CARE HOMES FOR OLDER PEOPLE
Ecclesholme Vicars Street Eccles Manchester M30 0DG Lead Inspector
Adele Berriman Unannounced 12 August 2005 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 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. Ecclesholme F55 F05 s6708 ecclesholme v244304 120805 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Ecclesholme Address Vicars Street Eccles Manchester M30 0DG 0161 788 9517 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Royal Masonic Benevolent Institution Responsible Individual - Mr Kevin Harris Julie Deakin CRH Care home PC Care home only 46 46 Category(ies) of OP Old age registration, with number of places Ecclesholme F55 F05 s6708 ecclesholme v244304 120805 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: The maximum number of service users who may be accommodated is 46. That care staffing levels do not fall below the minimum levels specified in the Residential Forum Guidance for Staffing in Care Homes for Older People That dependency levels of service users are assessed on a continuous basis and staffing levels adjusted where appropriate to ensure continued compliance with the Residential Forum Guidance for Staffing in Care Homes for Older People. One named service user under the age of 65 is currently accommodated. When this person leaves the category will revert to service users over 65 years of age (OP). One named service user under the age of 65 is currently accommodated for regular periods of respite. Should this person no longer require the service the category will revert to service users over 65 years of age (OP). The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Date of last inspection 25 February 2005 Brief Description of the Service: Ecclesholme is a care home that is registered under the Care Standards Act 2000 to provide residential accommodation for residents who require personal care only. The home is situated in a residential area of Eccles and is close to public transport and services. Ecclesholme is owned by the Royal Masonic Benevolent Institution. Places in the home are offered to older Freemasons and dependent females over the age of 65. All prospective residents are invited to complete an application form and to provide information about their Masonic eligibility. The home offers numerous communal areas that are furnished to a high standard and are pleasantly decorated. Residents spoke positively of the service that they received whilst living at the home. Ecclesholme F55 F05 s6708 ecclesholme v244304 120805 stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced and was conducted on 12th August 2005. During the course of the inspection time was spent talking to a number of residents, the home manager and the deputy home manager. Examination of records, care plans, complaints register, medication records, staff files, policies and procedures relating to the home took place. A tour of some areas of the interior and exterior of the building was also carried out. The home continues to provide long stay and respite accommodation. Throughout the inspection the inspector observed a pleasant atmosphere around the home with lots of conversation taking place between residents and residents and staff. What the service does well:
Staff were seen to address and support residents in a respectful and polite manner and demonstrated that they had a good awareness of individuals care and support needs. This was confirmed by residents of the home. Residents indicated to the inspector that they were happy with the service that they received from the staff team. Service users had regular access to their GP as they visited the home on a weekly basis for non-urgent appointments. The home had several communal areas that were furnished and decorated to a high standard. The home was clean and tidy. The home employed a full time activities co-ordinator that arranged recreational activities for individuals and groups of residents. Service users spoke highly of the activities that were offered in the home. Residents told the inspector that they benefited from the activities that were arranged and supported by the home’s Association of Friends. Service users spoke very highly of the quality and choice of food that they were offered at mealtimes. The homes complaints procedure was seen to be actively used and complaints were being dealt with appropriately. Several residents told the inspector that
Ecclesholme F55 F05 s6708 ecclesholme v244304 120805 stage 4.doc Version 1.40 Page 6 they would raise any concerns they had with the deputy home manager and they were confident that any issues raised would be addressed. There were sufficient carers and domestic support staff on duty to meet the needs of residents. The home supplied on-going training for care staff in care practices and several members of staff had completed or were working towards their National Vocational Qualification (NVQ). The had a clear policy and procedure for the recruitment of staff and the home ensures that all the relevant checks are made before a new member of staff begins to work at the home. What has improved since the last inspection? What they could do better:
There was some improvement in the homes care planning processes. However, some areas require further improvement. One of these areas was the reviewing process as some of the information was outdated and not fully complete. One file that was examined had been reviewed and the comments of the person who had carried out the review did not correspond with other information contained in the care plan. It is necessary that care plans contain accurate up to date information to ensure that staff are aware of individual changing needs and are able to deliver the appropriate care and support. Risk assessments formed part of the care plan. Some assessments were detailed but others lacked information. Again, risk assessment are required to be updated on a regular basis to ensure the safety and wellbeing of all. Improvements are required with regard to the administration of medication. Clear guidance and support is required to be available to staff