Inspection on 01/11/06 for Ebury Court

This inspection was carried out on 1st November 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ebury Court 23/10/08

Ebury Court 27/02/06

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

CARE HOMES FOR OLDER PEOPLE Ebury Court 438 Rush Green Road Romford Essex RM7 0LX Lead Inspector Mr Roger Farrell Key Unannounced Inspection 1st November 2006 11:30 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 Ebury Court DS0000065997.V305046.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. Ebury Court DS0000065997.V305046.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ebury Court Address 438 Rush Green Road Romford Essex RM7 0LX 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) 01708 728 734 01708 728 797 Ebury Court Residential Home Limited Mrs Beverley Anne Manzar Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39) of places Ebury Court DS0000065997.V305046.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th February 2006 Brief Description of the Service: Ebury Court is a private care home that can accommodate up to 39 elderly people. Set up as a family business over twenty years ago, the building has been expanded and up-graded to make sure it keeps up with modern expectations. The result is a comfortable, functional, and well-maintained building that has many merits. There are 37 bedrooms with en-suite wc’s. All are used as singles, but the two largest can be used as doubles by couples. The main communal rooms and service areas are on the ground floor, along with three bedrooms. The rest of the bedrooms are on the first and second floors, with all levels linked by a lift. It is set well back from Rush Green Road, which connects the main town centres of Romford and Dagenham. This handy position means that it is in a central spot for both the boroughs of ‘Havering’ and ‘Barking and Dagenham’. There is a good-sized forecourt, additional rear car park, and a delightful large secluded garden. The convenient location and good quality hotel-style accommodation are matched by a determination to achieve high standards of care. The manager, who is a qualified social worker, leads a stable and dedicated team. Ebury Court DS0000065997.V305046.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on Wednesday 1 November 2006 between 11.30am and 6pm. Beverley Manzar the manager was on duty and took a lead in dealing with the enquiries, though spent a couple of hours leading a staff training session on dementia care. The inspector returned the following Friday to complete the checks. Mrs Grace Key was also available, as was Richard Keys who deals with safety and building matters. The manager was efficient in responding to the inspection, including putting together a folder of supporting evidence. The inspector also appreciates the assistance provided by the deputy manager, including describing the medication arrangements and helping with the checks of bedrooms. He is grateful for the welcome he receives from residents and staff. Particular thanks are offered to the group of residents who talked to the inspector over lunch, the staff who attended the meeting, and all those who made individual comments over the two days. Appreciation is also due to residents who returned questionnaires, and all comments have influenced the conclusions contained in this report. The inspector has looked at the relatives’ questionnaires returned at the last main inspection. He has been given an updated list of contacts for relatives and social workers and a fresh batch of questionnaires will be sent out before the next visit. The inspector gave an overview of the changes in the way care homes are assessed. This includes the registered persons carrying out in-house monitoring audits, making sure the Commission is kept informed of changes and incidents, and from next Spring – publishing the home’s ‘quality rating’. The manager is good at keeping herself up-to-date on such changes, and wider issues to do with care services for older people. She has applied to have the homes registration extended to include older persons with a diagnosis of dementia. What the service does well: The main conclusion remains that this is a well-run service that is successful in meeting the needs of residents, and is much appreciated by them and their families. One typical quote from a relative at the last visit was – “Mum has been here over two years. One of the family visits most days. Everything seems okay….They are always happy to help. They keep us well informed, including by phone. Mum wants to be in her room a lot of the time and they are okay about that. Its fine…The staff are all friendly.” Another regular visitor said - “My mum is very happy at Ebury Court. One of us visits every day so we are well informed about what is going on. We are very satisfied with her care.” Ebury Court DS0000065997.V305046.R01.S.doc Version 5.2 Page 6 The manager who started two years ago has introduced some significant improvements. This includes setting up new style files that identify how each person’s care needs will be supported. These also have good detail on linking up with medical services. She is also paying particular attention to staff training, including dementia