Inspection on 06/07/07 for Ellacombe

This inspection was carried out on 6th July 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

Ellacombe 26/07/06

Ellacombe 15/10/05

Ellacombe 16/06/05

Ellacombe 01/02/05

Ellacombe 31/08/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Ellacombe Ella Road Norwich Norfolk NR1 4BP Lead Inspector Mr Pearson Clarke Unannounced Inspection 6th July 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Ellacombe DS0000035556.V346149.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. Ellacombe DS0000035556.V346149.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ellacombe Address Ella Road Norwich Norfolk NR1 4BP 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) 01603 613173 01603 624005 ellacombe@norfolk.gov.uk www.norfolk.gov.uk Norfolk County Council-Community Care Mr Christopher John Murphy Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Ellacombe DS0000035556.V346149.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. It is recommended that the home is registered to accommodate 28 Service Users all of whom will be Older People not falling within any other category. Any person who needs a wheelchair to assist with independent mobility at point of admission can only be accommodated in room 33. The Provider undertakes to review the dependency of all of the Service Users to ensure that the home is not accommodating people with mental frailty, if the home is still operating, by June 2004. The Provider undertakes to create a separate access to the Mental Health Unit if this unit continues to use the premises beyond March 2004. Separate entrance to be constructed by June 2004. 26th July 2006 4. Date of last inspection Brief Description of the Service: Ellacombe is a purpose built residential care home providing care for up to 28 older people. The home is situated within walking distance of the city centre with many shops and facilities. The home has a small car park and on street parking is available for a limited period. The home is also situated close to the railway station and close to main bus routes. At the rear of the home is a garden, which is landscaped and provides a pleasant area to sit during the summer period. The current fee levels for the home are individually assessed with a maximum weekly charge of £368.72. Ellacombe DS0000035556.V346149.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care services are judged against outcome groups which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out by using information from previous inspections, information from the providers ,the residents and their relatives, as well as others who work in the agency. This has included a recent unannounced visit to the agency and this report gives a brief overview of the service and current judgements for each outcome. What the service does well: What has improved since the last inspection? The most significant area of improvement since the last inspection of the home, has been in relation to staffing. Existing rota’s have been reorganised and some extra hours deployed resulting in more effective care delivery. This is likely to further improve in the near future when the registered numbers are increased and new staff come on stream. Work has continued to improve the homes care plans, which now give a more comprehensive picture of peoples needs and aspirations. There is generally a more consistent standard of catering with a reduction in the number of complaints about the food served, however this is an area that needs to continue to be monitored to ensure the improvement is maintained. Ellacombe DS0000035556.V346149.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. Ellacombe DS0000035556.V346149.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 Ellacombe DS0000035556.V346149.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. That the home achieves good quality outcomes with prospective residents being properly assessed leading to confidence that the home will meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the last year the home has begun to admit residents again. During the site visit the inspector was able to track two recent admissions and discuss the process with the homes manager. From this it was possible to see that the home has a sound admission process in which prospective residents are properly assessed so as to assure them that the home can meet their needs. Examination of care plans and further discussion during the site visit indicated that the needs of residents currently living there are being met. In addition to the homes own assessments social work assessments are sought and received and staff carry out visits to prospective residents in their current settings. Ellacombe DS0000035556.V346149.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. Residents benefit from effective personal and health care which is underpinned by a plan of care. Medication is safely managed and people’s healthcare needs are met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information received from the providers visiting reports indicates that the home has continued to achieve good results in these areas during the last year. As such care plans are well structured, regularly reviewed and the process involves the residents. During the site visit the inspector was able to track four care plans and this process confirmed the picture found by the provider. However one area for improvement is in relation to the nutritional needs of residents, where the home has yet to fully implement the MUST tool. This was discussed at inspection and the inspector is confident that this will soon be addressed. The service manager feels that the home is effectively managing medication and information received from visiting reports and Ellacombe DS0000035556.V346149.R01.S.doc Version 5.2 Page 10 statutory notifications support this picture. Inspection of medication carried out during the site visit found records to be accurate and storage secure. Staff are trained and a medication policy is in place. Temperature records are maintained and whilst these were in the expected range the upper temperature limit had been reached on occasions. As recent weather has not been hot the management need to take care to ensure that temperatures do not go above the range if the weather changes. Discussion with residents during the visit showed that people feel well cared for and that their privacy and dignity are protected by staff. This was further backed up by observation on the day. Ellacombe DS0000035556.V346149.