Inspection on 27/02/06 for Ebury Court

This inspection was carried out on 27th February 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 01/11/06

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 Unannounced Inspection 27th February 2006 11:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ebury Court DS0000065997.V284508.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ebury Court DS0000065997.V284508.R01.S.doc Version 5.1 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.V284508.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16 November 2005 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 side 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.V284508.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit took place between 12noon and 4pm on Monday 27 February 2006. The registered manager, Beverley Manzar was available for the first couple of hours to help with the inspector’s enquiries before going to a training planning meeting. The last inspection was an announced visit on 16 November 2005. At that time most of the core standards were checked, other than those covering the building. The report of that visit is available at the home, or can be seen on www.csci.org.uk. Some of the positive findings and comments from the visit three months ago are carried forward in this report. The main purpose of this recent visit was to follow-up on progress with the short list of requirements and recommendations set out in the last report, and to look at the building. The inspector gave the manager an overview of the changes in the way care homes will be monitored from April 2006. This will include the owners and manager having to show that they are carrying out worthwhile internal checks, including doing a main annual quality assurance report. They have since been sent a letter spelling out the new approach. In turn, the manager explained recent initiatives – including making full use of an experienced social care worker doing a three-month placement at the home. The inspector again found the manager helpful in presenting the information he asked to see. The deputy was efficient in demonstrating how the medication arrangements operate, and showing the inspector a sample range of bedrooms. Particular thanks are due to those residents and visitors who took time to speak to the inspector and answer his questions. What the service does well: The main conclusion remains that this is a well-run service that is successful in meeting the needs of the residents, and is much appreciated by them and their families. One typical quote from a relative at this 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 had 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.” The manager who started nearly eighteen months 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 Ebury Court DS0000065997.V284508.R01.S.doc Version 5.1 Page 6 on linking up with medical services. She is also paying particular attention to staff training. This includes dementia awareness, as there is an intention to specialise more in this 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 just over half having already gained the award. 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 acknowledges the very good housekeeping standards by awarding the ‘commendable’ score under that heading. What has improved since the last inspection? The manager described the action she has taken since the last visit. This includes working on assessment forms that include all the necessary areas that are set out under Standard 3.3 in the National Minimum Standards; encouraging staff to write down the help they have provided in day-to-day notes; and making sure there is an accurate log of the small amounts of money held for residents in the safe. Good progress has also been made on having individual social histories as part of the main files. The examples seen were excellent, this being a successful piece of work being done by the masters degree student working at the home for three months. She had also designed, and was in the process of circulating satisfaction questionnaires to residents, their families, visiting professionals and staff. The manager described other ways of involving people. She was very pleased with the number of relatives who attended the Christmas Bazaar and Party. A fund has been started to build a summerhouse in the garden, and some relatives are talking about setting up a ‘Friends of Ebury Court’ group to take a lead on such projects. Better links have been established with Barking and Dagenham Age Concern. This has led to six residents attending a music and dance club and quizzes. Monthly residents’ meetings are taking place, with the minutes up on the main notice board. Places on a yoga and mobilization course at a local college had been booked. The popular ‘music for health’ and art sessions at the home are still going strong. Ebury Court DS0000065997.V284508.R01.S.doc Version 5.1 Page 7 The birthday celebrations for a resident who is 101 had been featured the local newspaper a couple of weeks earlier. This person’s daughter was 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.” At this visit a resident told the inspector - “The staff are all very helpful, I would say without exception. That includes Beverley. They help as much as they possibly can…The accommodation is satisfactory. I have all that I need.” 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.V284508.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ebury Court DS0000065997.V284508.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4. These standards were covered in the last report, being listed as satisfactory. That report said – “The manager can show that adequate attention is paid to assessment and matching needs to what the home can provide. The consistently good ratings ticked in the large sample of questionnaires received shows that support needs and expectations are being met. A social worker wrote - “I have conducted reviews at the home. Staff are helpful and professional. Service users and relatives are pleased with the standard of care provided.” One resident wrote - ”Everybody here is kind and respectful.”” EVIDENCE: At the visit in November 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 Barking and Dagenham, Newham and Tower Hamlets – but those from Havering were seen to vary in their worth. The sample of residents’ files seen included the most recent person to move in. The ‘Admission and Manual Ebury Court DS0000065997.V284508.R01.S.doc Version 5.1 Page 10 Handling’ section had sufficient key-contact, referral and assessment information. Further, the detailed ‘care plan’ sections for the resident who had moved in the previous month had all been completed. At this recent visit 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. One comment from a family visiting at this 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.” Ebury Court DS0000065997.V284508.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 9. Good safeguards and arrangements were found covering medication. The deputy and team leader who take a lead make sure there is a methodical approach. The other main areas under this section were checked three months ago. The manager has successfully improved the way care plan files are kept. 