CARE HOMES FOR OLDER PEOPLE
Egerton House Residential Home 113 Hill Top Lane Kimberworth Rotherham South Yorkshire S61 2ER Lead Inspector
Ramchand Samachetty Unannounced Inspection 20 January 2006 09:30 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 Egerton House Residential Home DS0000056460.V273331.R01.S.doc Version 5.1 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. Egerton House Residential Home DS0000056460.V273331.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Egerton House Residential Home Address 113 Hill Top Lane Kimberworth Rotherham South Yorkshire S61 2ER 01709 559643 01709 559643 egertonhouse@aol.com 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) Mrs Parneet Virk Mr Sarbjit Singh Virk Post Vacant Care Home 21 Category(ies) of Old age, not falling within any other category registration, with number (21) of places Egerton House Residential Home DS0000056460.V273331.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. An action plan with timescales for the renewal of furniture and soft furnishings to be developed, agreed and provided to the NCSC within 3 months of this registration date. 28th June 2005 Date of last inspection Brief Description of the Service: Egerton House is a care Home providing care and accommodation for up to 21 residents in the category of older people. The Home provides both long and short-term care for its client group. The Home is owned by Mr and Mrs.Virk. The registered manager post is currently vacant, but there is a deputy manager in post. The Home is situated in the Kimberworth area of Rotherham and within easy reach of the town centre and other local amenities. It is accessible by public transport. Egerton is a two-storey building, which has been extended to provide its current accommodation. There are 17 single and two double bedrooms. There is a passenger lift to facilitate access between the floors. The communal areas consist of a dining room and two lounges. There is a small quiet room on the first floor for use by residents and their relatives as necessary. Bathrooms and toilets are available on both floors. The kitchen and laundry are located on the ground floor. There is a call system in all rooms for use by residents. The Home has a garden and a patio area and there is car-parking facility at the front of the Home. Egerton House Residential Home DS0000056460.V273331.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was carried out on 20 January 2006, starting at 09.30 hours and finished at 14.30 hours. The inspection comprised of a tour of the premises, conversations with three residents, two relatives and three members of staff. The inspector also checked care documentation and other records and observed some aspects of care provision. The inspector also spoke to the deputy manager and the registered provider, who were present during the inspection. What the service does well: What has improved since the last inspection?
The Home has a continuing programme of refurbishment and improvement. Four bedrooms have been decorated. One of the bathrooms has been refurbished. The kitchen walls have been retiled. The ventilation in the laundry has been improved. Assessment of care needs by the Home, care planning and care reviews are being addressed to ensure that the standard of care is continually improved. Training on a number of care issues have been provided to care staff and the home is close to achieving the target of 50 of its staff being qualified to NVQ level 2 in Direct Care. Egerton House Residential Home DS0000056460.V273331.R01.S.doc Version 5.1 Page 6 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. Egerton House Residential Home DS0000056460.V273331.R01.S.doc Version 5.1 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 Egerton House Residential Home DS0000056460.V273331.R01.S.doc Version 5.1 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): The key standards were assessed at the previous inspection. EVIDENCE: Egerton House Residential Home DS0000056460.V273331.R01.S.doc Version 5.1 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): The key standards were assessed at the previous inspection. EVIDENCE: Egerton House Residential Home DS0000056460.V273331.R01.S.doc Version 5.1 Page 10 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 and 14. Choice and individual preferences of individual residents are met and social activities are adequately organised to reflect the capabilities of the resident group. Residents are encouraged and supported to maintain contact with their family and friends. This helps to improve their quality of life. EVIDENCE: Care staff were noted to spend time with individual residents, to help them with expressing their preferences on a number of issues, including menu choices, how to spend their time and who to spend time with. In some instances, staff were observed spending time conversing with residents, on a one to one basis. Residents, who spoke to the inspector, stated that they enjoyed the company of staff and felt that they were ‘well looked after’. In discussion, some residents and relatives commented that there were always social activities and events at the Home. Some relatives said that they usually attend some of these activities, especially