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. Residents benefit from a relaxed home where they are free to exercise choice and control over their lives. The home has improved its provision of activity and there is more satisfaction with the food served. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the site visit the inspector spent time talking to residents, observing life in the home and in addition written comment was received. Since the last visit to the home more effort has been put into the provision of activity. The home has a newsletter which is informative and an events calendar was seen displayed in the home. Designated staff time is now provided in the week for both individual and group activity. The atmosphere in the home was relaxed and residents confirmed that this is normally the case. Visitors are free to come and go as they wish and comment received from families was positive about the home. At the time of the last inspection there was some concern about the standard of food served. This visit found improvement although there is still room for more consistency. This was discussed on the day and the inspector is satisfied that the service management are working to maintain improvement. Ellacombe DS0000035556.V346149.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. That the service takes complaints seriously and appropriate arrangements are in place to help protect service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Examination of the services complaints record and discussions during the site visit showed the home to continue to have an effective complaints process. Complaints were well documented and the record demonstrated that concerns are taken seriously and where necessary action is taken. The provider continues to have a robust approach to adult protection with sound procedures supported by staff training. Residents told the inspector that they would be confident to complain if they needed to and staff were confident they could report any possible bad practice. Ellacombe DS0000035556.V346149.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. Service users benefit from a comfortable and homely environment which is well maintained. This judgement has been made using available evidence including a visit to this service. Ellacombe DS0000035556.V346149.R01.S.doc Version 5.2 Page 14 EVIDENCE: During the site visit the inspector toured the building and found all areas to be clean and fresh. During the last year a major refurbishment programme has been underway and as with all building work this has proved somewhat disruptive. At the time of this visit the work was nearly complete and seems likely to be highly beneficial. During the last year a significant number of windows have been replaced addressing the issue of drafts and heat loss. Remaining windows are to be replaced in the near future. There has also been some general redecoration and the laundry has had new machines in anticipation of the increased numbers to be accommodated. The providers visit reports during the last year have indicated that issues relating to the building are considered and addressed. Ellacombe DS0000035556.V346149.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. Improvements in staffing levels mean that quality in this area is now good as staff are effective at their jobs, well trained and recruited in a thorough manner. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The providers visiting reports and information taken from the Annual Quality Assurance Assessment showed that concerns arising from the last inspection about staffing levels are being addressed. As such a major recruitment drive has taken place in respect of the proposed increased in numbers and although these staff are not yet working, reorganisation of the staff rota and other increases in hours have resulted in better delivery of care. Staff spoken to felt that the situation had improved and that they felt better able to do their job than a year ago. Residents were clearly appreciative of the care they receive and told the inspector that the staff are hard working and very caring. Training records seen show that the service continues to give staff the training they need and as last year the recruitment process is sound. Ellacombe DS0000035556.V346149.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is good. That residents benefit from a well run home operated safely and in their best interests. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information received from the services Annual Quality Assurance Assessment and visiting reports indicate a well managed home leading to effective care delivery. Regular residents meetings are held and these have been reorganised in to a series of small meetings based on each unit in order to make them more accessible. Minutes of these meetings indicate that where necessary action is taken in response to issues raised. Ellacombe DS0000035556.V346149.R01.S.doc Version 5.2 Page 17 During the site visit the views of stakeholders were sought and they supported the picture gained prior to the site visit. Records relating to Quality Assurance, residents finances and health and safety were inspected and found to be in order. Ellacombe DS0000035556.V346149.R01.S.doc Version 5.2 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 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 Ellacombe DS0000035556.V346149.R01.S.doc Version 5.2 Page 19 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. Refer to Standard Good Practice Recommendations Ellacombe DS0000035556.V346149.R01.S.doc Version 5.2 Page 20 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Ellacombe DS0000035556.V346149.R01.S.doc Version 5.2 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!