Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 05/01/07 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 5th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

What has improved since the last inspection?

The effort of the staff team to improve systems has meant that both of the statutory requirements made at the last inspection by CSCI have now been fully met. Continued commitment to the upgrade of the home by its owners has resulted in refurbishment of the communal bathroom with good quality fixtures and fittings. Improvement to care plan records means the home team can accurately record the events leading up to and following any incident a resident may experience a fall, although these records would also benefit more evidence of residents involvement.

What the care home could do better:

As a result of this inspection, one new statutory requirement has been made. In order to fully meet Health and Safety legislation, staff training needs further development to make sure all staff have had all necessary mandatory training including manual handling and fire safety training.

CARE HOMES FOR OLDER PEOPLE Ellesmere Community Nursing Home Trimpley Street Ellesmere Shropshire SY12 0AE Lead Inspector Janet Adams Key Unannounced Inspection 5th January 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 Ellesmere Community Nursing Home DS0000022248.V302670.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. Ellesmere Community Nursing Home DS0000022248.V302670.R01.S.doc Version 5.2 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 624084 01691 624084* * Number to ring to ask for fax to be turned on ECNH@micro-plus-web.net 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 (7), Physical disability (2) of places Ellesmere Community Nursing Home DS0000022248.V302670.R01.S.doc Version 5.2 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 9 Older Persons and 1 person may be receiving respite care, 2 may have a physical disability. The bedroom with the high window must only be used for clients receiving respite care or, in other instance, by direct written agreement with CSCI. 21st February 2006 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 which means it can be accessed by a variety of public transport. The home is owned by the Ellesmere Community Care Centre Trust,and the Registered Manager is Mrs L. K. Wright. Ellesmere Community Nursing Home is registered to provide accommodation and care, including nursing, for nine persons, one of who may be terminally ill, and two of who may have a physical disability. Occupying the upper floors of the former Ellesmere Cottage Hospital, it 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. Bedroom accommodation comprises of seven single and one double bedroom. The majority of these have en suite facilities. The residents have the opportunity to access a communal lounge and dining room also located on the first floor. The home makes its services known to people by means of its Statement of Purpose, and Service User Guide as well as the latest CSCI (Commission for Social Care Inspection) report. The ranges of fees currently charged are between £465 and £580 per week, according to the level of accommodation and service provided. Services such as hairdressing, complimentary therapies, dental care, eye treatments toiletries, newspapers and magazines are subject to additional charges. Ellesmere Community Nursing Home DS0000022248.V302670.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this inspection visit to the home, which lasted five hours. Some time before the inspection was carried out, CSCI (The Commission for Social Care Inspection.) wrote to the home to request some necessary information to assist with this process. This meant that although Ellesmere Community Nursing Home knew the inspection was imminent, they were not aware of any date or time. The inspection was carried out by observing activity within the home, inspecting the premises, having an ‘in depth look’ at records for residents and staff, observing, talking and listening to all of the nine people living there, and a variety of staff on duty at the time of the inspection. The Registered Manager, Mrs Wright was also on duty at the time of the inspection. A variety of information from other sources confirmed what was seen at the inspection, including the results of a survey carried out by CSCI, when seven of the nine people living there, five relatives and two visiting professionals all shared information about life at Ellesmere Community Nursing Home. Discussions with the management team took place throughout the day and feedback about the conclusions of the inspection was given at the end. Management and staff were wholly co-operative throughout and assisted the inspector in her tasks, for which she extends her thanks. A total of 26 out of a possible 38 National Minimum Standards for Older People were assessed on this occasion. What the service does well: Once again, inspection findings show that the home has continued to more than meet National Minimum Standards for some parts of the service and support it provides for its residents. The home excels in making sure much as possible can be done so that any prospective residents who move into Ellesmere Community Nursing Home are fully aware of what to expect, and that their needs and preferences will be met. All avenues where background information about the individual can be obtained about are fully explored as part of this process. The home meets the individual personal and health care needs of the elderly people living at the home in a desirable manner. Many residents spoken to state they were happy to be living at the home felt safe, and were well cared for. One resident commented: ‘I’m very happy here – I couldn’t be any happier.’ Ellesmere Community Nursing Home DS0000022248.V302670.R01.S.doc Version 5.2 Page 6 Others who were not able to confirm this as a result of their medical conditions all expressed feelings of well being when observed during their daily pastimes. Two visiting professionals backed up inspection findings and confirmed the home has a clear understanding of the medical needs of its residents, and that the home manages its medication systems well. Keeping all residents busy in a variety of daily life and social activities is considered to be vital at Ellesmere Community Nursing Home. The whole care team embrace the issue of activities to make sure people have the support they need to live as full a life as possible. A variety of activities seen being held and planned were as a result of people living there being involved in deciding what they were interested in and enjoyed doing. The home team has the highly valued input and support of volunteers from the local community to assist them put plans into action. They were seen involved in preparations being made for a social luncheon planned for 40 guests on the weekend of the inspection. Good recordkeeping is also evident in the home, and it is reflected in the home management systems such as quality monitoring, and welcoming comments and complaints. What has improved since the last inspection? What they could do better: As a result of this inspection, one new statutory requirement has been made. In order to fully meet Health and Safety legislation, staff training needs further development to make sure all staff have had all necessary mandatory training including manual handling and fire safety training. Ellesmere Community Nursing Home DS0000022248.V302670.R01.S.doc Version 5.2 Page 7 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. Ellesmere Community Nursing Home DS0000022248.V302670.R01.S.doc Version 5.2 Page 8 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.V302670.R01.S.doc Version 5.2 Page 9 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 &4 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Ellesmere Community Nursing Home’s admission procedures clearly demonstrate they can meet needs of people thinking about moving in there. This makes sure if prospective residents and relatives choose this home, it will meet their needs. EVIDENCE: When admissions to the home were explored it was established that the home not only makes sure it can meets the needs of any prospective resident, there is a focus to make sure that meeting the needs of any new resident will have a positive impact on the lives of the residents already living in the home. Ellesmere Community Nursing Home has a healthy waiting list, and it is always explained to the individual interested in living at home, that just because they are at the top of the list does not mean they will be the first to be considered to move in. Admissions are not made to the home until a full needs Ellesmere Community Nursing Home DS0000022248.V302670.R01.S.doc Version 5.2 Page 10 assessment has been undertaken by a skilled and experienced member of staff as well as other health professionals. Evidence seen in two sets of residents’ admission paperwork had been compiled by the Registered Manager.A wealth of information gets gathered by the home team from a variety of sources, including the local authority social work team, health professionals including hospital staff, and community nursing and physiotherapy teams where necessary, to make sure the home can fully meet any prospective residents’ needs. The contents of the details written down also confirm that the assessments are conducted professionally and sensitively and have involved the resident, as well as family members or representatives of the resident as necessary. The home is to be commended for gathering so much information about potential residents who have complex nursing needs in a relatively short period of time. The in – depth information seen in one person’s records had been swiftly collected in order for a decision to be made to move the individual into the home within 10 days. Both residents spoken to felt they had enough information about the home in readiness for moving in. One person confirmed her daughter had looked into it on her behalf, whereas another was already familiar with the ‘good reputation’ of the home has as it was ‘just round the corner.’ She stated was fortunate that there was a vacancy in the home of her choice exactly when she needed it. Ellesmere Community Nursing Home DS0000022248.V302670.R01.S.doc Version 5.2 Page 11 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. The health and personal care, which a service user receives, is based on their individual needs thus promoting good health. Staff have an excellent attitude to their work and the principles of respect, dignity and privacy are put into practice. EVIDENCE: By observing residents receiving the care and support they need to carry out their day-to-day pastimes, and by talking with five of them, it was confirmed, that the very good standards of care reported at previous inspections, continues to be carried out in this home. Written comments received from seven of nine the residents living at the home also stated that they liked living at Ellesmere Community Nursing Home, felt well cared for and the staff respected their privacy. Three of the seven people all commented they thought their care was ‘first class’ Ellesmere Community Nursing Home DS0000022248.V302670.R01.S.doc Version 5.2 Page 12 Feedback from all 5 relatives who filled in comment cards was good. One relative wrote: ‘It comes as great comfort to my family and me that (relative’s name) is so well looked after, thanks to this nursing home. We have no worries for her future.’ Another relative wrote to CSCI shortly after the inspection visit to reaffirm the positive comments. Althourth some people who live at the home were not fully able to talk to the inspector, or write opinions about the home, observations of the behaviours of these individuals in response to the care and support they were given, showed they appeared happy, were well groomed and had the support of knowledgeable staff on duty to give them the personal attention they needed. Resident dignity and privacy is very much an issue that is managed with a very individualised approach. The home is to be commended for the way it meets the diverse needs of the people living at the home. Attention to detail to ensure any physical needs which need to be met as part of a person’s spiritual beliefs is carried out with utmost discretion and respect. The above positive care practices are backed up by equally good record keeping .In the three care plans looked at, t was seen that each resident has a plan that considers all areas of the individual’s life including health, personal and social care needs. The plans also include all necessary risk assessments, which are colour coded pink to highlight their importance, and they have the full back up of a specific care plan. This details how staff are willing to support any risks residents take, which may have an impact on their rights. For example, in one set of records seen it showed that a resident clearly refused to have bedrails installed, and therefore a plan of care was devised to manage this issue to guide staff how to keep the person safe. The introduction of a falls records form since the last inspection shows how the home team continue to improve recordkeeping to make every effort to fully document any such incident. Written records also show there is some information available to show resident and family involvement (where agreed,) about care issues. However, there needs to be more written evidence to confirm this happens regularly. A ‘Service User Collaboration Form’ is used to record some of this action, although in two sets of records seen this had not been regularly completed as part of the monthly plan review. Recordkeeping in residents’ records shows individualised support and care based upon the advice of health professionals is carried out very well. Ellesmere Community Nursing Home DS0000022248.V302670.R01.S.doc Version 5.2 Page 13 The home has excellent working relationships with the community health team. A community nurse and a doctor who visit the home regularly both sent comment cards to CSCI to report positive findings at Ellesmere Community Nursing Home. They both agreed the home care staff demonstrates clear understanding of residents’ needs, and that their medication is appropriately managed. Upon review of the way the home manages its medications, it was seen that staff work to an efficient medication policy supported by sound guidance that meets all necessary legislation for this matter. Although none of the nine people living at the home look after and administer their own medicines, the home is well prepared to provide this support if they decide they want to. After having a look at the working systems in the medication storage cupboard and upon examination of the medicine records of three residents, it was confirmed that staff maintain good records to expected professional standards, which in turn, safeguards residents’ health. Ellesmere Community Nursing Home DS0000022248.V302670.R01.S.doc Version 5.2 Page 14 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 excellent. This judgement has been made using available evidence including a visit to this service. The social, cultural and recreational activities provided at Ellesmere Community Nursing Home meet the current residents’ expectations. Dietary needs of service users are very well catered for with a balanced and varied selection of food available that meets service users tastes and choices EVIDENCE: Similar findings as seen at the last two inspections since October 2005 confirm the home continues to have a sustained track record which shows it excels in providing a stimulating lifestyle to match the wishes, choice and feelings of the people living at Ellesmere Community Nursing Home. Findings of the home tour confirmed what was detailed in residents care plans showing that individual’s interests were being pursued. Bedrooms had personal touches to reflect individual choices, and preferences and also showed that recreational pastimes were actively in progress. One lady seen knitting socks was very proud of an intricately detailed crib scene she had knitted for the Xmas season. This was on display in at the Ellesmere Community Nursing Home DS0000022248.V302670.R01.S.doc Version 5.2 Page 15 reception area of the home. Another lady commented that four residents have a daily game of dominoes each morning to ‘get them going’, and they were appreciative of the efforts of the staff member who organised the regular outings they enjoy. Continuation of religious practices is encouraged and supported wherever possible. The availability of up to date magazines from local churches and societies around the home show this continues. The home team works hard to involve residents in a range of leisure opportunities, consistent with each resident’s capabilities, and have the support of a handful of highly valued volunteers to assist them in this matter. One volunteer was in the home at the time of the inspection, setting up tables for a special ‘friends and family’ social luncheon being held in the home during the forthcoming weekend. The administration manager reported that they were catering for approximately 40 guests, in order so that each of the nine residents could invite four people. Another two volunteers have been specifically recruited so that they can engage in 1:1 and group activities for residents on a weekend. Food is considered to be highly important at Ellesmere Community Nursing Home and meal times considered a social occasion. Lunchtime observations confirmed that knowledgeable staff gave assistance to the two residents who needed help to eat, in a discrete and sensitive manner. Tables were seen set to promote people’s independence, and choice, and equipment such as plate guards were seen in use. Two staff members agreed that the quality and choice of meals has improved during the past six months. Ellesmere