awareness as they have applied to be licensed in this more specialised area of care. This is being taken into account in practical ways too, such as contrast decorations and different coloured doorframes on loos and bathrooms. All staff are being encouraged to do the main NVQ qualifications, with the 50 target now well exceeded. Careful thought has been given to good design during the phases of expansion and upgrading. As a medium-sized home, the layout avoids institutional conditions by having three separate lounges, and two dining rooms. Good attention to quality is apparent in the new conservatory, including airconditioning and screening blinds. One regular visitor said – “Yes we did shop around. We chose {Ebury Court} because of the very good facilities. {Our relative} loves the outlook onto the garden. The conservatory is kept warm in the winter and cool in the summer”. This report again acknowledges the very good housekeeping standards by awarding the top ‘commendable’ score under that heading. What has improved since the last inspection? The manager has largely completed the major revision of how practice files are arranged. This includes working on assessment forms that cover all the necessary areas that are set out under Standard 3.3 in the National Minimum Standards. The standard of ‘service users files’ - including the ‘care-plans’; social histories; ‘listening forms’; and medical notes are very good indeed. In recognition of this achievement the top ‘commendable’ rating has been awarded under that important heading. Further innovations are being developed such as review forms and new monitoring sheets, such as for night checks and for residents who prefer to spend their time in bedrooms. The manager acknowledges the help provided by a masters degree social work student who did a placement at the home. The manager described other ways of involving people, such as encouraging participation from the ‘Friends of Ebury Court’, including volunteering to help with outings and activities. One result was the money raised at the ‘Summer Fete’ helped pay for the new summerhouse. Indeed the range of activities has been broadened, and still include the popular ‘music for health’ and yoga sessions. Better links have been established with Barking and Dagenham Age Concern. This has led to residents attending a music and dance club, and finding befrienders for the couple of residents who do not have visitors. Monthly residents’ meetings are taking place, with the minutes up on the main notice board. At the time of the last inspection the birthday celebrations for a resident who is 101 had been featured in the local newspaper. This person’s daughter was Ebury Court DS0000065997.V305046.R01.S.doc Version 5.2 Page 7 quoted saying how her mother has made remarkable recovery from a series of health problems, adding - “We had a musician come along and he played songs from right through the years. He finished off with Vera Lynn’s old wartime favourite ‘Well Meet Again’, and everyone joined in.” 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. Ebury Court DS0000065997.V305046.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 Ebury Court DS0000065997.V305046.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. Quality in this outcome area is ‘good’. This judgement has been made using available evidence including a visit to the service. This involved looking at the file and talking to the most recent person to move in. The ‘Admission and Manual Handling’ section had sufficient key-contact details, referral and assessment information, and the full care plan had been completed. The eight residents who completed questionnaires ticked ‘yes’ to the question about having enough information before moving to Ebury Court. All five applicable standards are rated as ‘met’, confirming that a helpful and methodical approach is used to help residents move in. EVIDENCE: At the last main visit the manager gave a description of the steps followed when a prospective resident is referred. This typically involves visiting the person in hospital to determine dependency levels, such as mobility. She discussed with the inspector the usefulness of the referral information made available from the four or so local authorities that mainly use the home. In general, these are satisfactory, with good assessments being provided from Newham, Barking and Dagenham and Tower Hamlets – but those from Havering were seen to vary in their worth. Ebury Court DS0000065997.V305046.R01.S.doc Version 5.2 Page 10 The sample of residents’ files seen at this recent visit included the last person to move in. This had a ‘pre-admission assessment’; ‘personal details section’; the ‘risk assessment ‘with additional pages; and a detailed eleven-page referral report from Newham social services. All sections of the main care plan had been completed covering eleven headings, with each having been reviewed a month after the person moved in. The first review with the social worker had been booked. The inspector pointed out one matter that needed following up about a vague diagnosis, but overall this represents a very high standard. This resident said – “The grub is very good. My room is very nice. Things meet my expectations. I