are so far as reasonably practicable free from avoidable risks; and (c) unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. This refers to hazardous liquids in the laundry. The registered person shall not employ a person to work at the care home unless - (c) he is satisfied on reasonable grounds as to the authenticity of the references referred to in paragraph 5 of 2 in respect of that person. Schedule 2 Paragraph 5 - Two written references relating to the person. This refers to only having one reference and no CRB, POVA or POCA checks for a new member of care staff. 31/12/05 4. OP29 19(1) 30/11/05 Ebberly House DS0000022086.V269726.R01.S.doc Version 5.0 Page 21 5. OP38 13(4)(a) The registered person shall ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. This refers to the electrical testing remaining overdue. The previous date of 30/09/05 was not met. 31/12/05 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 OP33 Good Practice Recommendations The home should have effective quality assurance and quality monitoring systems in place. Ebberly House DS0000022086.V269726.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Ebberly House DS0000022086.V269726.R01.S.doc Version 5.0 Page 23 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
