Inspection on 20/09/05 for Echelforde Resource Centre

This inspection was carried out on 20th 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 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

Echelforde Resource Centre 12/06/06

Echelforde Resource Centre 27/05/05

Echelforde Resource Centre 19/08/04

Echelforde Resource Centre 10/06/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Echelforde Resource Centre Echelforde College Way Ashford Middlesex TW15 2XG Lead Inspector Peter Benthom Unannounced Inspection 20th September 2005 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 Echelforde Resource Centre DS0000013890.V251576.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. Echelforde Resource Centre DS0000013890.V251576.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Echelforde Resource Centre Address Echelforde College Way Ashford Middlesex TW15 2XG 01784 255225 0178 442 3243 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) Care UK Community Partnerships Limited Mrs Linda Humphreys Care Home 50 Category(ies) of Dementia - over 65 years of age (50), Old age, registration, with number not falling within any other category (50), of places Sensory impairment (3) Echelforde Resource Centre DS0000013890.V251576.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Not exceeding 50 persons within the categories OP, DE(E) and MD(E). Of the registered Service Users, 3 (three) named service users may be within the category SI. 27th May 2005 Date of last inspection Brief Description of the Service: Echelforde Resource centre is a purpose built single storey home for older people with dementia. The home is organised in five units each with ten bedrooms. All accommodation is offered in single rooms. Each unit has its own lounge dining area and small auxiliary kitchen. The home is situated in its good-sized grounds with safe and well-maintained gardens. There is ample car parking facilities to the front and side of the home. It is conveniently located for all the local shops and community facilities. The home is part of Care UK, which is a private health care organisation that work with local authorities. Echelforde Resource Centre DS0000013890.V251576.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Home’s performance was measured against the National Minimum Standards for Care Homes for Older People. A tour of the premises took place and care, training and Health and Safety records were inspected. The home had a newly designed statement of purpose, which accurately depicted the services provided by the home. The service plans in place were comprehensive and are reviewed on a regular basis to ensure that they accurately depict service users’ needs. The home provided a high level of personal support to service users. This was a commendable part of the home’s operation. The menus provided were adequate and well presented using a new system of ‘cook chill’ pre-prepared food. Links with service users friends and family were well developed and maintained by the operation of the home. Service users’ health needs were well met. Senior staff are trained in the administration of medication. The home has a thorough complaints procedure. There has been one complaints received by the service since the last inspection. The homes management has taken appropriate action. The home has a positive and supportive relationship with the local surgery. Senior staff are trained in the administration of medication. The home is reasonably well maintained but furnished to poor standard despite the requirements of the last inspection. It offers spacious but poorly -equipped accommodation to its service users. There is a commitment from the proprietors and manager to provide staff with continual training and development. What the service does well: The manager is new in post and as yet unregistered. His application has been forwarded to Care UK for endorsement prior to it being sent to CSCI. Service Users were observed in their individual care settings and were positive about the home and the way they are treated. Service users are admitted only following a full assessment undertaken by the manager who was able to demonstrate the homes capacity to meet the assessed needs. Each service user has a clearly set out care plan and all the service users are registered with a GP. There were satisfactory facilities and procedures available Echelforde Resource Centre DS0000013890.V251576.R01.S.doc Version 5.0 Page 6 for the safe reception, storage, disposal, administration and recording of medication. Arrangements are in place to meet service users care needs in a respectful way that affords both privacy and dignity. Staff are committed to encouraging service users to take part in activities offered in the home. Full support is provided to enable individual choice in daily living activities. There is a day centre in the home that offers day care for seven days a week that resident Service Users are encouraged to participate in. Care plans; staff training records and medication procedures were examined and found to be in good order. What has improved since the last inspection? 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. Echelforde Resource Centre DS0000013890.V251576.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 Echelforde Resource Centre DS0000013890.V251576.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): 1, 2, 3, 4 and 5 Service users are admitted only following a full assessment undertaken by people trained to do so. The manager was able to demonstrate the homes capacity to meet the assessed needs. EVIDENCE: The Home has a Service User guide, which is informative and easy to read. Details of the practical provision the Home provides is included in the Statement of Purpose which ahs been extensively redesigned since the last inspection. All potential service users are assessed prior to admission. It was reported that the service only admits new service users based on an assessment of needs, and appropriateness of placement The initial assessment was used to form the basis of the care and the support plan, which identified the actions that carers should follow to assist an individual living at the home. Service users visit the home prior to moving in and visits are made to potential service users at their homes or in hospital. Service users are admitted on an initial month’s trial period and this information is reproduced in the contracts Echelforde Resource Centre DS0000013890.V251576.R01.S.doc Version 5.0 Page 9 and the statement of purpose. The home provides a respite care service and details of this provision are contained in the statement of purpose. Echelforde Resource Centre DS0000013890.V251576.R01.S.doc Version 5.0 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 Health, personal and social care needs are adequately met in this home. EVIDENCE: Care plans were reported to be drawn up in consultation with service users and with their relatives/representatives. Care plans sampled were comprehensive and up to date; there was evidence that regular reviews took place. Encouragement and support was given to service users to promote independence within the limitation of each individual’s capabilities The manager stated that all service users were registered with the local primary care trust for the provision of general medical services. A policy and procedure for the administration of medication was sampled as part of the inspection