with regard to the administration of ‘as and when required’ (PRN) to ensure that residents receive the appropriate medication. The practice of staff not signing the Medication Administration Record sheets (MAR) should stop and all medication that is dispensed for residents must be recorded appropriately. Several outdated procedures were found in a policies and procedures manual available to staff. These procedures require removing as they give inappropriate guidance to staff on practices that should not be carried out by the care home staff. The risk of staff carrying out these practices could compromise the wellbeing of residents. Ecclesholme F55 F05 s6708 ecclesholme v244304 120805 stage 4.doc Version 1.40 Page 7 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. Ecclesholme F55 F05 s6708 ecclesholme v244304 120805 stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Ecclesholme F55 F05 s6708 ecclesholme v244304 120805 stage 4.doc Version 1.40 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 standard(s) 2 & 3 The home had an appropriate admittance procedure that informed service users of the services that the home could offer. EVIDENCE: The home has a comprehensive Service User Guide and Statement of Purpose, a copy of both documents was readily available in the home. All residents were issued with a copy of the homes terms and conditions at the commencement of their placement. Prior to admittance to Ecclesholme an assessment of the individuals needs is carried out by either the home manager or the deputy home manager to ensure that the home can meet the individuals care needs and requirements. Copies of these assessments were available on residents’ files. Ecclesholme F55 F05 s6708 ecclesholme v244304 120805 stage 4.doc Version 1.40 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 standard(s) 7, 8, 9, 10 Issues relating to care planning and medication issues require addressing to ensure the health and well being of residents. EVIDENCE: Individual plans of care were available for each resident. These records were comprehensive and the majority contained all aspects of individuals’ needs and preferences. Each resident had a personal information sheet, personal history, health and social assessment, list of medication and numerous assessments to meet the individuals personal and social needs. However, some information was outdated and not fully completed. An example of this was residents six monthly review, which had not all been fully completed. Another example was the residents individual recreational activity records which had not been completed for some time, although residents confirmed to the inspector that they had the opportunity to participate in recreational activities on a regular basis. Information in different sections of care plans was on occasions contradictory. For example, care plans contained a section for the monitoring of residents weight management. One weight monitoring chart demonstrated that a resident had lost several kilograms in weight over a period of 10 weeks.
Ecclesholme F55 F05 s6708 ecclesholme v244304 120805 stage 4.doc Version 1.40 Page 11 However, further on in the care plan the person who was reviewing the monitoring sheets had recorded that the residents weight remains stable. Risk assessments formed part of individuals care plans. Some assessments were found to comprehensive but others contained insufficient information and were in need of reviewing to ensure that all aspects of the individuals needs were considered. Since the previous inspection the home has introduced a process for the monitoring of falls. The care manager stated that this exercise has proven useful in identifying the times and frequency of individuals falling. There was documentary evidence at the home that confirmed that residents had access to their GP and other primary health professionals when required. One local GP holds a regular surgery at the home. One resident said that staff were being very supportive to him whilst he was carrying out a health programme set by the hospital to address a medical need. The home has detailed policies and procedures for staff to follow when dealing with residents medication. However, information documented for one individual was contradictory. As and when required (PRN) medication was being administered to a resident at all times. The resident was unable to make the decision as to whether they needed the medication, the directions for staff were to ask the individual if they needed the medication. Other instances regarding PRN medication were also found to not be fully recorded. Medication Administration Records (MAR) were not fully completed. There were missing signatures and on occasions, there were no signatures or reasons for ‘stopped’ medication. Spare labels for medication were found to be in use in the home. This practice is dangerous and therefore the home should not continue this practice to ensure the safety of service users. Service users commented that they were treated respectfully by staff and one person said ‘nothing is too much trouble for the staff’. Ecclesholme F55 F05 s6708 ecclesholme v244304 120805 stage 4.doc Version 1.40 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 standard(s) 12, 13, 14 Recreational sessions and activities in the home meet the needs of residents. EVIDENCE: The home employed a full time activities co-ordinator. A programme of activities was clearly displayed in the lounge area. Residents commented that the activities co-ordinator was very good and that they enjoyed the sessions greatly. The home had a minibus that supports residents on days out and local journeys. One resident said ‘your never bored or never needy’. Daily records did not fully demonstrate what social and recreational activities individuals had participated in. This information should be documented as part of the care plan to demonstrate that individuals’ recreational needs were being met. Daily newspapers and magazines were available in the lounge area of the home. Two residents spoken to said that their visitors were always made welcome by the staff team.
