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Inspection on 15/11/05 for Ellesmere Community Nursing Home

Also see our care home review for Ellesmere Community Nursing Home for more information

This inspection was carried out on 15th November 2005.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The Home provides a warm, homely and welcoming environment. Staff appeared settled, happy, clear as to their responsibilities and work well at identifying/meeting the care needs of individual Residents in a flexible and effective manner. The Home has a well developed, and successful, fundraising culture with the benefits of related expenditure being evident throughout the Home.

What has improved since the last inspection?

The Home has worked effectively to meet both `Requirements` cited at the previous Inspection. The generally excellent standard of decoration has further benefited from the recent fitting of new carpets in the `public` areas.

What the care home could do better:

From observations made during the Inspection, together with verbal and written comments from Residents and Visitors relating to the care currently being provided, there appears nothing of significance to which the Home`s Management and Trustees might turn their attention, beyond their current development plans.

CARE HOMES FOR OLDER PEOPLE Ellesmere Community Nursing Home Trimpley Street Ellesmere Shropshire SY12 0AE Lead Inspector Keith Salmon Announced Inspection 15th November 2005 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 Ellesmere Community Nursing Home DS0000022248.V252746.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ellesmere Community Nursing Home DS0000022248.V252746.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ellesmere Community Nursing Home Address Trimpley Street Ellesmere Shropshire SY12 0AE 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) 01691 622364 01691 624592 Ellesmere Community Care Centre Trust Lydiann Kym Wright Care Home 9 Category(ies) of Old age, not falling within any other category registration, with number (6), Physical disability (2), Terminally ill (1) of places Ellesmere Community Nursing Home DS0000022248.V252746.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The home must comply with the Staffing Notice issued by the Shropshire Area Health Authority dated 14th February 1995 The home may accommodate a maximum of 9 service users The home may accommodate a maximum of 7 Older Persons, of whom 1 Person may be Terminally Ill, and 1 person may be receiving respite care. The bedroom with the high window must only be used for clients receiving respite care. 14th February 2005 Date of last inspection Brief Description of the Service: Ellesmere Community Nursing Home is situated in Ellesmere Town Centre and benefits from varied local amenities. Occupying the upper floors of the former Ellesmere Cottage Hospital, it is owned by the Ellesmere Community Care Centre Trust, and is accessed via shaft lift or stairs. The ground floor of the building is leased to the Meres Day Centre, which is managed by Shropshire Social Services. The Home is registered to provide accommodation and care, including nursing, for nine persons, one of whom may be terminally ill, and two of whom may have a physical disability. Accommodation comprises seven single and one double bedroom. Ellesmere Community Nursing Home DS0000022248.V252746.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Announced Inspection commenced at 09.30, lasted 5.5 hours, and was undertaken by one Inspector. This Report is the product of observations made during a tour of the Home, through discussions with Residents (7), Visitors (2), Ms. Kym Wright, Registered Manager, Mrs. Jan Wallace, Administration Manager, and other staff members. In addition, a sample of care related documentation was reviewed, together with a wide range of documents/records reflecting the general operation of the Home, plus Staff recruitment/deployment/training practices. Previous good standards of direct care provision, and overall management, have been maintained, in a setting, which is clearly very friendly and open. Written and verbal comments made by Residents or Visitors included:“This is a marvellous place...”, “very good care…”, “very pleased with the standard of care provided…”, “have been impressed with the care given to my Father and the cleanliness and general atmosphere within the Home....” “Father has told us he wants to make it his Home, that alone speaks for itself…”, “I would give the Home eleven out of ten…”. What the service does well: What has improved since the last inspection? The Home has worked effectively to meet both ‘Requirements’ cited at the previous Inspection. The generally excellent standard of decoration has further benefited from the recent fitting of new carpets in the ‘public’ areas. Ellesmere Community Nursing Home DS0000022248.V252746.R01.S.doc Version 5.0 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. Ellesmere Community Nursing Home DS0000022248.V252746.