didn’t really want to come into a home, but it has worked okay for me.” One comment from a family visiting at the last main visit was – “We are grateful that we chose Ebury Court. We did look at a few, and this appeared the most friendly. They offered us a copy of their unannounced report, others didn’t…..We do get invited to ‘residents’ meetings’. If we had a problem we would raise it, but there hasn’t been anything really. We are always offered a cup of tea.” The manager gave an update on how other agencies are chased up to make sure they pass on sufficient details. This includes ‘discharge reports’ from hospital staff when a resident returns following an admission for treatment. She also described recent difficulties getting a resident to be accepted for hospital re-admission. The large print ‘statement of purpose’ gives basic descriptions, such a main ‘who’s-who,’ and how to make complaints. This is used as part of the ‘serviceusers guide’, there being a laminated version available with inspection reports attached. There is also a colourful folder-style brochure with large photo inserts showing some of the home’s attractions - such as the pleasant lounges, the adapted mini-bus; the delightful garden, and the commitment to provide ‘freshly prepared home-style cooking’. The notice boards in the entrance areas relevant information on display, including ‘listening/comment forms’, details of activities and entertainers, and about a visiting clothes shop. There were also copies of the latest ‘Newsletter’ and minutes of October’s ‘resident and relatives meeting’. The sample of files seen had copies of the signed standard contract from the sponsoring agency, including for the most recent resident. There are also signed ‘disclosure of information’ agreements. Ebury Court DS0000065997.V305046.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is ‘good’. This judgement has been made using available evidence including a visit to the service. The manager has successfully improved the way care plan files are kept over the past year. These are now much better at showing individual needs and the specific help each person requires. This includes monitoring physical wellbeing, including linking in with medical services. A social worker wrote - “I know that my client is receiving the level of care that he needs. Beverley and her team have always been very supportive to my client and his family.” The highest ‘commendable’ rating has been awarded for the quality of the practice records. This includes comprehensive care plan files, innovative monitoring forms, and health care tracking sheets. EVIDENCE: The headline finding of the last main inspection was that the manager was close to completing a major overhaul of how care plans are recorded and monitored. This has been completed with further innovations being introduced. The ‘service users’ files’ are arranged in a neat and logical sequence with clear cover details and prompts, and a large photo. Section 2 of these files contains the main care plans, reviews and risk assessments. The standardised care plan proformas are set out under eleven headings using ‘Needs; Aims’; Risk; and Ebury Court DS0000065997.V305046.R01.S.doc Version 5.2 Page 12 Action’ columns. The range of examples seen had sufficient detail, with clear typed instructions and monthly re-evaluations. There is a general riskassessment, plus more specific entries such as risk of falls that had been updated recently. A social work student on placement had helped introduce further improvements, such as completing detailed social histories, and preparing pre-review updates. The files seen also had details of the last review. A new proforma has been developed for reviews. The sample seen at this visit included that of the resident with the highest dependency needs, and another who had deteriorated since he last spoke with the inspector at the last visit. Files contain additional guidance on relevant areas, such as the signs to look out for if someone has diabetes. There is now a section for the ‘listening forms’ that have been introduced to help ensure individual residents are receiving the service they expect. There is also a section for details of any complaint that has been made by, or on behalf of the service user, and accident reports. This comprehensive approach includes a section covering health care needs. This has a medication profile, and a series of tracking sheets listing contacts with doctors and other health care workers - including GP, dentist, chiropodist, eye care, and district nurses, and details of hospital treatments. The medication chart showed one resident’s medication had been changed recently. The inspector checked and found that the details on the main file had indeed been updated. The manger had previously stressed how helpful they were finding the care home health support team (‘NRHSS’). They carried out regular visits, with a primary aim of diagnosing and treating problems early, therefore preventing the need for hospital admissions. They would keep tracking sheets on residents’ files. They also provided training. However, this service had lapsed considerably over recent months. The lead consultant from this specialist medical team has promised that