those that are held in the evening and week-ends, so as to spend more time with their loved ones. They stated that outside entertainers like ‘lost chord’ and other artists attend fairly regularly and these events are well liked. Egerton House Residential Home DS0000056460.V273331.R01.S.doc Version 5.1 Page 11 One relative said ‘ Mum is well looked after. She is kept well stimulated and in fact, she gets to enjoy herself here, more than she has done before’. Relatives, who spoke to the inspector, stated that staff always made them welcomed at the Home. They could visit at any reasonable time. Staff kept them well informed of issues concerning their loved ones. Egerton House Residential Home DS0000056460.V273331.R01.S.doc Version 5.1 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): The key standards were assessed at the previous inspection. EVIDENCE: Egerton House Residential Home DS0000056460.V273331.R01.S.doc Version 5.1 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): The key standards were assessed at the previous inspection. EVIDENCE: Egerton House Residential Home DS0000056460.V273331.R01.S.doc Version 5.1 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): 28 and 30. Staff have adequate skills and knowledge in order to fulfil their roles, in a safe and competent manner, in meeting the care needs of the resident group. EVIDENCE: Staff have adequate skills to meet the needs of residents. Out of 14 care workers employed at the Home, 6 are qualified to NVQ level 2 in Direct Care. One care worker is currently doing her NVQ training. Other care workers have been provided with training on a number of topics, including moving and handling, fire safety, dementia, diabetes and adult protection. Six senior care workers have received accredited training in medicines administration. However, it was noted that a number of care staff would shortly require a refresher course in first-aid. A new care worker, who spoke to the inspector, stated that she had been provided with the relevant induction. She had been given training in ‘moving and handling’. She had worked as a carer before, and she stated that she was looking forward to enrol on the NVQ training. Egerton House Residential Home DS0000056460.V273331.R01.S.doc Version 5.1 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): 31, 33 and 35. The home is well managed to ensure the safety and protection, including the financial interests, of the residents. Efforts are made to ensure that residents’ views are taken into account in the way care is provided. These actions help to maintain and enhance the welfare of the resident group. However, there is a need to ensure that the vacant registered manager’s post is filled, without further delay. EVIDENCE: There is currently a deputy manager, who is responsible for the day-to-day running of the Home. She is receiving a high level of support from the registered provider, who is a first level nurse. Staff, residents and their relatives are satisfied with the running of the Home. However, action is now required to make sure that a manager is appointed and forwarded for registration by this office of the Commission.
Egerton House Residential Home DS0000056460.V273331.R01.S.doc Version 5.1 Page 16 In discussion, staff commented that they sought the views of the residents, on the way that care is organised and provided. Relatives, who spoke to the inspector, confirmed that they regularly asked for their views and felt that there was good communication among staff, residents and themselves. Staff also stated that relatives, who attend social events at the Home, use these occasions to share their views on behalf of their loved ones. The registered provider explained that a ‘satisfaction survey’ was being conducted. Questionnaires had been sent out to all relatives and advocates of residents. Once returned, an analysis would be done and the outcome reported. The Home was managing the personal allowances of 12 residents. Others were receiving assistance to manage their money from their relatives. Two residents were managing their own money. A sample of residents’ accounts, which are managed by the Home, was checked. The accounts were accurate. They provided explanation of all income and expenditure incurred on behalf of the residents. All withdrawals of money were evidenced by two signatories. Egerton House Residential Home DS0000056460.V273331.R01.S.doc Version 5.1 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 X 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X X Egerton House Residential Home DS0000056460.V273331.R01.S.doc Version 5.1 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 Standard OP31 Regulation 8, 18 Requirement A manager must be appointed and put forward for registration by this office of the Commission. Timescale for action 05/04/06 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 OP33 OP30 Good Practice Recommendations The satisfaction survey of clients should be concluded and the outcome used to improve the service as necessary. Refresher courses in first-aid should be provided to care staff. Egerton House Residential Home DS0000056460.V273331.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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