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ellesmere Community Nursing Home DS0000022248.V252746.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 & 3. Prior to admission prospective Residents are enabled to make an informed choice about entering the Home, and to fully understand the service they can expect to receive. All Residents are issued with Service Contracts appropriate to their needs. Processes to ensure appropriate, thorough, and effective care needs assessment are diligently undertaken and applied. EVIDENCE: A review of documentation showed the Home to have a Statement of Purpose and a Service User Guide, both of which are concise and easy to read, and have content that meets the requirements of the Standard. Residents are provided with a Statement of Terms and Conditions detailing the accommodation to be provided – incorporating a 28-day ‘trial’ period, which enables either party to terminate the arrangement if deemed appropriate. Information from four randomly selected Care Plans, together with discussions with Residents, demonstrated the Registered Manager assesses all prospective Residents/Service Users prior to admission. Emergency or crisis admissions are accepted following collaboration with the local General Practitioners, with assessment being completed during the 48-hour period following admission. Ellesmere Community Nursing Home DS0000022248.V252746.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10. The model of Care Plan utilised by the Home is of good, basic design, and is diligently and effectively utilised in aiding provision of care pertinent to Residents’ assessed care needs. Also, it is commendable that the basic Care Plan had been thoughtfully adapted, and developed, in various ways to meet individual Residents’ care needs. The storage, administration, and disposal of medicines are fully in accordance with accepted good practice. Staff relate to Residents and their families/visitors in a friendly, respectful, and when needed, supportive manner. EVIDENCE: Review of a sample of Care Planning Documentation showed them to be well organised, current, clearly written, and comprehensively encompassing the range of ‘care areas’ necessary to ensure delivery of care appropriate to the needs of each Resident. Operational Policies and Procedures were reviewed and found to be up-to-date and inclusive. Inspection of medicine storage provision, and administration records, demonstrated the Home’s practices meet the guidelines of the Royal Pharmaceutical Society. Ellesmere Community Nursing Home DS0000022248.V252746.R01.S.doc Version 5.0 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): 12,14 & 15. The Home works hard to involve Residents in a range of leisure opportunities, consistent with each Resident’s capabilities. Continuation of religious practices is encouraged and supported wherever possible. The Home provides the type of meals preferred by the Residents. EVIDENCE: Discussions with Residents, and reviewing of Care Plans and photographic records, provided evidence of a range of leisure activities, both within the Home and in the local community. Leisure activities are planned and co-ordinated by a nominated member of nursing staff, and have recently included organised ‘coffee mornings’, ‘narrow-boat’ trips, a visit to Chirk Castle and seasonal activities/celebrations, with regular board games (especially dominoes) and card games. The Home has a set 4-week menu cycle, which appeared well-balanced, nutritious, and was confirmed as responsive to individual likes and dislikes. However, the Home has recently appointed a new Chef, who is currently reviewing/developing the menu. Notwithstanding this review, Residents expressed total satisfaction with the meals provided at the Home, as being plentiful and to their liking. Ellesmere Community Nursing Home DS0000022248.V252746.R01.S.doc Version 5.0 Page 11 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): 16,17 & 18. The interests of Residents are protected through ready access to the Home’s Complaints Procedure and information relating to advocacy services. Staff are clearly aware of their role in protecting Residents from abuse. EVIDENCE: There are policies and procedures in place, which facilitate protection for vulnerable people, which meet the requirements of this Standard and the topic is covered both at induction and through on-going staff training. One complaint has been lodged with the Home since the previous Inspection and records are available to show it has been dealt with in accordance with the Home’s Complaints Policy/Procedure, and to the satisfaction of the complainant. Ellesmere Community Nursing Home DS0000022248.V252746.R01.S.doc Version 5.0 Page 12 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): 