Inspection on 30/08/06 for Eboracum

This inspection was carried out on 30th August 2006.

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

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

Other inspections for this house

Eboracum 22/08/07

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Snydale Care Home

Larchfield Manor

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Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Eboracum 177 Park Grove Barnsley South Yorkshire S70 1QY Lead Inspector Christine Rolt Key Unannounced Inspection 30th August 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Eboracum DS0000065058.V303506.R02.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. Eboracum DS0000065058.V303506.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eboracum Address 177 Park Grove Barnsley South Yorkshire S70 1QY 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) 01226 203903 F/P01226 203903 jf@eboracumhouse.wanadoo.co.uk Mr Stephen John Oldale Miss Susan Jane Leigh Miss Joanne Featherstone Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Eboracum DS0000065058.V303506.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Eboracum House is a stone built residence with a purpose built extension on two levels providing personal care for 18 elderly people. It is situated in a residential area of Barnsley, on a main bus route, close to the M1 junction 37, local bus routes and shops. It stands in its own grounds with mature trees and shrubs, with sitting areas for service users and their families. It is well decorated with 18 single rooms, two of which are ensuite, lounge, conservatory and dining room. Service users rooms are located on the ground and first floors and the home is equipped with handrails, other adaptations and a passenger lift to assist people in moving around the home. Aids for service users are provided in bathrooms and toilets. There is a car park to the side of the building. Eboracum DS0000065058.V303506.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection and comprised information already received from or about the home and a site visit. The site visit was from 9:30 am to 6.20 pm on 30th August 2006. The registered manager, Ms. Joanne Featherstone was present and provided assistance throughout the day. The majority of the residents were seen, chatted to and asked questions about the home. One resident was asked detailed questions about their opinions of the home. Comment cards were sent to ten residents and of these nine were completed and returned. Two residents were tracked throughout the inspection. Six relatives were asked for their views of the home. A sample of records was examined and a partial inspection of the building was carried out. The inspector wishes to thank the manager, staff, residents and relatives for their assistance and co-operation. What the service does well: Since the last key inspection, the Commission Social Care Inspection had registered the manager. She had recently completed NVQ Level 4 and her next objective was to attain the Registered Managers Award. She ensured that all staff were well trained. Residents were well cared for and liked living at the home. relatives were very positive. The environment was pleasant and comfortable. cleanliness was high. Comments from The standard of hygiene and The food was good and offered a wide variety of options and resident chose when and where they ate their meals. The home had a quality assurance system and residents’ and relatives’ views were sought to ensure that the home was run in the best interest of residents. What has improved since the last inspection? The homes recruitment procedure had improved. The home had attained the Barnsley Silver Award for Food. The home had attained the Investors in People Award. Eboracum DS0000065058.V303506.R02.S.doc Version 5.2 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. Eboracum DS0000065058.V303506.R02.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Eboracum DS0000065058.V303506.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 Quality in this outcome area is good. This judgement has been made from evidence gathered before, during and after the visit to this service Prospective residents had the information they needed to make an informed choice about where to live. Residents’ needs were assessed prior to moving into the home to ensure that their needs could be met. This home does not provide intermediate care. EVIDENCE: Residents and their relatives said that they had received sufficient information about the home. Several relatives said that they had visited a few homes before choosing this one. Reasons for choosing this home were “Location, and knew the previous owner Christine”, “Appealing”, “Had a good report”, “Convenient and knew the previous owner”, “Very good reputation”, “Blew my mind away” and “Recommended”. The Service User Guide was displayed in Eboracum DS0000065058.V303506.R02.S.doc Version 5.2 Page 9 the entrance hall. The manager said prospective residents or their relatives were given brochures of the home and copies of the Service User Guide were available on request. Residents were assessed prior to admission to the home and copies of the assessments were seen on residents’ files. Eboracum DS0000065058.V303506.R02.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made from evidence gathered before, during and after the visit to this service Residents’ needs were set out in their care plans. Health needs were generally met. Minor improvements needed to be made to the recording of medication. Residents were treated with respect and their rights to privacy were upheld. EVIDENCE: Residents and their relatives said that residents’ care and health needs were met and relatives were kept informed. Comments were, “ Excellent care, couldn’t do better, very settled”, “Very well co-ordinated in dress, always clean and well dressed”, “Clean, smells beautiful, fed and got company 24/7”, “Chiropodist visits regularly” and “Doctor visits frequently”. Two care plans were checked and these showed the action that needed to be taken to ensure residents’ physical needs were met. Risk assessments and life histories were kept in separate files. Medical visits were recorded but there was no information on daily records of what had prompted visits. Accidents Eboracum DS0000065058.V303506.R02.S.doc Version 5.2 Page 11 were recorded but more information was needed to determine the monitoring and action taken following accidents especially where there were no apparent