Inspection on 07/02/07 for Ella McCambridge Residential Home

This inspection was carried out on 7th 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

Ella McCambridge Residential Home 05/02/09

Ella McCambridge Residential Home 27/01/06

Ella McCambridge Residential Home 21/09/05

Ella McCambridge Residential Home 28/06/04

Ella McCambridge Residential Home 17/01/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Ella McCambridge Residential Home Mitchell Street Walker Newcastle Upon Tyne Tyne & Wear NE6 3PR Lead Inspector Allan Helmrich Key Unannounced Inspection 10:00 7 and 8th February 2007 th 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 Ella McCambridge Residential Home DS0000000441.V322919.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. Ella McCambridge Residential Home DS0000000441.V322919.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ella McCambridge Residential Home Address Mitchell Street Walker Newcastle Upon Tyne Tyne & Wear NE6 3PR 0191 2341881 0191 2343327 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) Manor Care Home Group Mr Kevin Bailey Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places Ella McCambridge Residential Home DS0000000441.V322919.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Three residents may be aged between 60-65 years. Date of last inspection 27th January 2006 Brief Description of the Service: Ella McCambridge is a modern purpose built care home providing accommodation with personal care for up to 37 older people. The home is owned by Manor Care Home Group who have two other homes in the vicinity. The home is in a residential area of Walker, close to shops, pubs and other local amenities. The home was opened in 1999 and was purpose built over two storeys. There is level access from the car park into the home and into the enclosed garden and there is a passenger lift between floors. One bedroom is registered to accept double occupancy and all but two bedrooms have en-suite toilet and wash hand basins. There are lounges and dining rooms on both floors and a separate lounge that is used by smokers. Inspection reports and information about the home are readily available. The weekly fees are £390. Ella McCambridge Residential Home DS0000000441.V322919.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s annual unannounced key inspection visit. The inspection was conducted over two separate days and took 8 hours. Time was spent talking to the manager, some care staff, several residents and their visitors. Some of the home’s care records were reviewed and the systems that maintain residents safety. Some residents’ case records were specifically assessed against the style of care provided. This is called ‘Case Tracking’. Questionnaires were provided for residents and visitors to the home. Responses were received from fifteen residents and nine visitors/relatives. Information provided by them is used in the report. What the service does well: What has improved since the last inspection? The home continues to be well maintained. Staff training continues. Ella McCambridge Residential Home DS0000000441.V322919.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Ella McCambridge Residential Home DS0000000441.V322919.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 Ella McCambridge Residential Home DS0000000441.V322919.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, 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission process reduces the possibility of admitting someone whose needs cannot be met. Intermediate care is not provided. EVIDENCE: Four care plans reviewed contained details of an assessment done by senior staff before a place is offered. This assessment was done before admission to the home and included information provided by care managers. This ensures the home can provide the level of care needed by the resident. Ella McCambridge Residential Home DS0000000441.V322919.R01.S.doc Version 5.2 Page 9 On admission the deputy manager summarises the initial assessment for the staff team, picking out the more important areas of care. A plan of daily living is produced and any risks to the resident are assessed. Files contained information about contracts and a confirmation the home’s brochure was provided to the resident. Of the fifteen resident responses to a questionnaire, everyone who answered stated they received enough information about the home before they moved in. A range of information about the home and the service it provides is on display in the home, together with recent inspection reports. The home does not accept referrals requiring rehabilitation but respite beds are available. Ella McCambridge Residential Home DS0000000441.V322919.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health and personal care needs are addressed. The home has appropriate procedures for handling and administering medicines. Residents’ privacy and dignity is maintained. EVIDENCE: Four care plans were reviewed. They all contained a social assessment and a plan for daily living. Care plans describing to staff how care is to be provided are written and risks in daily living are assessed. Risk assessments are written with how these can be reduced. Each resident’s health is assessed and this is Ella McCambridge Residential Home DS0000000441.V322919.R01.S.doc Version 5.2 Page 11 regularly reviewed. One care plan clearly showed the significant changes in one residents health and how this is addressed. Residents, weights are regularly recorded and care plans are generally reviewed monthly to ensure the care provided meets the individual’s needs. No one in the home currently has a pressure sore but systems are in place to assess residents at risk and equipment to support them is available. Not all care plans included a photo of the resident to identify them to new staff. Residents seen were dressed appropriately in their own clothes. Staff were seen to treat residents respectfully and deal with any personal issues with dignity. Locks on bathroom and toilet doors checked during a tour of the building worked smoothly. Residents spoken to during the