Inspection on 28/06/05 for Egerton House Residential Home

This inspection was carried out on 28th June 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

Egerton House Residential Home 28/01/09

Egerton House Residential Home 18/12/07

Egerton House Residential Home 16/01/07

Egerton House Residential Home 20/01/06

Egerton House Residential Home 02/03/05

Egerton House Residential Home 13/10/04

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Snydale Care Home

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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 EGERTON HOUSE 113 Hill Top Lane Kimberworth Rotherham S61 2ER Lead Inspector Ramchand Samachetty Unannounced 28 June 2005 10:00 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 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 20050824 Egerton House SUI X00015 J55 V198143 S56460 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Egerton House Residential Home Address 113 Hill Top Lane Kimberworth Rotherham S61 2ER 07930 749721 None None Mrs Parneet Virk Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Post Vacant Care Home 21 Category(ies) of Old age registration, with number not falling within any other category (21) of places EGERTON HOUSE 20050824 Egerton House SUI X00015 J55 V198143 S56460 Stage 4.doc Version 1.40 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. Date of last inspection 2 March 2005 Brief Description of the Service: Egerton House is a Care Home providing care and accommodation for up to 21 service users 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 was a Deputy Manager working at the Home at the time of this inspection.The Home is situated in the Kimberworth area of Rotherham and is within easy reach of the town centre and other local amenities. Egerton House is a two-storey building which has been extended to provide its current accommodation. Ther are 17 single and 2 double bedrooms. The communal areas consists of a dining room and two lounges. There is a small quiet room on the first floor for use by residents and their relatives. 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 used by residents. There is a passenger lift to facilitate access between the two floors. The Home has a garden and patio area and ther is car parking facility at the front of the building. EGERTON HOUSE 20050824 Egerton House SUI X00015 J55 V198143 S56460 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out on 28 June 2005, starting at 10.00 hours and finished at 18.00 hours. The inspection included a tour of the premises, conversations with three residents, three relatives and three members of staff, observation of some aspects of care being provided and the examination of care documentation and other records. What the service does well: What has improved since the last inspection? A number of bedrooms and other communal and service areas have been decorated, and this has made the Home more pleasant. New dining room furniture has been provided. This has made the dining area more comfortable and residents feel happy to partake their meals in such an improved setting. There has been an improvement in the management of the Home, although the post of registered manager was vacant. Efforts have been made to improve care documentation and overall training of staff. EGERTON HOUSE 20050824 Egerton House SUI X00015 J55 V198143 S56460 Stage 4.doc Version 1.40 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 20050824 Egerton House SUI X00015 J55 V198143 S56460 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection EGERTON HOUSE 20050824 Egerton House SUI X00015 J55 V198143 S56460 Stage 4.doc Version 1.40 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 standard(s) 3 and 5. The care needs of residents are assessed on admission to ensure that identified needs can be met. However, assessments were not always comprehensive and specific enough to address all areas of needs. Sometimes, this has led to needs not being fully met. The process of assessing needs must be improved and staff should ensure that they are able to carry out assessments satisfactorily. Prospective residents and their relatives are encouraged to visit the Home and to check whether it is suitable, before making their choice of a care home. EVIDENCE: Residents and relatives, who spoke to the inspector, stated that they had been encouraged to visit the Home and to assess its services and facilities before making their choice. One resident who had recently moved in the Home, said ‘ My husband and my daughter came to look round. They were most welcome and they spoke to staff and other residents. They found it to be very homely. I am here now and I find it homely’. Residents and relatives also confirmed that they were satisfied with the care that is provided. EGERTON HOUSE 20050824 Egerton House SUI X00015 J55 V198143 S56460 Stage 4.doc Version 1.40 Page 9 The care records of two residents were checked. They included copies of their needs assessments. These assessments were appropriately shared and agreed with the residents concerned and their relatives. However, such assessments did not include all areas of care needs. For example, issues regarding social care and mental health needs were not well assessed, and on occasions, were not fully addressed. EGERTON HOUSE 20050824 Egerton House SUI X00015 J55 V198143 S56460 Stage 4.doc Version 1.40 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 standard(s) 7,8,9 and 10. Documentation for care plans has been improved. Individual care plans for residents were developed on the basis of their assessed needs, to ensure that they were receiving the necessary care. However, actions to be taken to meet identified needs or risks were often vague and reviews of care plans were