injuries at the time of accidents. Care plans were reviewed monthly but there was no evidence that the residents or their relatives were involved in these reviews. This was discussed during the site visit. Individual files for each resident would ensure that care staff had all the information they needed and this was discussed with the manager during the site visit. The home used a monitored dose system for medication but some residents also had loose medication (i.e. in packets separate from the monitored dosage system.) There were minor discrepancies with this loose medication where the printed medicines administration sheet, supplied by the pharmacist, listed the total of medication supplied for the month on each week’s sheet. Also the care staff were not carrying forward the remaining tablets to give a true total of the tablets remaining. The manager was advised to discuss this with the pharmacist and also to ensure that staff dealing with medication carried forward any remaining tablets to ensure that stock checks could be carried out. The home did not have a medication room. Medication was kept in various parts of the home. Medication that required refrigeration was kept in its own container in a domestic refrigerator but the correct procedure for storage was not being followed. The viability of keeping all medication in one area was discussed with the manager. Residents and relatives considered that residents’ dignity and privacy were respected and comments were “Sure they do – they love her” and “Yes, she says they’re (staff) lovely” and “Love her to bits”. Residents who were capable, had keys to their bedrooms and lockable facilities. The manager said that where residents were not capable, relatives were offered the keys. Relatives confirmed this. Residents had mobility aids to maintain their independence. Eboracum DS0000065058.V303506.R02.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made from evidence gathered before, during and after the visit to this service Residents found the lifestyle in the home generally matched their expectations and preferences and maintained contact with their family and friends and local community. They had choice and control over their lives. Residents received a wholesome, appealing, balanced diet in pleasing surroundings at times convenient to them. EVIDENCE: During the site visit, an organist came to play music for the residents and encouraged them to join in. The manager said that this was a weekly event. Relatives’ views of activities in the home were mixed. Some considered that there were “lots of things to do”, “ Yes, plenty”, and “Yes, has activities”, whilst other comments were “Would like more – some activities that are appropriate to her, but quite happy” and “Never seem to do any”. The manager said that the home provided a range of activities including board games, bingo, music, video, crafts, sing-along, hand massage and nail care, reading material, and baking. She also said that they provided group and individual outings for shopping, dining out and day trips. Eboracum DS0000065058.V303506.R02.S.doc Version 5.2 Page 13 Relatives said they were made welcome and one comment was, “They bring a tray with tea, coffee and home made buns no matter how busy they are. It’s the icing on the cake” The manager said that church ministers visited the home and staff would accompany anyone wishing to go to church. The home had two pet cats. The organist brought her pet dog for residents to make a fuss of. The manager said that visitors were welcome to bring their pets when they visited residents. Residents were seen to get up when they wanted. They could go to their room when they wished and some chose to have their meals in their rooms. Meals were available at times convenient to residents. The cook was on duty from 8am to 6pm. Meals seen during the site visit were appetising with fresh produce. Breakfast offered a good selection and variety of cooked meals, cereals, fruit juices, prunes and grapefruit. Menus were displayed throughout the home and there was a good range of options available. The home had attained the Barnsley Silver Food Award. The dining room was pleasant and domestic in character. Several relatives said the food was excellent. Other comments were “Enjoyable”, “Mum’s eating well – back to feeding herself”, “Food available anytime of day or night” and “Nice substantial meals at lunch time, nice sandwiches and other meals at other times of the day”. Eboracum DS0000065058.V303506.R02.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made from evidence gathered before, during and after the visit to this service Residents and their relatives were confident that their complaints would be listened to, taken seriously and acted upon. Staff had not received adult protection training. EVIDENCE: Residents and relatives said that they would tell the manager if they were not satisfied and were confident that complaints would be addressed. The complaint procedure was displayed. This needed minor amendment to bring it up to date. There were no allegations of abuse. Staff had not received adult protection training. The manager said that she had made arrangements for someone from the Adult Protection Unit to visit the home and talk to staff about adult protection issues but no-one turned up. She was in the process of arranging adult protection training through Barnsley Council but earliest dates available were January 2007 and she was also making arrangements to undertake training to enable her to train staff in adult protection. Eboracum DS0000065058.V303506.R02.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22 and 26 Quality in this outcome area is adequate. This judgement has been made from evidence gathered before, during and after the visit to this service Residents lived in a clean well-maintained and hygienic environment but resiting the nurse call system for accessibility would improve residents’ safety. EVIDENCE: The home was cosy, welcoming, clean and hygienic and the gardens were well tended and pretty. Several bedrooms, a bathroom, a shower room, lavatories, both lounges and the dining room were checked. There were no offensive odours and the home was well decorated throughout. All rooms seen were clean, tidy and well furnished and bedrooms were individual to the residents. The call system pull cords in both lounges were not within reach of residents. The need to re-site these to make them accessible to residents was discussed with the manager. Eboracum DS0000065058.V303506.R02.S.doc Version 5.2 Page 16 Residents’ and relatives’ comments about the home were “Good”, “Beautiful, very well kept”, “Always beautiful and clean, absolutely fantastic”, “Lovely bedroom – couldn’t be better”, “Excellent and “Very good”. Mobility aids and equipment, i.e. wall bars, raised toilet seats, support rails, were provided to enable residents to maintain their independence. Eboracum DS0000065058.V303506.R02.