this support service would be revived, but this had not yet happened. This home had acted as a pilot for this innovative initiative. In his meeting with staff, a number said that this had been the biggest loss over the past year. Further, whilst still praising the support received from the main GP practice, there has been increased expectation that staff take residents to the surgery. Whilst access arrangements are suitable, there has been a knock-on effect regarding the availability of the home’s minibus, and on staff time. It was said that the owners have been very helpful in supporting surgery visits. The inspector also looked at the ‘daily report files’. These are mainly made up of repetitive one-line entries, but greater detail is entered where necessary. This file also contains good brief guidelines. The manager is also introducing a better monitoring records including ‘hour-by-hour’ night observation charts, and ‘key worker check-lists’ covering personal care such as nails, skin Ebury Court DS0000065997.V305046.R01.S.doc Version 5.2 Page 13 condition and hairdressing. The inspector also saw specific monitoring forms used for the few residents who prefer to spend most of their time in their bedrooms. Medication is provided by a local pharmacy in monitored dose blister packs, along with printed administration sheets. It is kept in a purpose-designed trolley, which is stored in the locked drugs cupboard in the outer office area. This store and trolley were clean and neatly arranged. The deputy and senior team leader double-check the in-coming four-week supplies. There have been occasions when they have picked up the need to check items with the pharmacist. They also take a lead in administering medication, one or other being on shift for about 60 of the week. Both have done the medication course at Oaklands College. Standard practice is that two people are always involved in giving out medication. When neither of the two main senior staff are available, the designated ‘shift leader’ takes responsibility - four of which are ‘approved’ having been through shadowing and at least three observations. The supplying pharmacist provides training spread over four sessions, and this includes a competency test. The inspector was told that there were no known errors over the past year. The sample of medication record sheets seen were all clear and neatly completed. This included extra checks, such as taking pulse readings. There is a laminated profile sheet for each person, including a photo and noting any known allergies. Up-to-date drug reference books are available. The deputy was able to give well-informed answers on a number of drugs being used. Where medication is changed, the GP is asked to confirm this by faxing over a letter, examples of which were seen. Therefore, the conclusion is that conditions and arrangements covering medication are satisfactory. The supplying pharmacist visits to check arrangements every three months. Ebury Court DS0000065997.V305046.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is ‘good’. This judgement has been made using available evidence including a visit to the service. This involved looking at what trips and in-house activities had taken place, how many residents were involved, and how residents and relatives are consulted and involved. Cultural considerations include visiting clergy, involvement with ethnic minority clubs, and following through a request for traditional East End meals raised at the previous month’s ‘residents and relatives’ meeting. The manager is continuing to expand the range of activities, and broaden active involvement of relative volunteers. There was lots of good evidence to confirm all these standards as ‘met’. EVIDENCE: The manager gave an update on the range of activities, and gave the inspector copies of the weekly ‘activities planners’. These cover regular sessions such as the Park Centre dancing sessions on Mondays, which about eight residents attend. Other outside events include a craft circle, and service and coffee mornings at St Augustine’s Church. Trips out for fish and chips are also popular. The home has its own minibus fitted with a tail-lift. The most popular in-house event is the fortnightly ‘music for health’ session led by two visiting organisers. Up to twenty residents join in, including those who have mental frailty. During the summer some of these sessions were held Ebury Court DS0000065997.V305046.R01.S.doc Version 5.2 Page 15 in the garden. The weekly ‘yoga and gentle exercise’ group is also proving popular, as is the ‘floristry club’; ‘knitting group’; and ‘cooking club’. There are also reflexology sessions, and they plan increase these ‘alternative health’ sessions, including head massages. There is an activity booked for most morning and afternoon slots, including at weekends, and a log is now kept of who has joined in. There is a visiting entertainer most months, with posters up showing the next event, such as for the Variety Show booked for the following Saturday. Outings this year have included Buckingham Palace; Eastbury Manor; Malden; and Burnham-on-Crouch. A trip to Hampton Court in the summer had to be cancelled due to the very hot weather. Catholic clergy visit each week, and a