inspection all said that staff provided good care and this was generally confirmed in the returned questionnaires. Twelve of the fifteen questionnaires returned stated that residents always get the care and support they need. Two visitors wrote their relatives are really well looked after by competent caring staff. Two other comments made were not so positive. One visitor was only half satisfied with the care provided and another felt that some staff are better than others but that on balance they were satisfied. The system for the administration of medicines was checked and found to be good. Staff who dispense medicines are trained and records are maintained for ordering, receiving, administering and disposal. Medicines are stored safely. The manager was confident about his system for dealing with alerts sent by the Medical Devices Agency and produced copies of recent notifications. A procedure is not in place to support this practice. The deputy manager had been made aware of tablets found on the floor in a residents bedroom. Action was taken to remind staff that they must ensure dispensed medicines are taken and if not the records should record any refusals. Ella McCambridge Residential Home DS0000000441.V322919.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can choose what to do. Visitors are made welcome in the home. A range of good healthy food is provided in the home. EVIDENCE: During the inspection residents were playing bingo. This is a regular weekly event organised by the home’s dedicated activities person. Several residents spoken to later in the dining room said they enjoy bingo and other activities organised in the home. Some residents spoken to were not interested in the activities provided and several comments in the returned questionnaires supported these comments. The manager was aware of those residents who Ella McCambridge Residential Home DS0000000441.V322919.R01.S.doc Version 5.2 Page 13 were not interested in activities provided by the home and respected their opinions. Some residents go out independently and others are supported to use local shops and other community services. One residents in the smoking room said she enjoys a cigarette and conversation with other residents and staff. Residents stated they could choose when to get up in the morning and what to do during the day. One resident who enjoys a lie in said that she gets a breakfast and that her lunch is held back until she is ready. Visitors also said the home routines are flexible to meet individual needs. Visitors were seen during the day talking to residents. Those spoken to stated that visiting was not restricted. The home has a visitors’ policy to ensure residents’ rights are respected. Residents and their families are encouraged to handle their own finances and a system is in place to invoice families for services provided outside of the normal care services. Information about advocacy is on the home’s notice board. The proprietor stated that anyone without family support would be directed to this service. Most of the residents spoken to said that the meals provided were either good or excellent. One resident who said he does not eat much said the meals were alright. A sample of the menus provided prior to the inspection showed that each day residents were provided with a range of vegetables and fruit. The lunchtime meal was observed. It was unhurried with adequate staff numbers supporting residents in a quiet dignified way. The kitchen is well equipped and a range of foodstuffs to enable the cook to meet individual choice was available. Following comments made, residents were consulted about the timing of teatime. This resulted in a change to 4:00pm from 4:30pm. Ella McCambridge Residential Home DS0000000441.V322919.R01.S.doc Version 5.2 Page 14 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, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are safe and well protected in the home. Their concerns are listened to and addressed. EVIDENCE: The home has a complaints procedure and this is given to each new resident. A copy of the complaints procedure is also displayed in the home. The majority of respondents to a questionnaire were aware of the complaints procedure and who to complain to. The home has received one complaint from a visitor since the last inspection. The details of the complaint were recorded in a log together with the actions taken. Staff are provided with training related to protecting vulnerable adults and procedures are in place regarding this. Staff spoken to understand how to protect vulnerable people. The home have previously involved professional people to provide training and support for staff in dealing with challenging behaviours. Ella McCambridge Residential Home DS0000000441.V322919.R01.S.doc Version 5.2 Page 15 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, 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is safe, clean and well maintained. EVIDENCE: The home that is purpose built is clean and well maintained. A programme of maintenance is in place. When bedrooms are empty the opportunity is taken, if needed, to replace carpets and any other items of furniture. Residents and their visitors spoken to during the inspection are happy with the standard of appointment. Ella McCambridge Residential Home DS0000000441.V322919.R01.S.doc Version 5.2 Page 16 A programme of cleaning is in place, the home is clean and no odours were detected. Requirements relating to fire doors, made by the local fire service, are in hand. The kitchen is well equipped and a good standard of hygiene was observed. The laundry contains appropriate equipment to meet disinfection standards and dedicated laundry staff are provided with information and instruction regarding laundry. As with many large homes, there are issues regarding lost and damaged clothing, however, management are aware of these issues and try to limit these with the systems they have in place. New coloured washing baskets have been provided to identify where the laundry is from. Ella McCambridge Residential Home DS0000000441.V322919.R01.S.doc Version 5.2 