Inspection on 19/02/07 for Eden Court Nursing Home

This inspection was carried out on 19th February 2007.

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

Eden Court Nursing Home 11/03/09

Eden Court Nursing Home 08/11/05

Eden Court Nursing Home 07/07/05

Eden Court Nursing Home 22/12/04

Eden Court Nursing Home 23/06/04

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

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

CARE HOMES FOR OLDER PEOPLE Eden Court Nursing Home Ghyllroyd Drive Birkenshaw Bradford West Yorkshire BD11 2ES Lead Inspector Bronwynn Bennett Unannounced Inspection 19th February 2007 09:00 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 Eden Court Nursing Home DS0000001080.V322846.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. Eden Court Nursing Home DS0000001080.V322846.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eden Court Nursing Home Address Ghyllroyd Drive Birkenshaw Bradford West Yorkshire BD11 2ES 01274 652002 01274 689054 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) Speciality Care (UK Lease Homes) Limited Mrs Linda Elizabeth Davis Care Home 45 Category(ies) of Old age, not falling within any other category registration, with number (45), Physical disability over 65 years of age of places (45), Terminally ill (1), Terminally ill over 65 years of age (2) Eden Court Nursing Home DS0000001080.V322846.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Elderly persons over 60 years of age Date of last inspection 8th November 2005 Brief Description of the Service: Eden Court is a care with nursing. The home provides care, nursing and accommodation for up to forty-five people. The home is purpose built. It has thirty-seven single rooms, four double rooms and ten of these bedrooms have en-suite facilities. There is a large lounge, one quiet lounge, a small smoking lounge and a quiet sitting area on the upstairs landing. There is a large garden at the home, where residents are able to sit in the better weather. The home is situated within close proximity of the A58 Leeds Road, with access to public transport links and local shops. Ample car parking is available at the home. Eden Court Nursing Home DS0000001080.V322846.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced visit carried out by two inspectors. The visit began at 9.00am and finished at 1.00 pm. During this visit the inspectors spoke to some service users, some of the staff and the home’s acting manager. The inspectors read records of people’s care, staff records, looked at how medicines are given and looked at the accommodation available in the home. There were forty two service users living at the home on the day of this visit. To reflect the views of service users living at the home twenty questionnaires were sent to individuals living at Eden Court. Seventeen completed questionnaires were returned some of which had been completed with the support of the staff. Surveys were sent to ten service users’ relatives and five responses were received. Surveys were also sent to nine social workers, and eight GP’s. Two GP responded. Other information used as part of this inspection process includes notifications from the home to the Commission for Social Care Inspection about deaths, illnesses, accidents and incidents at the home, and a pre inspection questionnaire was completed by the manager. The inspector would like to thank everyone for their assistance during this inspection process. What the service does well: The staff team at Eden Court continue to work hard to provide a good standard of care to service users. The residents spoken with said that they were satisfied with the care and support they receive from the staff in the home. There is a relaxed atmosphere in the home and the service users spoken to during this visit said they were satisfied with the care provided. The staff at Eden Court work hard to ensure the home is run in the service users’ best interests. Eden Court Nursing Home DS0000001080.V322846.R01.S.doc Version 5.2 Page 6 Service users said they enjoyed the food served at the home. There is a choice of meals and service users are supported appropriately by the staff to enjoy their meals. There is ongoing training provided for staff working at the home. 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. The summary of this inspection report can be made available in other formats on request. Eden Court Nursing Home DS0000001080.V322846.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 Eden Court Nursing Home DS0000001080.V322846.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The needs of service users are assessed prior to being admitted to the care home. EVIDENCE: The care records looked at showed details of a pre-admission assessment to assess the potential needs of service users and how they will be met. Nine service users who responded to the survey said they had received enough information about the care home prior to moving in. Eden Court Nursing Home DS0000001080.V322846.