vicar and church helpers call at least once a month. Awareness was shown about the needs of residents from ethnic minorities, including one Afro-Caribbean elder who has told the inspector about his role as Honoury President of a club he has been involved with over many years. This person also chairs the home’s ‘resident and relatives meetings’. The minutes of the last meeting on 17 October 2006 were available in the lobby. One resident had been introduced to a Vietnamese cultural centre, but access and dialect problems became apparent. He now attends a more local and appropriate Vietnamese centre, which includes accessing video films and books in his first language. One family arranged for a care worker to accompany a resident on a pilgrimage to Lourdes. One staff member wrote saying - “There is a good quality of care given at Ebury Court. Health issues are dealt with promptly. Activities are provided daily - both in-house and outside. Yoga and ‘music for health’ are popular with the service users.” Another wrote – “I feel that our residents are well looked after and that they are offered plenty of choices on what to do.” This year greater effort has been put into involving the “Friends” group. This included supporting the summer fete, where £500 was raised towards the cost of the new sturdy summerhouse in the garden. The brochure says that visitors are welcome at anytime. One couple that visit regularly had told the inspector said – “We visit every second day and bring our dog along. I would describe the staff as very good. Occasionally you see different ones but mostly it is the same girls. We are always offered tea straight away. {Our relative} is very pleased with her bedroom and says the staff are very helpful with personal care.” The manager gave an overview of visits, with all residents except three having regular, usually weekly visits from family. A befriender from Age Concern visits two residents who do not have contact with family. One request at the previous month’s ‘resident and relatives’ meeting was for ‘old fashioned pie, mash and liquor’. Mrs Keys gave a commitment that this Ebury Court DS0000065997.V305046.R01.S.doc Version 5.2 Page 16 would be followed up within a couple of weeks once the quality of suppliers was checked out. True to her word, this was a choice on the day the inspector had lunch with residents, supplied by a traditional East End pie shop. The cook and her assistant were testing a sample to see if they could produce a similar recipe themselves. Comments on the quality of catering made by residents were again consistently positive. Ebury Court DS0000065997.V305046.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18. Quality in this outcome area is ‘good’. This judgement has been made using available evidence including a visit to the service, including looking at documents and speaking with staff. The inspector is satisfied that information on complaints is readily available, and that the manager and owners treat any concerns seriously. Staff showed a good understanding of what to do if there was a suspicion of abuse. EVIDENCE: Details of how to make a complaint are up on the main notice boards, and included in the brochure. There have been no entries in the ‘complaints book’ since November 2004. The owner checks complaints as part of her ‘monthly reports’. Copies of all the main guidance covering adult protection procedures are available, including ‘No secrets’; the local procedure, and those for all councils who use the home; and the home’s policies, including that covering ‘whistle blowing.’ The inspector has seen the log of actions followed the last time a relative raised a possible concern. Staff gave good answers when asked about their understanding of ‘whistle blowing’ responsibilities, some saying that they had covered this area again as part of their NVQ training. The one issue previously raised by the inspector has been followed through – staff confirmed that they have all been given a copy of the General Social Care Council’s code of practice and have signed to say they have read it. On the second day of the visit the manager was providing a training session on protection procedures. Ebury Court DS0000065997.V305046.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is ‘good’. This judgement has been made using available evidence, including looking at all communal areas, and a sample of ten bedrooms. This is very well maintained building, with excellent attention to hygiene and safety. Satisfaction with cleanliness and comfort features in comments made by residents and visitors. The consistently good household standards seen again at this unannounced visit are a credit to the housekeeping team, and deserve repeating the top ‘commendable’ score that has been awarded in that category. EVIDENCE: Two of this family-run small company are chiefly involved in making sure the building is maintained in a good condition, including one being the full-time onsite premise manager with a separate office. Redecorations this year have included the main tv lounge, downstairs corridors, and about a third of the bedrooms. Consistently excellent standards of cleanliness and safety were found in all areas, including the kitchen. The spacious