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.” EVIDENCE: 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 off 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 Ebury Court DS0000065997.V284508.R01.S.doc Version 5.1 Page 12 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 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. Up-to-date drug reference books are available. The deputy was able to give well-informed answers on a number of types medication in use, and about one item that a resident takes herself. Therefore, the conclusion is that conditions and arrangements covering medication are satisfactory. The supplying pharmacist visits to check arrangements every three months. The headline finding of the last inspection was that the manager was close to completing a major overhaul of how care plans are recorded and monitored. The new-style files are arranged in a neat and logical sequence. Section 2 contains the main care plans, reviews and risk assessments. The standardised care plan proformas are set out under 11 headings using ‘Needs; Aims’; Risk; and Action’ columns. The range of examples seen had sufficient detail, with clear typed instructions and monthly evaluations. There is a general riskassessment, plus more specific entries such as risk of falls. More recently, the social work student was helping introduce further improvements, such as completing detailed social histories, and preparing pre-review updates. There is a section on the main care plan covering skin condition. In line with the inspector’s advice, more systematic skin viability assessments are still being considered, such as the Waterlow scale. These files also have a section covering health. This includes 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. There is regular health care monitoring through weekly visits by a specialist medical team. The manager has stressed how helpful she finds this expert support, saying – “We have a main contact nurse, with another giving back-up. They have been able to respond to requests on the same day. It is designed to prevent hospital admission, but it gives us much broader medical advice. They have also been able to provide training, such as on diabetes.” Where there were special medical needs, such as diabetes, the files contain useful guidance. Details of any hospital admissions are also clear. Descriptions of the support received from the main GP who provides most cover included the comment - “He is a very good practitioner, with an excellent manner.” Following sections have day-to-day notes, details of any accident and complaints, and copies of correspondence. Ebury Court DS0000065997.V284508.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 13. The evidence supporting these standards as satisfactory are included in the last report, including a range of comments such as – • “We are very happy with all aspects of the home. Meals are nutritious. The activities and outings are varied and interesting”; • “We are very well looked after. We have a choice at breakfast, lunch and dinner. You are asked before hand. You can have something else even if it is not on the menu if you don’t like the two choices.”; • “Yes, {the staff are} always this bright and jolly, making sure we’re all alright. At tea you’ll find there are lots of different types of sandwiches to choose. Tonight I fancied bacon and beans, and that is what they’re making me.” ; • “The food is very good. I have put on weight. I have the same GP and he is very pleased. My cholesterol and blood pressure are also down.“ • “I would have to say that everything is okay. {My relative} says that there are things to do, and I see things on the notice board such as the Christmas Bazaar, the Christmas Party and various people come in and entertain”. EVIDENCE: All comments made by residents and service users at this visit showed the same level of satisfaction, for example – “I have a gluten free die. I never need to remind staff. I will say that the food is very good and to my liking.” Ebury Court DS0000065997.V284508.R01.S.doc Version 5.1 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): 0. Information on complaints is readily available, and the last report said that the manager and owners treat any concerns seriously. Staff who met with the inspector 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. Comments and suggestions sheets are readily available in the entrance hall. 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. When the inspector met with a group of eight staff three months ago they gave good answers about their understanding of ‘whistle blowing’ responsibilities. One response was – “It’s about telling the right people if you think something is wrong. This is something we are told about soon after you start. It is included in the induction.“ Some staff said that they had covered this area as part of their NVQ training. One gap raised at the last visit was the need to tell staff about the role of the General Social Care Council, and about the need to sign-up in the future. This has now been covered in individual supervision, and each person has been given a copy of the GSCC’s national code of practice for care workers. Ebury Court DS0000065997.V284508.R01.S.doc Version 5.1 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, 20, 21, 22, 23, 24, 25 and 26. This is very well maintained home, with good attention to hygiene and safety. Satisfaction with cleanliness and comfort feature in comments made by residents and visitors. The consistently good household standards seen at this unannounced visit are a credit to the housekeeping team, and deserve 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. At this visit the inspector looked at all communal and service areas, as well as a sample of ten bedrooms. Consistently excellent standards of cleanliness and safety were found in all areas, including the kitchen. The spacious laundry was also tidy, with clothing kept in residents’ individual baskets. 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 Ebury Court DS0000065997.V284508.R01.S.doc Version 5.1 Page 16 loos. 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’. By comparison to the rest of the good facilities, it is the bathrooms that now need some attention. The bathroom on the second floor has an electric hoist seat, and chair scales. However, the sit-up ‘medibath’ on the first floor is not popular, and it is some time since it has been used, some staff thinking it may be faulty. Also, the ground floor shower room was cluttered with items such as hoists. The appearance of these rooms is basic and functional. The only safety issue pointed out by the inspector around the building was to make sure the loo seats are tightened as a couple were loose. Staff who spoke with the inspector agreed that bathrooms need to be put at the top of the improvements list. The manager said that the feasibility of fitting a ‘walk-in’ shower was being considered. The same careful attention to safety can be seen around the outside of the building, including the garden that is now fully enclosed. Ebury Court DS0000065997.V284508.R01.S.doc Version 5.1 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 and 30. The manager has introduced increased training, and there is an