Page 17 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, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good staffing levels enable residents’ needs to be met. The home has exceeded the standard for the numbers of staff who have a care qualification. The recruitment procedure helps keep residents safe. Staff are provided with training that is relevant to the needs of the people they care for. EVIDENCE: The staff team is consistent; only three new staff have been employed since the last inspection. Staff left in charge of the home are over 21 years of age and although two recently employed staff are under 18 years of age, they are on shift separately with two experienced carers supporting them. Other staff providing personal care to residents are at least 18 years old. Ella McCambridge Residential Home DS0000000441.V322919.R01.S.doc Version 5.2 Page 18 Appropriate care staffing levels are provided to meet residents needs. The rota showed that there are four carers during the day until 2:00pm and three carers from then and through the night until 8:00am. In addition the manager is available in the home each weekday. The home employs an activities person, an administrator and a maintenance person. The home has suitable domestic, laundry and catering staff hours. Existing staff provide cover for absences. Comments recorded on questionnaires praised the quality of the staff team and those residents who commented liked the staff and felt they provide a good standard of care. Two comments made, suggested some staff provide better care than others although nothing specific was identified. The home employs 22 care staff, 19 staff have achieved National Vocational Qualifications (NVQ) Level 2 or 3 in care. This exceeds the standard expected of 50 . A sample of staff recruitment files were examined. They all contained appropriate references and had Criminal Records Bureau (CRB) checks carried out. This reduces the risk of employing unsuitable people. Two files did not contain information to identify the members of staff. This was corrected before the end of the inspection. Two new staff are doing induction training. These were inspected and were signed and dated. Each staff members training is recorded and training certificates are in the individual staff files. A range of training is provided that includes safe working practices, fire safety, moving and handling, first aid and food hygiene. Senior staff had completed medication training. Ella McCambridge Residential Home DS0000000441.V322919.R01.S.doc Version 5.2 Page 19 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, 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager has demonstrated his ability to provide good care by obtaining the Registered Managers Award. The home has a quality monitoring system to promote good care practices. A system to monitor residents’ financial interests is in place. Residents are safe. Systems to monitor welfare and good hygiene are in place. Ella McCambridge Residential Home DS0000000441.V322919.R01.S.doc Version 5.2 Page 20 EVIDENCE: The manager has been in charge of the home since January 2000. He has the Registered Managers Award which demonstrates his knowledge and experience in managing a care home for vulnerable people. A quality monitoring system is in place and this has been used to assess the quality of care provided in the home. As part of this process questionnaires were sent to relatives. 13 (52 ) were returned and issues identified were addressed. Since then a suggestion box has been provided at the ground floor entrance for visitors and residents. Each year the manager holds an annual meeting. The last meeting of this type was in January 2007. The minutes of this meeting are being typed and will then be distributed. Other meetings are held with different staff groups; senior staff, kitchen staff and domestics. The manager does hold residents meetings but his preferred method is for a member of staff to speak individually to each resident and then record the outcomes. This was last done between the 8th and 12th December 2006. A system is in place to encourage residents and their families to control their own finances. The home sends invoices for any monies they spend on behalf of residents and any monies that are held for residents are recorded and each transaction has two signatures. A recommendation at the last inspection to improve the system of auditing has been considered by the company but not taken up. The home uses a pooled system for holding residents monies. Systems are in place to ensure the home is safe for residents. Certificates were seen to demonstrate maintenance tasks carried out by external contractors were done. Water temperatures are checked and a risk assessment is in place to show the water system is free from Legionella. Accidents in the home are recorded. A fire risk assessment has been produced and regular fire checks are recorded and staff training provided to ensure residents are safe. Ella McCambridge Residential Home DS0000000441.V322919.R01.S.doc Version 5.2 Page 21 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Ella McCambridge Residential Home DS0000000441.V322919.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 OP7 OP9 OP33 Good Practice Recommendations The manager should improve the system for obtaining photographs of new residents to ensure they are on file earlier. The manager should produce a procedure for handling information provided by the Medical Devices Agency to ensure critical advice is reacted to. The manager should use the home’s quality monitoring system to ensure; • The activities provided in the home meet the expectations of residents. Those resident who choose not to be involved should be consulted. • The service provided by the laundry meets the expectations of the residents and their supporters. Ella McCambridge Residential Home DS0000000441.V322919.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 Ella McCambridge Residential Home DS0000000441.V322919.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. 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