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users’ health and personal care needs are recorded in their plan of care. Generally service users are treated with dignity and respect. Greater care is required to ensure the service users are sufficiently protected by the home’s medication policy and procedure. EVIDENCE: The service users spoken with said the staff are helpful and supportive and during this visit there was good interaction observed between service users and the staff. Seven people who responded to the survey said they always receive the care and support they need and seven people said they usually receive the required care and support. Eden Court Nursing Home DS0000001080.V322846.R01.S.doc Version 5.2 Page 10 The relative and GP surveys received by the CSCI said that overall they were satisfied with the care provided at Eden Court. During this visit service users were observed being treated in a dignified and respectful manner. The care records for three service users were looked at. Generally there was some good information recorded that was up to date and had been reviewed. There were risk assessments in place for identified risks such as nutrition, the risk of developing a pressure sore and manual handling. However, there was no risk assessment available for how an individual had chosen to use their wheelchair. This was discussed with the acting manager during this visit. The daily records require some improvement and should show how a person has chosen to spend their day in addition to recording the care being provided to the individual. The home’s medication system was audited and the medication for five service users was checked. Not all medication could be fully reconciled with the records kept. The stock balance of pain relief in two records did not correspond with the current MAR (Medication Administration Record) sheet. In addition the home must take greater care with the safe keeping of the medication system. These issues were discussed with the acting manager who agreed to take immediate action to rectify the matter. Eden Court Nursing Home DS0000001080.V322846.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users’ cultural, religious, social and recreational needs are generally being met, and they are supported to maintain contact with their family and friends. The service users are able to exercise choice and control over their lives. The home provides the service users with a varied and nutritious diet. EVIDENCE: The service users spoken with said there were activities arranged by the home that they are able to take part in. Two people said that they enjoy spending time alone in their room. Six surveys received from service users said that are “always” activities arranged that they are able to take part in, four said there are “usually”, three said “sometimes” and one responded there are “never” activities that they are able to take part in. Eden Court Nursing Home DS0000001080.V322846.R01.S.doc Version 5.2 Page 12 The choice of activity is available in the home. There is an activity co-ordinator who arranges some of the activities available. Some of the service users spoken with said they enjoyed sitting in the company of others and watching the television. Religious observance is respected for service users, with a religious service being held on a regular basis. A service user said they choose not to attend the church service. There are no restrictions on visiting to the home and service users are able to see their visitors in private. The relative surveys said that the staff always welcomes them in to the home. And service users said there relatives are always welcome at Eden Court. Service users manage their own finances should they wish to do so. Individual rooms were seen during a tour of the home and service users’ rooms were personalised. Seven service users who responded to the survey said they always liked the food served at the home, three said they “usually” and four said they “sometimes” liked the food served. Individuals spoken with during this visit said they enjoyed their meals and there was a choice of food available. The home offers a varied diet and a choice of foods and caters for specific dietary needs. During this visit both the breakfast and lunchtime was observed and the meals were served in a relaxed and unhurried manner. Staff were observed supporting service users appropriately to eat their meals. Eden Court Nursing Home DS0000001080.V322846.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Generally service users and their relatives are confident their complaints will be listened to and acted upon. Service users are protected from abuse. EVIDENCE: The complaints procedure is displayed in the home. The relatives who responded to the survey said they were aware of the home’s complaints procedure. Service users who took part in the survey said that they knew who to speak to if they were not happy and knew how to make a complaint. And a service user spoken with said they always feel the staff listened to what they had to say and knew who to speak to if they were not happy. The staff spoken with during this visit had a good understanding of adult protection issues and the necessary action that must be taken should there be any allegations of abuse. Eden Court Nursing Home DS0000001080.V322846.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a safe and generally well-maintained environment that is clean and comfortable. EVIDENCE: The response from the service users surveys indicates the home is fresh and clean. The service users spoken with said they liked their room. During this visit the home was noted to be generally fresh and clean however, an odour was noted in a lounge and a corridor. And the designated smoking room requires adequate ventilation. These issues were discussed with the acting manager who agreed to take action to rectify the matter. Eden Court Nursing Home DS0000001080.V322846.R01.S.doc Version 5.2 Page 15 There is an ongoing programme of maintenance carried out at the home. Since the last visit by the CSCI the dining room has been redecorated and new dining tables and chairs have been purchased. Greater care is required in the dining area to ensure dining tables do not restrict access to the fire doors during meal times. This concern was raised at the time of this visit. The laundry facilities were seen and were clean and well organised. Eden Court Nursing Home DS0000001080.V322846.