Inspection on 21/09/05 for Ecclesfold

This inspection was carried out on 21st September 2005.

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

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

Other inspections for this house

Ecclesfold 04/07/06

Ecclesfold 27/10/04

Ecclesfold 21/04/04

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

CARE HOMES FOR OLDER PEOPLE Ecclesfold Manchester Road Chapel en le Frith High Peak Derbyshire SK23 9TJ Lead Inspector Stuart Hannay Unannounced Inspection 21st September 2005 10:30 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 Ecclesfold DS0000035813.V253416.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ecclesfold DS0000035813.V253416.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ecclesfold Address Manchester Road Chapel en le Frith High Peak Derbyshire SK23 9TJ 01298 308181 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) Derbyshire County Council Jane Catherine Harvey Care Home 6 Category(ies) of Old age, not falling within any other category registration, with number (6) of places Ecclesfold DS0000035813.V253416.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th May 2005 Brief Description of the Service: Ecclesfold provides respite care in a six-bed unit as part of a Resource Centre, which includes day care provision and support to a housing complex. A domiciliary services team is also based in the main office. The six-bedded respite care unit can be independent of the day centre, however service users usually prefer to spend the day in the centre and eat with day care service users. Ecclesfold is situated on the outskirts of Chapel en le Frith and the home provides transport to local amenities. Ecclesfold DS0000035813.V253416.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Three of the six people currently receiving respite care were interviewed during the inspection. A check was made of their care plans and how they were assessed prior to coming into the home. A check was made of the environment and the fire testing and staff fire training records. What the service does well: What has improved since the last inspection? The home has begun the process of having a full kitchen refurbishment, which includes the provision of a new kitchen for service users. Ecclesfold DS0000035813.V253416.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ecclesfold DS0000035813.V253416.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ecclesfold DS0000035813.V253416.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Pre admission assessments ensure that the service is able to meet the needs and preferences of potential service users. EVIDENCE: There is a pre admission visit made at home for all service users referred to the service. A detailed information pack is provided for service users and their relatives, which provides information about how Ecclesfold works and what they can expect during their stay. The deputy manager stated that this information is available on tape and in large print. During the visit, the home ascertains how service users prefer to spend their day and go into significant detail to meet their preferences; for example, whether they prefer quilts or sheets and blankets for their bedding, whether they would prefer a male or female carer. Dietary, health and personal care needs are fully assessed. Potential service users are invited to spend the day at the home or to attend for lunch if they prefer. The service users interviewed all confirmed that they had visited prior to coming to stay for the first time and felt that staff generally met their personal needs and preferences. Ecclesfold DS0000035813.V253416.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 10 The service users’ care plans ensure that their health, social and personal care needs are met by a staff team who treat them with respect and dignity. EVIDENCE: All 6 service users’ plans were examined in detail. They included information about their health and personal care needs and identified how these would be met during their stay. There was an emphasis on ensuring that the service users were consulted about how the plan is made and implemented. Risk assessments had been completed and service users had signed to say whether they wished to continue managing their own medication and to have a key for their room whilst at the home. Dietary, nutritional and skin integrity charts were completed. There was information about what activities the person might like to be involved in whilst at the home. Plans were reviewed after each period of respite care and may be changed during the respite period if significant changes were noted since the previous stay. Ecclesfold DS0000035813.V253416.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 Service users had control over how they live their lives and they maintain links with family and friends. There was a range of leisure activities which matched their interests and preferences. EVIDENCE: The three service users spoken with said that daily routines were flexible and varied. They confirmed they were able to choose how they spent their day and what leisure activities to join in with. The majority preferred to spend their days with the service users in the day centre, despite their being dedicated private space for the respite service. Information was recorded in the care plans about their preferred daily routines. They said that a good choice of food was available and that they liked the food. Again, most service users chose to eat with people from the day centre. They said they were able to pursue their own interests and could choose what activities to participate in. There were regular opportunities to go out on trips. The care plans records of activities were recorded in care plans and the activities files. Ecclesfold DS0000035813.V253416.R01.S.doc Version 5.0 Page 11 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 The home has complaints procedures which promote their right to complain or comment about the service. Service users feel that complaints will be taken seriously. EVIDENCE: The home had a complaints procedure which contained details of how to contact the Commission for Social Care Inspection to make a complaint and that complaints would be responded to in 28 days. Three service users interviewed said that they thought staff would listen to their complaints and deal with them fairly. No complaints about the home had been received by the Commission for Social Care Inspection. Ecclesfold DS0000035813.V253416.R01.S.doc Version 5.0 Page 12 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 21 23 24 26 The environment was well-decorated and well-maintained. Service users rooms had been adapted to meet their needs. The home was clean and free of unpleasant odours. EVIDENCE: The building was checked on the day of the inspection. It was clean and tidy with no discernable unpleasant odours in any parts of the building checked. There are separate, private areas for the service users receiving respite, although it was noted that they generally prefer to be in the larger lounge with the people attending the day centre. Whilst the bedrooms could not be highly personalised, as they may be only occupied for one to two week periods, the layout of the room is agreed with the service users prior to their arrival. This takes into account their personal preferences and any personal or health care needs. Furnishings and fittings were in good condition. The communal areas were well-decorated, bright and homely. The home has a sufficient number of bathrooms and toilets, which were clean and well-maintained. Work has Ecclesfold DS0000035813.V253416.R01.S.doc Version 5.0 Page 13 commenced on the refurbishment of the kitchen, which has been an outstanding issue for some time. Ecclesfold DS0000035813.V253416.R01.S.doc Version 5.0 Page 14 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 Staff were employed in sufficient numbers and were knowledgeable about the needs of service users. EVIDENCE: The home is a short-term care facility and the dependency of service users changes from week to week. One staff member interviewed said that extra cover was provided when necessary. Service users interviewed stated that they felt there were always sufficient staff on duty. There is one waking night staff member with a senior sleeping-in at the home. Two weeks rotas were seen which showed that staffing levels were being maintained. The home has a stable staff group. Ecclesfold DS0000035813.V253416.R01.S.doc Version 5.0 Page 15 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 38 Ecclesfold is managed by a suitably qualified and experienced manager who promotes the rights of service users fosters an open atmosphere at the home. Fire testing and fire training are well-maintained promoting the health and safety of the service users. EVIDENCE: The registered manager has at least 5 years experience in senior management and a level 4 National Vocational Qualification in management and care. Service users spoke about her commitment and positive attitude. They felt that she was friendly and would have no hesitation in speaking to her if they had any concerns. Staff had undertaken fire training every six months. One staff member was asked to describe the fire procedure and was able to do so in detail. Regular fire drills, alarm testing and equipment checks had taken place. The home had been visited by the fire officer in March 2005 and he had not made any recommendations. Ecclesfold DS0000035813.V253416.R01.S.doc Version 5.0 Page 16 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 4 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 2 X 3 X 3 3 X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X X X 3 Ecclesfold DS0000035813.V253416.R01.S.doc Version 5.0 Page 17 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP15 Regulation 16 Requirement The home must upgrade the kitchen including improving the ventilation. (previous timescale for completion: 31/12/04) Timescale for action 30/03/06 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 Ecclesfold DS0000035813.V253416.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Ecclesfold DS0000035813.V253416.R01.S.doc Version 5.0 Page 19 - 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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