Inspection on 13/11/06 for Ecclesholme

This inspection was carried out on 13th November 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

Ecclesholme 11/03/06

Ecclesholme 12/08/05

Ecclesholme 25/02/05

Ecclesholme 11/08/04

Ecclesholme 29/02/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Ecclesholme Vicars Street Eccles Manchester M30 0DG Lead Inspector Adele Berriman Key Unannounced Inspection 10:00 13th November 2006 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 Ecclesholme DS0000006708.V309743.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. Ecclesholme DS0000006708.V309743.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ecclesholme Address Vicars Street Eccles Manchester M30 0DG 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) 0161 788 9517 0161 707 8296 eccleshm@rmbi.org.uk www.rmbi.org.uk Royal Masonic Benevolent Institution Julie Deakin Care Home 46 Category(ies) of Old age, not falling within any other category registration, with number (46), Physical disability (2) of places Ecclesholme DS0000006708.V309743.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users who may be accommodated for personal care only by reason of old age is 46. One named service user under the age of 65 is currently accommodated within the maximum of 46, when this person leaves the category will revert to service users over 65 years (OP). One named service user under the age of 65 is currently accommodated for regular periods of respite within the maximum of 46. Should this person no longer require the service the category will revert to service users over 65 years of age (OP). 11th March 2006 Date of last inspection 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 their dependent female relatives 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. The cost of the service is between £419.00 and £446.00 per week. Ecclesholme DS0000006708.V309743.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place on 13 November 2006. The visit to the home was over a period of six hours. During the course of the visit the inspector spent time talking to a number of residents, three staff, the home manager and the deputy home manager. Prior to the visit taking place the manager of the service had completed and returned a pre-inspection questionnaire containing detailed information about the service. Questionnaires were made available in the home for people who use the service or their relatives to complete. Twelve people chose to complete a questionnaire and the responses are contained in this report. During the visit an assessment of a selection of records, care plans, staff files and policies and procedures took place. The home continues to provide long stay and respite accommodation. Throughout the visit to the service the inspector observed a pleasant atmosphere around the home. What the service does well: What has improved since the last inspection? Ecclesholme DS0000006708.V309743.R01.S.doc Version 5.2 Page 6 The home continues to develop their care planning process. 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. Ecclesholme DS0000006708.V309743.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 Ecclesholme DS0000006708.V309743.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): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information about the service and appropriate admittance procedures in place to ensure that people were aware of what the service was able to offer people. EVIDENCE: The home has a comprehensive Service User Guide and Statement of Purpose, a copy of both documents are readily available in the home. Prior to a person moving into the home they are encouraged to visit Ecclesholme and spend some time with the residents and staff. All twelve people who completed questionnaires said that they had received enough information before they moved into the home so they could decide that it was the right place for them. One person wrote ‘We received written information about the home and we were invited to visit to see it for ourselves’ and somebody else wrote ‘The home also operated a come in and get to know each other time, for our assessment of the home and their on us.’ Ecclesholme DS0000006708.V309743.R01.S.doc Version 5.2 Page 9 An assessment of need is carried out by a senior member of the staff team to ensure that the home has the facilities to meet the needs of the individual. This assessment is recorded on a set format which considers all aspects of a person’s day to day needs. Copies of these assessments were available in the home. Ecclesholme does not provide intermediate care facilities. Ecclesholme DS0000006708.V309743.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 judgment has been made using available evidence including a visit to this service. People’s needs and wishes were supported by detailed care planning. People’s choices were respected by the staff team. EVIDENCE: Individual care plans were available for each resident and contained detailed information about the individual’s needs and wishes along with a summary of the person’s past life and personal history. Care plans were broken down into sections to identify the individuals specific needs in areas such as communication, mouth care, pain and discomfort, eating and drinking, continence, sleep patterns, mobility, washing and dressing, foot and nail care, orientation and awareness, moods and anxieties and social and leisure interests. These documents are reviewed on a regular basis. Eleven people said in their questionnaires that they always receive the care and support they need and one person said that they usually receive the care and support they need. One relative wrote ‘the full care programme is very detailed and the medical care is much better than I was able to administer at home’ and another relative wrote ‘the staff are very caring and we have Ecclesholme DS0000006708.V309743.R01.S.doc Version 5.2 Page 11 regular contact with them. If mum is unwell or there are any difficulties they contact us to let us know.’ Another relative wrote regarding their relative’s care ‘Ecclesholme is extremely caring and I have total confidence that the staff look after her with professionalism and the dignity they would wish for their own parents.’ Records also demonstrated that individual assessments were carried out for each person in relation to skin pressure areas, moving and handling and nutrition. People’s weights were also monitored in a regular basis. Records available in the home demonstrated that residents had regular opportunity to access chiropody, optical and district nursing services. Each resident was registered with a local general practitioner. A record of all medical visits is maintained on the residents care plan files. Daily records were maintained by the staff team of what care and support they had delivered to residents. The majority of these records were informative and well written. However, there were a few entries that gave little information and one entry used inappropriate wording, for example, ‘X had made a mess in his bedroom’ and ‘X has been today – no problems.’ The home has a detailed policy and procedure for staff to follow when dealing with residents’ medication. All medication was found to be stored appropriately and a random number of medication administration records were assessed and found to be completed appropriately. An audit of controlled drugs was carried out and found to be correct. During the visit to the home the inspector observed staff addressing people in a dignified and respectful manner. However, one member of staff was observed instructing a resident to do something in an abrupt manner. The inspector told the manager of the home about the observation and the manager said that she would address the issue. Ecclesholme DS0000006708.V309743.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 excellent. This judgment has been made using available evidence including a visit to the service. Residents are given opportunities to access regular activities both in their home and the local community. A wide choice of food was available to residents. EVIDENCE: The home employs a full time activities co-ordinator who facilitates activities and entertainment in and around the home. A programme of activities planned for the month was displayed around the building. Information about individuals’ preferences for recreational, social and religious activities is contained on residents’ care plans and the activities co-ordinator records all activities in people’s individual files. The home has a minibus that supports residents on days out and on local journeys. Seven people who completed a questionnaire stated that there was always activities arranged in the home that they could take part in. Five people said there was usually activities arranged for them to take part in. One person wrote that they were not always able to take part due to their ‘immobility’. Daily newspapers were available in the home’s main lounge and a resident confirmed that the home supported individuals in ordering any newspaper of Ecclesholme DS0000006708.V309743.R01.S.doc Version 5.2 Page 13 their choice. There is a small library at the home and the manager stated that the books are changed on a regular basis when the local mobile library visits the residents. Ecclesholme is supported by the Association of Friends of Ecclesholme who arrange social events throughout the year and fundraise for activities for people living at the home. Male residents are supported by the home in attending their Masonic Lodge meetings. At the time of the visit to the home communion was being held in one of the quiet lounges. The services of an advocacy service is displayed in the home. Eleven people who completed the questionnaires said that staff listen and act on what they say. Meals are served in pleasantly decorated and furnished dining rooms positioned on the ground floor of the building. Tables were set with the appropriate crockery and individual’s choices of condiments. Menus offer residents a choice of meals and a further supplementary menu is available for people with further alternative light meals. The cook demonstrated a thorough knowledge of peoples likes and dislikes and talked about information she had gained regarding the nutritional needs of older people. The home was awarded a Gold certificate for the third year running by Salford City Council’s environmental health department. Eight people who completed a questionnaire said that they always liked the meals at the home and four people said they usually liked the meals. During the visit the four residents told the inspector that they enjoyed the food that was served at mealtimes. Ecclesholme DS0000006708.V309743.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 excellent. This judgment has been made using available evidence including a visit to this service. Policies and procedures around the home minimise the risk of harm to people and provide opportunity for people to raise concerns or complaints. EVIDENCE: The home has a comprehensive complaints policy and procedure that is readily available in the home. During the last twelve months the home had received three complaints and records demonstrated that all had been responded to appropriately. No concerns about the home had been raised with the Commission. All twelve people who completed questionnaires said that they always knew how to make a complaint. A policy on the protection of vulnerable adults was available in the home along with a copy of Salford Social Services adult protection policy. Information on staff files demonstrated that staff had received awareness training in adult protection. The manager of the service has experience in referring concerns relating to adult protection through the appropriate procedures and these referrals have been managed appropriately by the home. Ecclesholme DS0000006708.V309743.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 & 26 Quality in this outcome area is excellent. This judgment has been made using available evidence including a visit to the service. Residents live in clean, well maintained home. The décor and furnishings around the home were pleasant and homely. EVIDENCE: Accommodation is provided over three floor of the building and each floor has a lounge facility. The home was clean, tidy and provided a comfortable environment for people to live. All areas of the home are fully accessible via two passenger lifts. Furnishing and décor around the home were of a high standard that met the needs of the residents. All bedrooms were en-suite and were furnished to a good standard. Residents are able to access an outside courtyard where seating was available. The home has several communal lounges which were situated on several floors around the home for people to access. A handy person is employed at the home to carry out day to day maintenance of the building and grounds. Ecclesholme DS0000006708.V309743.R01.S.doc Version 5.2 Page 16 CCTV is in use to monitor the external entrance to the home for security purposes only. Ecclesholme DS0000006708.V309743.