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are employed in sufficient numbers and receive training to ensure they are competent to do their jobs. Generally service users are protected by the home’s recruitment practices. EVIDENCE: There were some positive comments made about the staff during this visit and everyone spoken to said the staff are “good”. The GP’s who responded to the survey felt the staff had a good understanding of individual care needs. Six respondents to the service user survey said that staff are “always” available when they need them, eight said “usually” and one responded that there are “sometimes” staff available. It was noted during this visit that service users were left in the lounge area without a care worker present. This was discussed with the acting manager. The management should ensure that staff are deployed throughout the home to ensure that service users are adequately supervised. Eden Court Nursing Home DS0000001080.V322846.R01.S.doc Version 5.2 Page 17 The information received by the CSCI states that there are 30 of the care staff working in the home that have achieved NVQ (National Vocational Qualification) level 2 or above. Three staff files were looked at. These records generally contained the information required to ensure service users are protected by the home’s recruitment procedures. However, there was a gap in an employment history for an individual. This matter was discussed with the acting manager at the time of this visit. Staff have undertaken induction training and there is ongoing training for staff to ensure they are suitably trained to meet the needs of the service users. During this visit the inspector observed a poor movement and handling practice. This was discussed with the acting manager who agreed to address the matter. Eden Court Nursing Home DS0000001080.V322846.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users live in a home run by a person who is fit to be in charge. The home is generally run in the best interests of the service users. The financial interests of the service users are safeguarded. Generally the health, safety and welfare of the service users is promoted and protected. EVIDENCE: The registered manager is currently taking extended leave. The acting manager is Mr Khalid Muhammad who is a registered nurse and has experience of working with the service user group. Mr Muhammad has previous experience of acting manager and said the organisation is supporting him in his position. Eden Court Nursing Home DS0000001080.V322846.R01.S.doc Version 5.2 Page 19 The home has a quality monitoring system in place that seeks the views of service users and their relatives. There are service user, staff and relatives meetings held regularly. The organisation is currently developing its methods of communicating with service users in order to gain their views. The procedure for handling service users money was discussed during this visit. Service users are supported to handle their own finances should they wish to do so and are provided with lockable facilities for this purpose. The financial records for five service users were checked and correct. The information received by the CSCI shows that the equipment in the home is serviced regularly. The fire records were looked at. There is weekly testing of the fire alarm system and the staff receive fire safety training and take part in fire drills. Good practice advice was given regarding the testing of emergency lighting. This should be tested on a weekly basis. The appointed person for fire safety said they would address the matter immediately. Eden Court Nursing Home DS0000001080.V322846.R01.S.doc Version 5.2 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 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 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Eden Court Nursing Home DS0000001080.V322846.R01.S.doc Version 5.2 Page 21 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 OP9 Regulation 13.2 Requirement Greater care must be taken with the medication kept in the care of the home. The stock balance of medication must correspond with the MAR sheet. All the medication must be kept safely in the home. Timescale for action 19/02/07 2. OP9 13.2 19/02/07 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 OP8 Good Practice Recommendations Where there is a risk identified in the care records a risk assessment should also be completed that highlights the risks and the measures in place so the risk can be managed. Action should be taken to eliminate odours in the home. The smoking lounge should be fitted with a system that provides adequate ventilation. Greater care is required to ensure the dining furniture does not obstruct the fire exits in that area. The management should ensure that staff are deployed throughout the home to ensure that service users are DS0000001080.V322846.R01.S.doc Version 5.2 Page 22 2. 3. 4. 5. OP19 OP19 OP19 OP27 Eden Court Nursing Home 6. 7. 8. OP28 OP29 OP38 adequately supervised. Staff should continue working towards achieving NVQ level 2 certificate. Gaps in staff’s employment history should be explored as part of the homes recruitment policy and practice The emergency lighting should be checked on a weekly basis. Eden Court Nursing Home DS0000001080.V322846.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Eden Court Nursing Home DS0000001080.V322846.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. 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