laundry was also tidy, with clothing Ebury Court DS0000065997.V305046.R01.S.doc Version 5.2 Page 19 kept in residents’ individual baskets. A new heavy-duty washing machine with disinfecting action has been installed. The main gas stopcock has been moved outside for greater safety. The inspector looked at about a third of the bedrooms, seeing examples on each of the three levels. Without exception, these were suitably furnished, clean, and had good signs of personalisation. All bedrooms have their own loos, and a couple have en-suite bathrooms. Positive points included call-bells being in the right position; one person having good arrangements for his computer; some rooms having balconies; and consideration for a resident who can smoke safely in her own room. As areas have been decorated, this has included improved safety arrangement such as radiator covers. Good thought is given to helping with mobility, notably having a couple of top-of-the-range ‘steady transporters’. Recent redecorations have taken into account the move towards dementia care, such as having contrast colour painted frames on main toilets. The last report said it is now time to consider improvements to bathrooms, as their appearance is basic but functional. Staff who spoke with the inspector agreed that bathrooms need to be put at the top of the improvements list. The maintenance manager is researching ways of changing the sit-up ‘medibath’ on the first floor with a fully enclosed large shower unit. The bathroom on the second floor has an electric hoist seat, and chair scales. Further improvements to bathrooms are planned. The same careful attention to safety can be seen around the outside of the building, including the well maintained garden that is now fully enclosed. A new Summerhouse has been added with a solid base. Ebury Court DS0000065997.V305046.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is ‘good’. This judgement has been made using available evidence including a visit to the service that involved checking staff files and training records, and having a meeting with a group of staff. The manager is continuing with her programme of increased training, and there is an enthusiastic approach to supporting training for NVQ qualifications. Staff speak positively about the good teamwork and the style of leadership. Proper vetting takes place. One comment was – “We work well together as a team and get on well together. (The manager and owners) are friendly and approachable.“ Another added – “(The manager) is very hot on training, and I think we could now be described as a very knowledgeable team.” EVIDENCE: The manager provided details of staff cover levels. There is a ‘team leader’ on each shift, and normally at least one senior care assistant. There is a total of 705.25 care hours each week, which breaks down to just over 19 day care hours per resident each week. There is a full-time cook and four part-time housekeepers. Comments and returned questionnaires from residents said staff cover was adequate. However, two staff questionnaires said there was insufficient cover. Further, an anonymous call to the Commission said shifts during a certain period had been below the minimum level. The inspector enquired about this matter. Due to a sudden death and another staff member becoming ill, cover for a short period was put under pressure a couple of months earlier. However, records showed sufficient cover was achieved, including one of the owners stepping in to supervise night shifts when there was agency cover. Staff who met with the inspector said cover levels were Ebury Court DS0000065997.V305046.R01.S.doc Version 5.2 Page 21 adequate, though one typical comment was – “ We are busy and it’s easy to say we could do with more, but you have to take into account that there has been more training and (supervision), so we all have to take that into account. In the end we are all working towards the same thing.” The inspector checked a sample of staff files, including for those who had started recently. These files had all the required paperwork showing that the right checks are being carried out, including – application forms; two written references; proof of identity; CRB certificates; and where appropriate, permission to work in the UK. These files also have a record of induction and training, saying when that person attended training on the core areas such as first aid; infection control; food hygiene; adult protection; using hoists; fire safety; and general health and safety. These forms also record attendance on the phased training on dementia care – as well as details of recent supervision. Copies of the staff training diary were also provided, listing attendance at each session. A positive feature is that ancillary staff are included in the care training. The two housekeepers have done the relevant NVQ in household standards Of the fifteen day carers, seven have NVQ L2; three have L3, and one has L4 – currently four have moved onto L3, and one person is doing L2. There is also a similar level of qualifications amongst night staff. This home is therefore able boast that it is well above the target level of qualified staff. The manager said that she is now seeking to recruit staff who have already achieved a NVQ qualification. One staff member commented – “Some of us have worked at other homes. This home is always clean and the food is excellent. There are quite a few activities, and I feel that we all pull together and everyone does their bit to make sure residents are happy.” Ebury Court DS0000065997.V305046.