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 good. This judgment has been made using available evidence including a visit to this service. Good recruitment procedures and regular training opportunities ensure that staff have the knowledge to deliver appropriate care and support to residents. EVIDENCE: During the visit there were a team of eight carers and several ancillary staff on duty to meet the needs of the residents. Rotas demonstrated that sufficient staff were on duty at all times to meet the needs of the residents. Staff demonstrated a good awareness of individuals’ needs and wishes during the visit and the inspector observed a shift handover between staff where information on each resident’s wellbeing was passed between the staff teams. Nine people commented in their questionnaires that staff were always available when you need them. Three people said that staff were usually available when you needed them, one person wrote ‘Night staff not always able to attend to panic-button calls promptly.’ Ecclesholme has a clear policy for the recruitment of staff. Five staff files were assessed, three of which belonged to the most recently recruited members of staff. Information on the files demonstrated that appropriate referencing and Criminal Record Bureau/POVA checks had been carried out prior to the member of staff commencing their employment. Ecclesholme DS0000006708.V309743.R01.S.doc Version 5.2 Page 18 All newly recruited staff undertake an induction programme and also receive an Employers Handbook. The home has policies and procedures list that staff sign to say that they have read the policy and understood it. Copies of these lists were available on staff files. In addition, the home identifies a ‘policy of the month’ where again staff are requested to sign to say they have read and understood the policy. The home had a policy relating to the supervision of staff. Records demonstrated that staff were receiving regular formal supervision from their line manager and this was confirmed by two staff who stated that they received regular supervision and support from the management of the home. Information supplied by the manager of the demonstrated that 72 of staff had undertaken their NVQ level 2 or above. One member of staff stated that she had recently completed her NVQ level 3 in administration which she had found very useful when maintaining records. During the past twelve months training courses and distance learning opportunities relating to safe handling of medication, infection control, dementia, first aid, health and safety, understanding Parkinsons disease, moving and handling, abuse in care homes and fire training had been made available to staff. Further training that is planned in whistle blowing. One member of staff said that there was always training available. At the time of the visit a training session on COSHH was taking place for staff. Staff files contained information relating to what training staff had undertaken. Some staff files contain training passports where a record was kept of what induction training and development training the member of staff had received. Ecclesholme DS0000006708.V309743.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, 33, 35 & 38 Quality in this outcome area is excellent. This judgment has been made using available evidence including a visit to the service. Residents benefit from a well run home. EVIDENCE: The manager of the home has many years’ experience in her role and holds a qualification relevant to her role. Regular residents’ meetings take place. Minutes of these meeting were available. During discussions it was evident that residents’ opinions and views raised in the meetings were listened to. An example of this was that during a discussion with the cook she referred to the most recent residents’ meeting and that no concerns had been raised about the quality of the meals provided. The RMBI have their own quality assurance process that is used in the home on a regular basis. Ecclesholme DS0000006708.V309743.R01.S.doc Version 5.2 Page 20 The home had a computerised data base in use for the recording of all resident money transactions. Residents’ monies are deposited in a non interest bearing account and all transactions are receipted. A monthly statement of individuals’ accounts is generated by the administrator of the home. However, if needed a statement can be produced at any time. The home has a facility for the safekeeping of valuables. The home has comprehensive collection of policies and procedures to support the safety and wellbeing of all. Records demonstrated that regular maintenance checks are carried out of lifting equipment, hot water provision and fire detection equipment. Accidents are recorded and a copy of the record is placed in the resident’s care plan and when required the Commission is informed of any accidents, injuries or incidents. Ecclesholme DS0000006708.V309743.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 X X 3 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 4 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 3 X 3 Ecclesholme DS0000006708.V309743.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. 2. Refer to Standard OP7 OP12 Good Practice Recommendations It is recommended in this report that daily records are written in a consistent manner using appropriate terminology. It is recommended that activities available for people are reviewed on a regular basis to ensure that all residents have the opportunity to participate in an activity of their choice and ability. Ecclesholme DS0000006708.V309743.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection CSCI, Local office 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 © 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 Ecclesholme DS0000006708.V309743.R01.S.doc Version 5.2 Page 24 - 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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