Inspection on 04/07/06 for Ecclesfold

This inspection was carried out on 4th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Ecclesfold 21/09/05

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 Denise Bate Key Unannounced Inspection 4th July 2006 10:00 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 Ecclesfold DS0000035813.V298616.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. Ecclesfold DS0000035813.V298616.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ecclesfold Address Manchester Road Chapel en le Frith High Peak Derbyshire SK23 9TJ 01298 308181 01298 308184 Not given 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.V298616.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st September 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. The sixbedded 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. There is a range of prices for short term care service users. Ecclesfold DS0000035813.V298616.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over approximately five hours. During the inspection 4 service users, and 3 staff members were spoken with. The manager and a deputy manager were present during the inspection and provided assistance and information. Written information was provided by the manager prior to the inspection and included staff rotas and sample menus. Some service user surveys were also received. A number of records were examined, including risk assessments and care plans, health and safety documentation, staff files, and medication records. Four service users were case tracked. A tour of the part of the building took place. What the service does well: What has improved since the last inspection? There has been a major investment in the building: there is a completely refurbished kitchen and a new smaller kitchen for use in rehabilitation, an attractive new garden area has been created with new garden furniture, the outside of the building has been redecorated, and there are new carpets in the corridors and in one bedroom. Ecclesfold DS0000035813.V298616.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ecclesfold DS0000035813.V298616.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ecclesfold DS0000035813.V298616.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home have a system for assessing service users’ needs to ensure that the care provided can meet service users’ needs appropriately. EVIDENCE: The Statement of Purpose and Service User Guide was available in the reception area and in the lounges. The information includes details of service users rights and respect for individual service users needs and preferences. The manager stated that this information is available on tape and in large print. Case tracked service users had all had assessments done prior to their periods of short term care. Usually the short term care was identified as one provision within a range of provisions, e.g. domicilliary care, CPN. There is a pre Ecclesfold DS0000035813.V298616.R01.S.doc Version 5.2 Page 9 admission visit made at home for all service users referred to the service. The manager is clear in her judgement of whether admissions are appropriate. Most service users come for short term care on a rotating basis. Ecclesfold DS0000035813.V298616.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care plans relating to personal and social care needs of service users are good. Service users are encouraged and supported to be independent and to exercise choice in all aspects of the home and are treated with dignity and respect. This contributes to the enhancement of service users’ everyday lives. EVIDENCE: All case tracked service users had personal development plans, daily logs, assessment forms for nutrition and tissue viability, risk assessments and monitoring forms. Service users had signed documentation indicating that care plans had been discussed with them. 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. Staff said that communication within Ecclesfold DS0000035813.V298616.R01.S.doc Version 5.2 Page 11 the home was effective; updating of care plans and regular meetings ensured that staff were aware of how service users needs could best be met. Staff said that managers were responsive to any reports that service users needs had changed. Some ‘current’ care planning files contained out of date information that could be transferred to another file. The administration of medication was inspected and records found to be satisfactory. It was noted that great care had to be taken in matters relating to medication as there is a constant change of service users. A record of staff signatures was kept. The home has a separate medication room with the medicines trolley, fridge and controlled medication cupboard. Derbyshire County Council have recently introduced a new medicines code for their residential homes. A copy of the latest advice from the Royal Pharmaceutical Society was available. Some service users are able to administer their own medication, which is kept securely in their rooms. Service users seen on the day of inspection and responding to the service user surveys confirmed that they regard the service received from staff very highly and are treated with dignity and respect at all times. Staff spoken to were knowledgeable and prided themselves of providing a service that is tailored to service users’ individual needs, including both physical and/or dementia. They gave several examples of where they helped maintain service users independence. Ecclesfold DS0000035813.V298616.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities are provided that suit the expressed preferences of service users. Regular outside contacts are encouraged and supported. This assists in contributing to a pleasant atmosphere and the overall high level of satisfaction for service users. Dietary needs of service users are well catered for with a balanced and varied selection of food available that meets service users’ tastes and choices. EVIDENCE: Service users spoken with a care planning documentation indicated 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, although there is a dedicated private lounge/dining area for the respite service. Information was recorded in the care plans about their preferred daily routines. Ecclesfold DS0000035813.V298616.R01.S.doc Version 5.2 Page 13 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. There are regular opportunities to go out on trips. The records of activities were recorded in some care plans. Carers needs were sometimes noted in the assessments for short term care service users. The inspector was informed that the home has close links with several community and religious groups, and examples given where this had been particularly beneficial to individual service users. There is a range of community contacts, and the home had been involved in the recent carnival held in the town. Service users spoken to and feedback from questionnaires were complimentary about the standard of catering, and the choice of menus that are available. Meals were attractively presented in a pleasant dining area. Ecclesfold DS0000035813.V298616.