process. The inspector evidenced that staff that administered and recorded medication had received training. Echelforde Resource Centre DS0000013890.V251576.R01.S.doc Version 5.0 Page 11 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 and 15 The systems in place for full Service User participation indicated that Service Users views are both sought and acted upon. EVIDENCE: Organised activities take place on a daily basis and are arranged by designated activities staff n the home’s day centre. Service Users choose to participate if they wish. The home has very good links with the local community. There are garden parties and Christmas Fairs arranged every year. Service Users on the whole do not handle their own financial affairs. If they are unable to manage their finances, relatives or advocates act on their behalf. The menu on the day of inspection was found to be wholesome and nutritious and is provided as a ‘cook chill’ method whereby it is cooked and appeared prior to delivery and then heated effectively in specially designed appliances. On the day of the inspection it was felt to be well-presented and sufficient in quantity and content. Echelforde Resource Centre DS0000013890.V251576.R01.S.doc Version 5.0 Page 12 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, 17 and 18 Service Users are well protected by the companies training policies and procedures with regard to the protection of vulnerable adults. EVIDENCE: The complaints procedure was displayed in the entrance hall and was simple, clear and accessible. The procedure included stages and time scales for processing complaints and information to the local Commission for Social Care Inspection office. Training records and displayed certificates sampled, evidenced that staff had received training for the Protection of Vulnerable Adults. Echelforde Resource Centre DS0000013890.V251576.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 The condition of décor and equipment in some parts of this home is of a very poor standard with little satisfactory evidence of significant improvement through maintenance and refurbishment. EVIDENCE: The Home is situated in a large and well-maintained garden and is very close to Ashford Town centre. The Home was purpose built in 1988 and has been designed to meet the needs of older people. There are ample dining and lounge areas. This Home’s facilities for washing and toileting meets the minimum standards expected. All rooms were accessible to Service Users. The home has grab rails and adaptations in place to support Service Users to maintain their independence. However some of the interior standards of decoration and furnishings are of an unacceptably poor standard despite the requirements that were made at the last inspection. Echelforde Resource Centre DS0000013890.V251576.R01.S.doc Version 5.0 Page 14 The beds in Caenarvon, Windsor, Balmoral and Kensington unit are unsafe, broken in places and have stained and unhygienic mattresses on them • New carpets that have been supplied to some bedrooms are already showing signs of poor incontinence management Staff must be commended for providing a service in surroundings that are not entirely favourable in terms of comfort and quality, but have been improved since the last inspection and since the arrival of the new manager. The inspector obtained a programme of redecoration and refurbishment from the manager on the day of the inspection. Please see requirements on Page 20 of this report. • Echelforde Resource Centre DS0000013890.V251576.R01.S.doc Version 5.0 Page 15 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 and 30 The staff have a good understanding of the service users’ needs. This is evident from the positive relationships that have been formed between the staff and service users. However staffing levels on three of the five units are inadequate. EVIDENCE: The Home has a policy whereby all gaps in the staff rota are met by existing staff. The manager is very committed to staff training. There is a training room provided for staff where various courses are conducted. All staff have induction training for three days with a Care UK trainer, followed by three weeks hands on supervision. The home has a recruitment policy in place. Employment records seen on the day of the inspection were well maintained and included the relevant documentation required. Some staff files still require a photograph of the staff member to be included. All staff have a CRB disclosure in place. The Home has a continual programme of NVQ training for all staff and is committed to staff training. All staff have completed induction and foundation training and there is a good training package for all staff. Three of the five units have inadequate staffing levels to meet the needs of the service users and this must be addressed as soon as possible. There have been a significant number of falls on Windsor Echelforde Resource Centre DS0000013890.V251576.R01.S.doc Version 5.0 Page 16 and Caenarvon, which indicated that there was insufficient staff supervision. Please see requirements on Page 20 of this report. Echelforde Resource Centre DS0000013890.V251576.R01.S.doc Version 5.0 Page 17 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, 36, 37 and 38 The newly appointed manager has a clear development plan and vision for the home, which he has effectively communicated to Service Users, staff and relatives. EVIDENCE: The newly appointed manager is competent and experienced to run the home. Information from service users and staff confirmed that the management style in the home was open and that registered the manager is approachable at all times. There was a positive and relaxed atmosphere at the home during the inspection. Meetings were held for both staff and service users; all were encouraged to contribute to the development of the home. Records required for the protection of service users and sampled on the day of the inspection were well maintained, accurate, and up to date. Echelforde Resource Centre DS0000013890.V251576.R01.S.doc Version 5.0 Page 18 The staff-training programme includes training in first aid, manual handling, infection control, fire safety, health and safety and basic food hygiene. Systems were in place to safeguard the health and safety and welfare of the service users. Echelforde Resource Centre DS0000013890.V251576.R01.S.doc Version 5.0 Page 19 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 3 3 3 3 X 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 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 3 2 3 3 2 2 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 3 3 3 Echelforde Resource Centre DS0000013890.V251576.R01.S.doc Version 5.0 Page 20 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. 1 Standard OP22 Regulation 23 (2)(c) Requirement It is required that all remaining broken, stained and unhygienic mattresses and beds are replaced as soon as possible. It is required that staffing levels on Windsor, Balmoral, Caenarvon and Kensington are increased to meet the needs of the service users Timescale for action 31/12/05 2 OP27 18 (1)(a) 31/12/05 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 Echelforde Resource Centre DS0000013890.V251576.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Echelforde Resource Centre DS0000013890.V251576.R01.S.doc Version 5.0 Page 22 - 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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