enthusiastic and well-supported approach to gaining NVQ qualifications. Staff speak positively about the good teamwork and the style of leadership. Proper vetting takes place. One written comment was – “I feel the care given is excellent and all staff are helpful and friendly”. EVIDENCE: The manager provided details of staff cover levels. There is a ‘team leader’ on each shift, along with 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 two housekeepers. The inspector has 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; where appropriate, permission to work; and CRB certificates. These files also have a record of induction, a fire safety test, training record, and details of recent supervision. Training over recent months has included has included - the aging process; health and safety; using hoists; hearing aids and walking aids; and first aid. Particular attention is being paid to ‘dementia awareness’, and the inspector saw the test papers staff complete as they work through the modules the Alzheimer’s Society’s ’Yesterday, Today and Tomorrow’ programme. The manager wrote – “I am very committed to staff Ebury Court DS0000065997.V284508.R01.S.doc Version 5.1 Page 18 training and development and am of the opinion that good quality supervision and training are the best tools for attaining the highest possible standards.” There is a forward plan for training, including topics such as first aid, infection control, and adult protection safeguards. Of the eight staff who met with the inspector in November, two had NVQ L3, five had NVQ L2, and the eight person was doing Level 2. The manager said that they have now achieved the expected ‘qualification target’ of having 50 of the team with an NVQ award. A positive feature is that ancillary staff are included in the care training. The two housekeepers have done the relevant NVQ in household standards. At this recent visit there were six staff on the NVQ level 3 scheme. Only one person had left the team in recent months, confirming the good level of staff retention. One staff member wrote saying - “The care provided to residents is excellent. There is regular training courses made available to staff, and the proprietors and manager are easy to talk to and their door is always open”. The most recent starter confirmed that she had been led through the induction booklet, saying – “It was well explained, and I did sign saying that I had covered the subjects.” She added – “I was made to feel very welcome, and was shown what to do by Beverley.” All these staff confirmed that they were now receiving regular supervision. They presented as enthusiastic, confident and relaxed. One said – “There is very good teamwork, it’s a very friendly place. You’ll find that new staff will agree. All the carers are nice, and they will always stay back if things are busy. I think we’re also supportive towards families.” Ebury Court DS0000065997.V284508.R01.S.doc Version 5.1 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, 34 and 38. The home has many signs of a well-managed 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 three times a week, 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. She is working towards gaining the registered manager’s award. Part of the new way of assessing homes will be looking at how they carry out quality control audits. A positive initiative is already underway. The inspector saw a series of comment and rating survey forms ready to be circulated. This includes ones specifically for residents; relatives and friends; health and social Ebury Court DS0000065997.V284508.R01.S.doc Version 5.1 Page 20 care workers; and for staff. These questionnaires well designed, including the resident version being in large bold type. One intention is to also use these forms ahead of each resident’s annual review. At the last visit Mrs Keys described the considerable stress that has resulted from an error that was made in transferring one resident’s money. She is keen to see this matter finally resolved, saying that she has found the procedures complicated and drawn out. She has had opportunity to meet with managers from the Commission about this matter. In November the inspector was given details of the systems in place to help residents with their personal money. He saw the ‘personal allowance record sheets.’ These work as a ‘debit account’. This means that the home pays for expenses such as hairdressing and chiropody, and these are settled once a month or so. At that time 34 residents were using this system, with accounts being paid off by family members in 31 instances, two by local authorities and one person was handling his own cash. Payments are dealt with through a separate ’Ebury Court Residents’ bank account. Photocopies of the account sheets and receipts are given to the person settling the account. The inspector said that it might be an added safeguard to ask people to sign when they settle by making cash payments, and for this to be countered signed by a staff member. 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. Checking this group of standards at the announced visit included asking to see a sample range of safety paperwork. This included the in-house and contractor checks of fire equipment, hoist maintenance; and electrical, gas and water safety certificates. 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. The inspector gave some advise on how to improve the safety monitoring documentation: • Use a checklist to record the routine building safety checks. These should be used at least once a month; • Keep a record of the hot water temperature checks; • Make sure the record of fire drills and training cover night staff; • Add columns to the weekly fire checklist covering the magnetic door catches; clear escape routes and that extinguishers are in place; At this recent visit the maintenance manager was due to go with the manager to the training planning meeting. The date set for compliance with these matters had not yet fallen due, and it was agreed that this requirement would be carried forward, and covered at the next visit. 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. Ebury Court DS0000065997.V284508.R01.S.doc Version 5.1 Page 21 Ebury Court DS0000065997.V284508.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 3 3 3 3 3 3 4 STAFFING Standard No Score 27 3 28 3 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 3 X X X 2 Ebury Court DS0000065997.V284508.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? 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 OP38 Regulation 13(4) Requirement Include in the health and safety records the following items: • General health and safety checks; • Hot water safety checks; • Checks on magnetic latches, fire escapes, and that extinguishers are in place; • Fire drills and training covering nights. Develop a plan to improve bathroom/shower facilities, where appropriate fitted with equipment to meet the needs of residents. Timescale for action 30/04/06 2 OP21 23(2)(j) 30/07/06 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.V284508.R01.S.doc Version 5.1 Page 24 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.V284508.R01.S.doc Version 5.1 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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