Community Nursing Home DS0000022248.V302670.R01.S.doc Version 5.2 Page 16 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 have access to robust, effective complaints procedure that offers residents and supporters assurance their views will be to be listened to and acted upon. Management systems and on-going training regarding adult protection provides staff with the relevant knowledge to safeguard service users from many types of abuse. EVIDENCE: It is positive to report that neither CSCI nor the home have not received any complaints during the last 12 months. Very clear, easy to understand complaints information continues to be available in the reception area of the home. It is also part of the information detailed in the Service User Guide examined during the inspection, which shows the home openly welcomes people to make comments and complaints if they are unhappy. This information is backed up by a good system for the manager to record, investigate and monitor any complaints received. Ellesmere Community Nursing Home DS0000022248.V302670.R01.S.doc Version 5.2 Page 17 Discussion with two residents confirmed they knew what they had to do if they wished to complain, and all twelve residents and relatives who sent comment cards back to CSCI stated they have never had to make a complaint. One resident commented – ‘I don’t think I will ever need to complain about the home – nothing is too much trouble for the staff – I am very happy.’ The home has the following good systems in place to show they promote the welfare of residents at all times: • Robust policies and procedures regarding protection of residents that are regularly reviewed and updated. These are located at the nurses’ station and accessible by any team member who may need to refer to them. Recordkeeping seen in care and finance records seen show systems are in place to ensure that resident’s rights are respected and enjoyed by residents in all areas of their life. Staff training for adult protection is also in hand. The care manager confirmed she had booked four places on each course being held by a local professional organisation for care homes to ensure all team members are kept up to date about this sensitive matter. • • All comments from residents stated that they are very satisfied with Ellesmere Community Nursing Home; feel very safe and well supported by a home that has their protection and safety as a priority. Ellesmere Community Nursing Home DS0000022248.V302670.R01.S.doc Version 5.2 Page 18 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): 19,20,21,22,24 &26 Quality in this outcome area is Excellent. This judgement has been made using available evidence including a visit to this service. The standard of the environment continues to be improved and adjusted to provide residents with a clean, comfortable and well-maintained home to live in. EVIDENCE: The standard of décor, quality of furnishings and cleanliness in all parts of the home is high. Staff members confirmed that the well-kept external garden areas of the home won ‘Ellesmere in Bloom’ this year. All residents’ comments confirmed the home is always clean and tidy and smells fresh. A GP who wrote to CSCI stated ‘This home is the best I have visited in Shropshire – always clean, fresh and in good order’. Ellesmere Community Nursing Home DS0000022248.V302670.R01.S.doc Version 5.2 Page 19 The home is well stocked with its own good quality equipment to enable staff to care for residents more effectively at all stages of their life. For instance, the provision of suitably designed commodes means people who cannot walk can be wheeled to their own toilet and have the enhanced privacy of their en-suite to deal with their personal needs. This is an example, which shows the positive vision that exists within the home to make sure all care practices support and facilitate people to be as independent as possible, as well as maximising their dignity. It is positive to see that the refurbishment of the bathroom carried out with good quality fixtures and fittings. The specialist bath installed was especially chosen as it is a design, which best suited to fully meet the needs of all its current residents. In addition to its well maintained communal areas and bedrooms for residents, the home also has the added advantage of a ‘guest rest’ room where visitors are welcome to make themselves drinks, and wait in comfort should their relative need nursing care during the course of their visit. Discussions with the care manager during the tour of the home confirmed that funding had been secured to upgrade the sluice room, and plans were already taking place to make this happen. This will further enhance its good infection control practices. Clinical waste is properly managed and stored in all parts of the home. Ellesmere Community Nursing Home DS0000022248.V302670.R01.S.doc Version 5.2 Page 20 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 adequate. This judgement has been made using available evidence including a visit to this service. Staff in the home are skilled and in sufficient numbers to fulfil the aims of the home and meet the changing needs of residents, although systems in the home need to be further developed to keep staff up to date with refresher training to ensure residents are in safe hands at all times. EVIDENCE: The small team are flexible in their role to ensure the home is adequately staffed at all times. Clear, easy to understand rotas are compiled to reflect this. Residents report that staff working with them knows what they are meant to do, and that they are able to meet their needs. Examination of the records for two new staff who have recently started work at the home shows there is a recruitment procedure that generally meets the regulations and the national minimum standards. However, the records did show the need for one area of improvement, to ensure paperwork has dates to confirm when references are returned and interview checklists completed. This will clarify