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are systems in place which promote the protection of service users from abuse and neglect. A complaints procedure is in place. EVIDENCE: The home has a complaints procedure which contains details of how make a complaint and that complaints would be responded to in 28 days. Service users indicated that they feel staff are approachable and any problems can be discussed with them or with one of the managers. No complaints about the home had been received by the Commission for Social Care Inspection. Derbyshire County Council has clear procedures for dealing with the safety of service users and protecting them from harm. Staff spoken to had had training in the protection of vulnerable adults and showed an awareness and knowledge of adult protection issues and would pass any concerns on to their line manager. Ecclesfold DS0000035813.V298616.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment within the home is well maintained and provides service users with an attractive and homely place to stay. EVIDENCE: A tour of the building took place. It was clean and tidy with no discernable unpleasant odours in any parts of the building. There are separate, private areas for the service users receiving respite including a pleasant lounge/dining room where service users generally have breakfast. At present most service users 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 Ecclesfold DS0000035813.V298616.R01.S.doc Version 5.2 Page 16 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. As noted earlier, there has been significant investment in the home with a new kitchen provided, substantial work on the garden, and the exterior of the home decorated. Some new lights were in the process of being installed and some decoration will be needed when this programme has been completed. Ecclesfold DS0000035813.V298616.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. A trained and competent workforce are in place which meet the dependency needs of service users currently accommodated within the home. EVIDENCE: The home is a short-term care facility and the dependency of service users changes from week to week. Staff spoken two were knowledgeable, enthusiastic and committed. They are able to spent one to one time with service users, and gave examples where they maximise service user choice and independence, e.g. in personal care. The inspector was informed that extra staff 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. Discussions took place with the manager on matters relating to equality and diversity. Most service users are local and reflect the cultural background of the locality. There is a male member of staff and service users can generally have a choice if they wish their personal care to be provided by a male or female member of staff. Ecclesfold DS0000035813.V298616.R01.S.doc Version 5.2 Page 18 Staff said they feel supported by both their colleagues and their managers, and feel that they are offered good training opportunities. Thorough induction training had taken place, including shadowing more experienced staff, and this was seen as helpful and contributing to staff job satisfaction. Over 80 of staff had achieved NVQ2, and many had gone on to complete NVQ3. Training opportunities were valued. It was felt that the training and support given helped staff gain expertise and insight into the various needs of service users, and staff displayed an enthusiasm for continuous professional development. Staff felt they worked well as a team and that there was excellent communication between themselves and the managers. Staff files seen had evidence of CRB checks, copies of contracts and references. Derbyshire County Council has a thorough and detailed recruitment and selection procedure. Ecclesfold DS0000035813.V298616.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The manager provides clear leadership throughout the home with staff demonstrating an awareness of their roles and responsibilities ensuring that the home is run in the best interests of the service users. EVIDENCE: Service users and staff spoke very highly about the manager and the management team. The registered manager has over 5 years experience in senior management and a level 4 National Vocational Qualification in management and care. She is seen as approachable, responsive, knowledgeable and supportive and displays good leadership skills. The Ecclesfold DS0000035813.V298616.R01.S.doc Version 5.2 Page 20 manager has overall responsibility for the planning and development of the home, the day care centre, and support to residents in the flats. Three deputies have responsibility for daily operations and have their own areas to manage. The home is visited regularly by a representative of the registered person. There had been a quality assurance exercise which indicated that the service provided by the home has been rated as good or excellent by 93 of service users and relatives. The results of the survey have been made available to service users. One of the deputy managers holds a ‘consultation’ meeting every month with a group of service users. The meeting concentrates on a particular aspect of the running of the home, usually covering a couple of national minimum standards, and is written up in detail and includes comments from service users. Staff confirmed that they have regular supervision. The manager supervises all new staff during their probationary period. The supervision system is seen to work well. Information on maintenance and health and safety records was provided by the manager in the pre-inspection questionnaire and on the day of inspection. This indicate that matters pertaining to maintenance and health and safety are satisfactory. Standards of cleanliness are good, and this was commented on by service users, as well as being observed on the day of inspection. Ecclesfold DS0000035813.V298616.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X 3 3 X 3 STAFFING Standard No Score 27 4 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 4 X 3 4 X 3 Ecclesfold DS0000035813.V298616.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? no 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP19 Good Practice Recommendations The kitchen fan in the new kitchen should be adjusted so that it can operate appropriately during the winter. Ecclesfold DS0000035813.V298616.R01.S.doc Version 5.2 Page 23 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. 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