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37 and 38. Quality in this outcome area is ‘good’. This judgement has been made using available evidence including a visit to the service that involved checking paperwork including safety documents. The home has many signs of a wellmanaged service. The manager stresses that she has strong support from the deputy and senior team. The owner who managed the home for many years visits regularly, including doing checks at weekends. Another of the owners is the on-site maintenance manager and has his own office. There is good cooperation across all levels of this cohesive team. EVIDENCE: Beverley Manzar took over as manager in September 2004. She is a qualified social worker with over twenty years experience of managing social care services. This year she has concentrated on completing the practice supervisor course. She is researching ways in which her current qualifications can be used as credits towards the Registered Managers Award. Ebury Court DS0000065997.V305046.R01.S.doc Version 5.2 Page 23 Part of the new way of assessing homes will be looking at how they carry out quality control audits, including introducing a standardised audit schedule next year. This service is gearing itself up to fulfil these expectations. This includes one of the owners doing detailed ‘monthly reports’, which she sends to the Commission. Other positive initiatives include the ‘listening forms’ referred to earlier; and developing satisfaction survey forms for residents; relatives and friends; health and social care workers; and for staff. These questionnaires are well designed, including the resident version being in large bold type. The inspector was given an update of the systems in place to help residents with their personal money. He saw the ‘personal allowance record sheets.’ These mainly work as a ‘debit account’. This means that the home pays for expenses such as hairdressing and chiropody, and these are settled once a quarter or so by relatives or by the sponsoring authority Payments are dealt with through a separate ’Ebury Court Residents’ bank account. The inspector said a better system was needed covering where cash or other valuables are held in the safe. At this visit the inspector was shown the new ‘safe log book’ with triple signing for each item. The owners or manager do not act as an agent or representative for residents’ personal accounts, nor hold bankbooks or cards. At present cash was being held for ten residents, this normally being limited to £20. There is one exception for a resident who does not have a next-of-kin. Balances and spends are recorded in the ‘safe receipt book’ with receipts attached - which are triple signed, including by the resident. The two random accounts checked were correct. The only other item held for safe- keeping is one person’s passport. The maintenance manager was efficient in presenting the health and safety records. This included the fire log that confirms in-house weekly equipment checks, and regular drills; staff training; and contractor visits. The right certificates are available covering electrical, gas and water safety, as well as hoists. Along with the good attention to safety seen around the building and grounds, benefits of an on-site building manager are apparent. This includes a notice board outside his office where staff report any problems they spot. Advice last year on recording more systematic monthly health and safety checks has been followed. The maintenance manager said that he has checked with his insurers and is confident that the lift maintenance company’s paperwork is suitable for their purposes, but they still need to have a certificate that clearly confirms this. The last visit by an environmental healthy inspector was on 3 August 2006, and the minor recommendations have been followed. The last visit from a fire safety inspector was on 20 July 2006, and again the two recommendations have been tackled. Ebury Court DS0000065997.V305046.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 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 3 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 3 18 3 3 3 3 3 3 3 3 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 Ebury Court DS0000065997.V305046.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No – other than Following through plans for improved bathrooms. 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 OP21 Regulation 23(2)(j) Requirement Develop a plan to improve bathroom/shower facilities, where appropriate fitted with equipment to meet the needs of residents. Timescale for action 28/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ebury Court DS0000065997.V305046.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 Ebury Court DS0000065997.V305046.R01.S.doc Version 5.2 Page 27 - 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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