auditing to show all of this information is gathered before a person Ellesmere Community Nursing Home DS0000022248.V302670.R01.S.doc Version 5.2 Page 21 starts work at the home. This matter was discussed with the administration manager. It is positive that all but one of the nine carers employed at the home are trained to NVQ Level 2 and 3.Training records for the past year also show that the home management encourage and supports staff members to undertake training courses beyond the basic requirements, for topics covering medical conditions such as depression, care of people who are terminally ill and complementary therapies. Funding has also been sourced for staff to undertake computer training. The home recognises the benefits of developing a skilled, trained workforce earlier in this report it confirms that the Registered Manager has organised refresher training for adult protection issues to keep staff updated.However, some staff training shortfalls identified under the next section of this report, named ‘Management and Administration’ show that all ongoing training needs have not been met to fully promote the health and safety of people living and working at the home. Ellesmere Community Nursing Home DS0000022248.V302670.R01.S.doc Version 5.2 Page 22 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): 31,232,33,35, &38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The trustees of Ellesmere Community Nursing Home have employed an experienced, suitably qualified, competent individual who ensures the management and administration of the home is based on openness and respect, with effective quality assurance systems. This has resulted in good outcomes for service users in most areas of care. EVIDENCE: With the additional support from its trustees and administration manager, the Registered Manager, and her staff team generally ensure the effective and smooth running of Ellesmere Community Nursing Home. Ellesmere Community Nursing Home DS0000022248.V302670.R01.S.doc Version 5.2 Page 23 Mrs Wright, the Registered Manager is appropriately qualified and has the necessary experience to run the home. She continues to develop herself professionally and is currently undertaking training to be an NVQ assessor, as well as having booked a place to be a ‘moving and handling trainer’ in June 2007.Inspection findings demonstrates her effectiveness in working in partnership with family of residents, professionals and with the home trustees. Both managers and trustees have developed systems that monitor practice and compliance with the homes plans, policies and procedures. Due to the small size of the home it has successful has formal and informal systems for resident, relative and staff consultation, with evidence suggesting that their views are sought and acted upon. The planned social luncheon organised for the weekend after the inspection is also an exercise to get comments and feedback about the home. The administration manager reported plans for a satisfaction survey to be carried out at this event. Trustees, management and staff meetings are held monthly, and detailed minutes confirm all aspects of home management are discussed and followed up. The administrators report for the management meeting of December covers maintenance issues for gas servicing, legionella and a new bell for the nurse call system. Most aspects of the health, safety and welfare of service users and staff are promoted by the home’s established safe working systems. Accident records are of a good standard and are routinely completed. -All necessary service and maintenance records requested were seen to be up to date and complied with most health and safety legislation showing the home’s commitment to providing a safe place for people to live. The home team have also held three health and safety meetings in the past six months. It is of note that the home have a very good system so people know exactly what to do in the event of having to carry out an emergency evacuation of the premises. However, an in depth look of three sets of staff records alongside analysis of the staff training monitor confirms that although staff have undertaken infection control training, necessary training to comply with heath and safety legislation, including COSHH, manual handling and fire safety is not being carried out as regularly like it should be. This matter was discussed with both the care manager and administration manager to confirm their awareness. This needs to be prioritised, as some staff have not received refresher training for these matters since 2004 and 2005. Residents have the opportunity to manage their own money if they wish, and robust procedures and secure facilities are provided to help keep it safe. Where the home manages money on residents’ behalf a system is in place to Ellesmere Community Nursing Home DS0000022248.V302670.R01.S.doc Version 5.2 Page 24 record transactions and accounts for spending. Spot checks on two sets of resident records show that they are robust and up to date. Ellesmere Community Nursing Home DS0000022248.V302670.R01.S.doc Version 5.2 Page 25 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 4 4 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 3 3 4 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 3 3 X 3 X X 2 Ellesmere Community Nursing Home DS0000022248.V302670.R01.S.doc Version 5.2 Page 26 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. 1 Standard OP38 Regulation 18 (1) Requirement The registered persons must ensure the health welfare and safety of the staff team. All staff must undertake necessary mandatory training as required by Health and safety legislation, including moving & handling and fire safety. Timescale for action 16/03/07 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.V302670.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Ellesmere Community Nursing Home DS0000022248.V302670.R01.S.doc Version 5.2 Page 28 - 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!