inadequate. Care staff were proactive in ensuring that the health care needs of residents were adequately addressed. The administration of medicines was appropriately undertaken. Staff attitude and approach to care was based on respect for the individual and this helped to safeguard and enhance the rights and dignity of residents. EVIDENCE: Residents and relatives who spoke to the inspector, confirmed that staff were ‘ Good and caring’. Interactions between staff and residents were noted to be friendly and courteous and this helped to foster a good atmosphere at the Home. One relative commented that she found the care staff to be very helpful. ‘ It’s the little things they do. They always ring me regarding my mum. They give her good care. Mum always look clean and comfortable’. EGERTON HOUSE 20050824 Egerton House SUI X00015 J55 V198143 S56460 Stage 4.doc Version 1.40 Page 11 Residents were offered personal care in the privacy of their own rooms or in bathrooms. Residents were in good attire and this enhanced their selfconfidence and their dignity. A sample of care plans was checked. The documentation for care plans was good. Care plans were developed on the basis of needs assessment. However, care plans continue to appear weak because they did not address all areas of need and because actions to be taken to meet care needs and risks were not specified and detailed enough. Records of care provided, were too generalised, to be of help in care evaluation. In some cases, care plans have not been reviewed on a monthly basis and staff therefore had little guidance on the appropriateness of the care being provided. Medication records and discussion with care staff confirmed that the storage and administration of medicines at the Home were adequately undertaken. Care records of residents showed that they were appropriately referred to a range of health care professionals as and when needed. District nurses were attending to a small number of residents at the Home. One visiting health care professional commented that care staff had good rapport with the community health services in the locality. EGERTON HOUSE 20050824 Egerton House SUI X00015 J55 V198143 S56460 Stage 4.doc Version 1.40 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 standard(s) 15 The Home was providing a good catering service, which met both the nutritional needs and preferences of residents. Mealtimes were well managed and the environment in which meals are taken has been much improved. Both these factors help to make mealtimes enjoyable. EVIDENCE: Care plans which were checked, showed that nutritional needs and food preferences of individual residents were assessed and catered for. Menus were displayed in the dining area and staff were observed helping residents to express their choice of food and drinks. Special diets were also available. One relative commented that the food provided at the Home was quite good. She said, ‘ It’s the type of food my mum likes’. The inspector observed lunch being served. The dining room has been recently refurbished. It was well laid out. Care staff offered assistance to some residents, to eat their food. A few other residents were provided with adapted cutlery to assist them in partaking their meals. Residents, who spoke to the inspector, said they enjoyed lunch. They said that the food was well cooked and well presented and the meal was unhurried. EGERTON HOUSE 20050824 Egerton House SUI X00015 J55 V198143 S56460 Stage 4.doc Version 1.40 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18. The Home has appropriate policies and procedures in place to manage complaints and any allegations of abuse. Residents and their relatives were provided with adequate information to enable them to raise concerns about care or other issues relating to the Home. Complaints received by the Home, were appropriately dealt with. However, a small number of staff was noted to be requiring training on issues of adult protection, in order to ensure the proper implementation of existing policy and procedures. EVIDENCE: The Home has a complaint procedure, which residents and relatives are made aware of. This procedure is also well documented in the Service User Guide of the Home. The deputy manager and senior care staff commented that they regularly seek feedback from residents and relatives, in order to address any concerns straight away. Residents and relatives, who spoke to the inspector, confirmed this approach, which they found to be reassuring. The Home had received two complaints since the last inspection (March 2005). The inspector examined documentation relating to the two complaints and was satisfied that they were appropriately managed. The home has an adult protection policy, which includes whistle- blowing. The policy is in line with the local multi- agency approach to the management of adult protection issues. However, in discussion with care staff, it was noted that a small number of them, were unaware of good practice in the field of adult protection and that they required training on the subject. EGERTON HOUSE 20050824 Egerton House SUI X00015 J55 V198143 S56460 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 26. The building and its surroundings were generally well maintained, thereby enhancing its appearance and facilities. The owners have carried out a programme of refurbishment and the Home now offers a comfortable standard of accommodation. However, further improvement is now needed to address a small number of potential health and safety issues. Good hygiene standards were maintained at the Home and this helped with the control of infection and with making it more pleasant. EVIDENCE: The inspector, accompanied by the deputy manager, undertook a tour of the Home. The communal areas and some