Ecclesholme F55 F05 s6708 ecclesholme v244304 120805 stage 4.doc Version 1.40 Page 13 The home had a long established Association of Friends that supports the home via visits, fundraising for the home and the production of a newsletter. Several days before this inspection took place a BBQ had been organised by the Association of Friends at the home. Several residents commented that the BBQ had been very enjoyable. Service users spoke highly of the food that was offered and served in the home. Ecclesholme F55 F05 s6708 ecclesholme v244304 120805 stage 4.doc Version 1.40 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 standard(s) 16, 18 Residents were confident in the homes system for dealing with complaints/concerns. EVIDENCE: The home had a comprehensive complaints policy and procedure in the home. Information regarding the procedure was readily available in the home. Since the previous inspection the home had received three complaints, all of which had/were being dealt with appropriately. Residents said that they knew who to contact if they had a complaint and were confident that any issues raised would be addressed. There was a comprehensive procedure regarding the protection of vulnerable adults in the home which was accessible to all staff. A copy of Salford Social Services Adult Protection Policy was also available. Ecclesholme F55 F05 s6708 ecclesholme v244304 120805 stage 4.doc Version 1.40 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 standard(s) 19, 23, 24, 26 Residents live in a pleasant environment, where the standard of furnishings and décor is high. EVIDENCE: At the time of the inspection the home was found to be clean, tidy and well maintained. A full time ‘handy person’ is employed at the home for general maintenance. Several residents bedrooms were inspected and all were found to be personalised with the residents personal effects. Rooms were decorated and furnished to a high standard. Ecclesholme F55 F05 s6708 ecclesholme v244304 120805 stage 4.doc Version 1.40 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29, 30 The staff team on duty met the needs of residents. The home had a good recruitment procedure. EVIDENCE: On the day of the inspection the manager of the home was on duty. The deputy home manager supported the inspector throughout the inspection. A team of six carers, 3 domestic staff, 2 laundry workers, a cook and kitchen assistant were on duty to meets the needs of the residents. The staffing rotas demonstrated adequate staffing levels throughout the day and night to meet the needs of individuals. The home had a clear policy for the recruitment of staff. The files of four recently recruited staff were examined. The files were found to contain the appropriate referencing and Criminal Records Bureau/POVA 1st checks. One file did not contain a photograph of the staff member. A formal induction programme was available for all newly recruited staff. There was evidence in the home that ongoing training for staff was available and taking place. The assistant manager stated that since the previous inspection, courses on appraisal training, care of medicines, moving and handling for trainers and basic food hygiene had taken place.
Ecclesholme F55 F05 s6708 ecclesholme v244304 120805 stage 4.doc Version 1.40 Page 17 Several staff members had completed their NVQ level 2/3 qualification and others were in the process of completing. Seven staff members were palnned to commence their NVQ level 2 training in October 05. Staff were observed supporting residents in a positive, professional manner. Several residents commented to the inspector that staff were ‘good’. Ecclesholme F55 F05 s6708 ecclesholme v244304 120805 stage 4.doc Version 1.40 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 36, 37, 38 Policies and procedures not relevant to current care practices require removing to ensure that staff are not carrying out inappropriate practices. EVIDENCE: Staff were observed being supported by the deputy home manager at the time of the inspection and it was the home’s policy that staff receive formal supervision on a regular basis. There was evidence that staff meetings for day and night staff took place and the minutes of these meetings were available. The home had a comprehensive policy on confidentiality and service users care plans were stored in secure cabinets. However, during the inspection medical records from residents GP’s were found to be available to be looked at. This was of concern due to the confidential information stored in these documents.
Ecclesholme F55 F05 s6708 ecclesholme v244304 120805 stage 4.doc Version 1.40 Page 19 Policies and procedures relating to care practices were available in the home to support staff in their day to day working. However, the inspector found that some outdated policies and procedures were still available to staff. For example, procedures and guidance were available for the administration of suppositories, the administration of enemas, taking service users blood pressure with a sphygmomanometer and stethoscope and how to collect a specimen of urine from a catheter using a needle and syringe. These polices and procedures require removing from the homes procedures file as they are nursing practices that are not to be carried out by the staff of a residential home. There was a comprehensive collection of organisational polices and procedures to support the safety of all. There was documentation available to demonstrate that regular maintenance of lifting equipment, environmental checks and fire equipment checks. Ecclesholme F55 F05 s6708 ecclesholme v244304 120805 stage 4.doc Version 1.40 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x
COMPLAINTS AND PROTECTION 3 x x x 3 4 x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x x 2 2 Ecclesholme F55 F05 s6708 ecclesholme v244304 120805 stage 4.doc Version 1.40 Page 21 yes 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 OP7 Regulation 15 Requirement It is required that all care plans provide clear, up to date information and provide clear directions for what needs, wishes and care is required by the individual, and that they are reviewed and updated on a regular basis. Risk assessments are required to contain detailed information, be signed and dated by the assessor and reviewed on a regular basis. The home is required to ensure that staff adhere to the homes procedure for the recording, storage, handling and administration of medicines. The practice of using spare medication labels supplied by the chemist must stop. It is required that all policies and procedures available to staff are relevant to the service provided in the home. It is required that all records kept in the home are stored appropriately. Timescale for action 21st October 2005 2. OP7 15 21st October 2005 7th October 2005 3. OP9 13 4. 5. OP9 OP38 13 13 7th October 2005 21st October 2005 7th October 2005 6. OP37 17 Ecclesholme F55 F05 s6708 ecclesholme v244304 120805 stage 4.doc Version 1.40 Page 22 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 Good Practice Recommendations Ecclesholme F55 F05 s6708 ecclesholme v244304 120805 stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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