Inspection on 08/11/05 for Eden Court Nursing Home

This inspection was carried out on 8th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Eden Court Nursing Home 11/03/09

Eden Court Nursing Home 19/02/07

Eden Court Nursing Home 07/07/05

Eden Court Nursing Home 22/12/04

Eden Court Nursing Home 23/06/04

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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 8th November 2005 08:40 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.V251193.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. Eden Court Nursing Home DS0000001080.V251193.R01.S.doc Version 5.0 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.V251193.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Elderly persons over 60 years of age Date of last inspection 7th July 2005 Brief Description of the Service: Eden Court is a care home 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, 4 double rooms and 10 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 the residents are able to sit in the better weather. The home is situated within close proximity of the A58 Leeds Road, with access to the public transport links and local shops. Ample car parking is available at the home. Eden Court Nursing Home DS0000001080.V251193.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out over a seven and a half hour period and was the second inspection conducted during this inspection year. The inspector made a tour of the building and looked at a sample of the records kept by the home. The inspection was conducted with the manager of the care home. The inspector spoke with some of the residents, staff and a relative. What the service does well: What has improved since the last inspection? What they could do better: The care records should clearly identify the residents’ changing needs. The present arrangements for the disposal of medication are not satisfactory and must be reviewed. Eden Court Nursing Home DS0000001080.V251193.R01.S.doc Version 5.0 Page 6 The manager must take action to ensure the health, safety and welfare needs of the residents and the staff are promoted and protected. 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. Eden Court Nursing Home DS0000001080.V251193.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 Eden Court Nursing Home DS0000001080.V251193.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): 3. The care needs of the residents are assessed prior to admission. EVIDENCE: The care records for one resident recently admitted into the home held the details of the care management assessment and the manager had completed a detailed pre-admission assessment. Eden Court Nursing Home DS0000001080.V251193.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Generally, the residents’ health and personal care needs are set out in their plan of care. The residents are treated with dignity and respect. The general management of medication is satisfactory, however the registered manager must review the current arrangements for the safe disposal of medication. EVIDENCE: The residents spoken with said that they are satisfied with the level of care provided by the staff. A relative spoke highly of the standard of care provided at the home and said she had been actively involved in the care planning process. During this inspection the inspector observed the residents being treated with dignity and respect. Eden Court Nursing Home DS0000001080.V251193.R01.S.doc Version 5.0 Page 10 The care records for three residents were examined. There has been a general improvement in the detail kept in the care records. Some of the care records looked at had been updated and reviewed. The inspector noted that the oral hygiene need of the residents is not clear. One resident had not been weighed for three months, the nurse on duty said this was due to a health condition but the care records did not indicate this. It is important that the care records reflect any changes so that when a risk is identified there is evidence that the appropriate action has been taken. The medication records for three residents were looked at and all could be reconciled with the medication records kept with the exception of one PRN (when required) medication. A discussion took place with the manager regarding the safe disposal of medication. The current practice adopted in the home is not acceptable and must be addressed. Eden Court Nursing Home DS0000001080.V251193.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): 14. The residents are supported to make choices in their lives. EVIDENCE: The residents are supported to manage their own finances if they wish. The inspector was advised that the residents are able to bring personal possessions with them into the care home and, during a tour of the building, some residents’ rooms were seen and were personalised. Eden Court Nursing Home DS0000001080.V251193.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): EVIDENCE: This standard was not fully assessed on this occasion, however the residents spoken with, and a relative, said that they would feel comfortable to raise any concerns or make a complaint. The manager informed the inspector that she has reviewed the manner in which complaints are received. Eden Court Nursing Home DS0000001080.V251193.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): 26. The home is generally clean and tidy but the manager must ensure that there are adequate facilities provided to safely manage clinical waste in the home. EVIDENCE: On the day of this unannounced inspection, the home was generally clean and odour free. There is ongoing maintenance and redecoration in the home, and there is a programme of renewal to replace all the furniture in the residents’ bedrooms. During a tour of the home, the inspector observed a clinical waste bag left open on the floor, this is not good practice and must be addressed. All clinical waste bags must be placed in a suitable container. A prescribed bath lotion and razors were left in a bathroom. This practice is not acceptable and poses a potential risk to the residents. (See standard 38). Eden Court Nursing Home DS0000001080.V251193.R01.S.doc Version 5.0 Page 14 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): 29,30. The home’s recruitment practice needs to improve to support and protect the residents. Generally, the home is able to demonstrate that the staff are trained and competent to do their jobs. EVIDENCE: The files for three staff that work in the care home were looked at in detail. Two of the records had gaps in the employees’ employment histories; this was identified during the last inspection and needs to be addressed. The organisation has an induction and foundation training programme for staff. The home receives some external support for the training of its staff in infection control, movement and handling and medication administration. Eden Court Nursing Home DS0000001080.V251193.R01.S.doc Version 5.0 Page 15 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): 33,35,38. Quality assurance systems need to improve to ensure the home is run in the best interests of residents. Service users’ financial interests are safeguarded. The health, safety and welfare of residents and staff are not adequately protected. EVIDENCE: The organisation has a system for monitoring the quality of care provided by the home. However, this system needs to improve and include an annual questionnaire that seeks the views of the residents, their relatives and other stakeholders. The results of such surveys should be published with copies made available to the Commission for Social Care Inspection. The manager has Eden Court Nursing Home DS0000001080.V251193.R01.S.doc Version 5.0 Page 16 taken action since the last inspection to monitor the quality of care provided and has set up residents’ and relatives’ meetings on a monthly basis. The money for three residents was checked and all could be reconciled with the financial records. The residents are supported to manage their own finances and they are provided with lockable space for any valuables. During a tour of the building the inspector observed poor movement and handling practice. The manager must address this to ensure the protection of the residents and the staff. All new staff should receive movement and handling training from a competent person prior to moving and handling the residents in the care home. The recording of hot water temperatures for bathing was discussed with the maintenance person. Razors and prescribed bathing lotion must not be left in the home’s bathrooms as it poses a potential risk to the residents. Eden Court Nursing Home DS0000001080.V251193.R01.S.doc Version 5.0 Page 17 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 1 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X 1 STAFFING Standard No Score 27 X 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X 1 Eden Court Nursing Home DS0000001080.V251193.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? Yes 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. 2. Standard OP8 OP9 Regulation 15 (2) (b) 13 (2) Requirement The registered person shall keep the residents care plan under review. The registered person shall make arrangements for the safe disposal of medicines in the care home. The present system for the disposal of medication must be reviewed. The registered person shall make suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home. The registered person shall make suitable arrangements to provide a safe system for the movement and handling residents. The registered person shall promote and make proper provision for the health and welfare of the residents. Razors and prescribed bathing lotions must not be stored in the homes bathrooms. Timescale for action 08/12/05 08/12/05 3. OP26 13 (3) 08/12/05 4. OP38 13 (5) 08/12/05 5. OP38 12 (1) (a) &13 (2) 08/12/05 Eden Court Nursing Home DS0000001080.V251193.R01.S.doc Version 5.0 Page 19 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. 3. Refer to Standard OP29 OP33 OP38 Good Practice Recommendations Gaps in staff’s employment history should be explored as part of the homes recruitment policy and practice. The present system for quality monitoring needs to improve. The results of questionnaires should be published and copies made available to the residents and the CSCI. The hot water temperatures for bathing and showering should be tested on a weekly basis. Eden Court Nursing Home DS0000001080.V251193.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 Eden Court Nursing Home DS0000001080.V251193.R01.S.doc Version 5.0 Page 21 - 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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