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made from evidence gathered before, during and after the visit to this service Staffing levels did not always meet residents’ needs. Residents were supported and protected by the homes recruitment procedures and staff competence. EVIDENCE: There were two staff and a trainee on work experience on duty during the site visit. It was noted that the staff office was quite isolated and quite some distance from residents, therefore when one carer went to the office, there was only one member of staff available to attend to residents’ needs. During the site visit it was observed that a member of staff had to call several times for the second member of staff (who was in the office) to attend an accident/incident. The need to ensure that two staff are available at all times was discussed with the manager. This means re-siting the staff office or providing extra staff. Three staff files were checked. All contained the relevant documentation and checks to ensure that residents were protected from abuse. There was also evidence that staff had undertaken induction training. For ease of reference, a method for improving the filing of staff documentation was discussed and recommended. The Pre-inspection Questionnaire provided information that 67 care staff were qualified to NVQ Level 2 or above, which exceeded the minimum requirement of 50 . During the site visit, the manager stated that Eboracum DS0000065058.V303506.R02.S.doc Version 5.2 Page 18 staff were keen to improve their knowledge and increase their skills and several were to undertake NVQ level 3 in care. Individual supervision sessions were held. Staff were observed to be calm and caring and treated residents with respect and dignity. Relatives’ comments about the staff were all positive and one comment was “She (the resident) says they’re lovely. They love her to bits.” Eboracum DS0000065058.V303506.R02.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made from evidence gathered before, during and after the visit to this service Residents live in a home that is run and managed by a person who is fit to be in charge. The home is run in the best interests of resident. Residents’ financial interests were safeguarded and their health, safety and welfare were promoted and protected. EVIDENCE: The registered manager has worked at this home for several years and was known to residents and their relatives. She had recently completed NVQ Level 4 and her next objective was to undertake the Registered Managers Award. This year the home achieved the Investors in People Award. Written reports of visits to the home by the registered provider were available and these were Eboracum DS0000065058.V303506.R02.S.doc Version 5.2 Page 20 checked during the site visit. A relative also confirmed that the registered provider had asked for her views of the home. The home had carried out resident and relative questionnaires and these were seen during the site visit. The manager also carried out environmental audits of the home. Audits could be increased to include practices within the home e.g. care plans, accident monitoring, medications etc., as part of the Quality Assurance monitoring system and this was discussed with the manager. Money held on behalf of residents was checked against written records. These tallied. Receipts were available for purchases made on behalf of residents. Money was stored safely. Relatives said that they did not receive receipts for money handed over on behalf of residents, but said that this was not a problem. However, the manager was advised to start issuing receipts. It was also recommended that residents signed for any money that was given to them. There were good records of staff training, which ensure that all staff were up to date the mandatory health and safety training. The servicing and maintenance of systems and equipment within the home had been carried out and the manager provided information and dates in the Pre-Inspection Questionnaire. Eboracum DS0000065058.V303506.R02.S.doc Version 5.2 Page 21 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X 2 X X X 4 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Eboracum DS0000065058.V303506.R02.S.doc Version 5.2 Page 22 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 2 Standard OP7 OP8 Regulation 15 13 Timescale for action Residents and/or relatives must 24/11/06 be consulted about the reviews of their care plans. Information on how residents’ 24/11/06 health needs are monitored following a fall or accident must be recorded The manager must discuss with 24/11/06 the pharmacist the situation regarding pre-printed sheets for loose medication and ensure that staff are aware of the procedure for carrying forward loose medication. The correct procedure must be 24/11/06 followed for medication that requires refrigeration. Activities must be appropriate to 24/11/06 residents’ needs and abilities to ensure motivation and stimulation. All staff must receive adult 24/11/06 protection training and guidance. (Requirement outstanding from or before 31st August 2005) The call system pull cords must 24/11/06 be accessible to residents. Staffing levels must be 24/11/06 appropriate to residents’ needs. DS0000065058.V303506.R02.S.doc Version 5.2 Page 23 Requirement 3 OP9 13 4 5 OP9 OP12 13 12 6 OP18 13 7 8 OP22 OP27 13 13 Eboracum RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard OP9 OP27 OP33 OP35 OP35 Good Practice Recommendations Consider the feasibility of having a medication room for the storage of all medication Consider the feasibility of moving the staff office nearer to residents Increasing the audits to cover aspects of care practices would enhance the quality assurance monitoring system. Receipts should be issued for money handed over on behalf of residents. Residents should (where possible) sign for any money that is given to them. Eboracum DS0000065058.V303506.R02.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Eboracum DS0000065058.V303506.R02.S.doc Version 5.2 Page 25 - 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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