residents’ private rooms which were viewed (the latter with residents’ permission) were in good decorative state. All central heating radiators, except for two, had been provided with protective guards. The Home was found to be clean and tidy and there were no malodours. The grounds were tidy, well maintained and accessible. However, the laundry area was found rather cluttered and lacked ventilation. EGERTON HOUSE 20050824 Egerton House SUI X00015 J55 V198143 S56460 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29. The number of care staff appeared adequate to meet the needs of the resident group. There was a good staff team in place and care staff had the skills and knowledge to fulfil their roles within the Home. The staff recruitment and selection procedures appeared to be in line with good employment practice and with the need to protect and safeguard vulnerable adults. EVIDENCE: There were three care assistants throughout daytime hours and two on night duty. The deputy manager was also on duty during the day. Adequate kitchen and laundry staff were also on duty. On the current number of residents (17), the number of staff appeared able to meet the care needs of the resident group. It was noted that management at the Home was using the formula of the Residential Forum to assist in calculating the staffing level. Staff spoken to, showed that they were aware of the aims and objectives of the Home and had enough knowledge and skills to provide care and support to the client group. Care staff felt that they were working better as a team. A sample of staff files was checked. The recruitment and selection procedures were appropriately being followed. Care staff started their employment only after safety checks and references were obtained and were judged satisfactory. EGERTON HOUSE 20050824 Egerton House SUI X00015 J55 V198143 S56460 Stage 4.doc Version 1.40 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 and 38. Although the post of registered manager has been vacant for some time, management of the Home has been adequately maintained through the appointment of a deputy manager and the overall supervision of the registered provider. Action must now be taken to ensure that the post of Home manager is filled. The Home is well managed to ensure the safety and protection of the residents. However, a few potential health and safety issues are now requiring remedial action, in order to enhance the welfare of both residents and staff. EVIDENCE: A deputy manager has been in post since the last inspection. She is supported in her tasks, by the registered provider. In discussion, relatives, residents and staff commented that management at the Home had improved. One relative said ‘ The owner seems very efficient and she makes sure things get done EGERTON HOUSE 20050824 Egerton House SUI X00015 J55 V198143 S56460 Stage 4.doc Version 1.40 Page 17 properly’. The deputy manager has undertaken some training but would require further training in Care and Management. However, the post of Home manager must now be filled, to ensure that the duties and responsibilities of the post are appropriately assigned to a registered person. The residents’ safety and welfare were safeguarded by providing staff with training on a range of topics including’ moving and handling’ fire safety, and food hygiene. Records of safety checks and maintenance of equipment were up to date. However, there were still two central heating radiators that required protective guards. The laundry room also needed further improvement, in particular with its ventilation. EGERTON HOUSE 20050824 Egerton House SUI X00015 J55 V198143 S56460 Stage 4.doc Version 1.40 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 2 x x x x x x 2 EGERTON HOUSE 20050824 Egerton House SUI X00015 J55 V198143 S56460 Stage 4.doc Version 1.40 Page 19 yes 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 3 Regulation 12, 14 Requirement Timescale for action Immediate and ongoing. 31.08.05 2. 7 3. 7 4. 18 5. 19, 38 6. 7. 19,38 31 Assessment of care needs must be improved to ensure all health, personal and social care needs are considered. 12, 15 Individual care plans must be improved to indicate details of the action to be taken to meet identified needs. Care given to individual residents must also be appropriately recorded in their care plans. 12, 15 Care plans, including risk assessments must be reviewed at least once a month. (Previous timescale of 01/05/05 not met). 13, 18 All care staff must be provided with training on adult protection issues, including the local multiagency approach. 12,13, 23 The two central heating radiators as identified, must have low surface temperature of be fitted with appropriate protective guards.(Previous timescale of 01/06/05 not met). 12, 13, 23 The ventilation in the laundry must be improved. 8, 18 A manager must be appointed and put forward for registration by this office of the Commission. 20050824 Egerton House SUI X00015 J55 V198143 S56460 Stage 4.doc Immediate and ongoing. 30.09.05 31.08.05 30.09.05 31.08.05 EGERTON HOUSE Version 1.40 Page 20 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 3 Good Practice Recommendations Care staff who undertake assessments of needs of residents should ensure that they have received training to do so, and that they follow the recommended practice. EGERTON HOUSE 20050824 Egerton House SUI X00015 J55 V198143 S56460 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection 1st Floor, Barclay Court Heavens Walk Doncaster DN4 5HZ 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 EGERTON HOUSE 20050824 Egerton House SUI X00015 J55 V198143 S56460 Stage 4.doc Version 1.40 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. 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