19,20,22,23,24,25 & 26. The Home’s lounge/sitting and dining areas offer a good variety of size and outlook, with furnishings and decoration being of good order and presenting a ‘domestic’ ambience. Specialist equipment is available to facilitate provision of care, e.g. hoists, wheelchairs, stand-aids, and are consistent with the needs of the Service Users, and with the demands of tasks carried out by Care Staff. The small garden to the front of the property provides a safe environment. The standard of cleanliness in the Home is excellent. EVIDENCE: All communal rooms and bedrooms were seen to be comfortably furnished and in good decorative order, providing a clean, warm and welcoming atmosphere. The small garden area, to the front of the building, has recently been landscaped for the benefit of Residents, and attendees at the Meres Day Centre. The Home is well situated to access the varied amenities available in Ellesmere and, though occupying the second floor of the building, Staff make every effort to assist individual Residents in accessing these facilities. The Home has a full range of maintenance contracts in place, which are current. Ellesmere Community Nursing Home DS0000022248.V252746.R01.S.doc Version 5.0 Page 13 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): 27,28,29 & 30. Staff numbers and skill-mix on duty were consistent with those shown on the rota, and were sufficient to meet the assessed care needs of current Residents. Recruitment and employment practices are consistent with safeguarding Residents. The commitment of the Home to providing training for Care Staff is exemplary. EVIDENCE: The current staffing rota, and those from the immediately preceding weeks, were examined. Staffing numbers and skill-mix enable a service provision, which meets the care needs of the Service Users. Staff Personnel Files demonstrated evidence of full compliance with the Standard and Schedule 2 of the Regulations. Staff are subject to a thorough, and relevant, orientation/induction programme, which is followed by comprehensive ‘foundation’ training, e.g. ‘manual handling and lifting’, ‘fire safety’, ‘simple infection control’. In addition, the Home enjoys an excellent record for the continuing development of Care Staff, and supporting Staff in undertaking appropriate training based on a well-structured plan for determining individual training needs. The current very high level of NVQ Level 2 attainment (90 of Care Staff) reflects a very positive approach to enabling skills development. The Inspector considers the Trust/Management are to be commended for their continued commitment to staff training. Ellesmere Community Nursing Home DS0000022248.V252746.R01.S.doc Version 5.0 Page 14 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): 31,32,33,34,36,37,38. The Home has excellent leadership from the Registered Manager who, in turn, is well supported by Members of The Trust, Administration Manager, several longstanding and experienced staff and, not least, by local community groups and businesses. The ambience of the Home is warm, friendly, and inclusive. Operationally, the Home is very well organised, with the central purpose being ‘the best interests of Residents’. Lines of accountability are clearly defined and observed. Staff are subject to effective support with regular ‘supervision, and appeared involved and happy in their work. Business Planning, accounting and financial procedures are conducted and recorded efficiently. EVIDENCE: The Manager has recently received ‘Registered Manager’ approval from the CSCI, and successfully completed the NVQ Level 4 Managers’ Award. Staff training records demonstrated the Manager’s staff ‘supervision’ style that is a ‘day-by-day, hands-on management approach and which is both effective and exemplary in it’s approach. Evidence of effective Business Planning has Ellesmere Community Nursing Home DS0000022248.V252746.R01.S.doc Version 5.0 Page 15 been lodged with CSCI, and inspection of current financial records showed that matters are conducted in a satisfactory manner. In the context of health, safety and welfare of Residents, Visitors and Staff, the Home’s practices were seen to be in accordance with the Regulations. Ellesmere Community Nursing Home DS0000022248.V252746.R01.S.doc Version 5.0 Page 16 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 3 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 x 3 3 3 3 4 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 3 3 x 4 3 3 Ellesmere Community Nursing Home DS0000022248.V252746.R01.S.doc Version 5.0 Page 17 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 Ellesmere Community Nursing Home DS0000022248.V252746.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Ellesmere Community Nursing Home DS0000022248.V252746.R01.S.doc Version 5.0 Page 19 - 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!