Inspection on 11/11/08 for Ellesmere House

This inspection was carried out on 11th November 2008.

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

Ellesmere House 23/12/09

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 29/01/2009.

CARE HOMES FOR OLDER PEOPLE Ellesmere House Church Hill Ellesmere Shropshire SY12 0HB Lead Inspector Mike Moloney Unannounced Inspection 11th November 2008 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 DS0000072092.V373117.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. DS0000072092.V373117.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ellesmere House Address Church Hill Ellesmere Shropshire SY12 0HB 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 623 657 01691 623 657 BestCare Limited Manager post vacant Care Home 28 Category(ies) of Dementia (28), Old age, not falling within any registration, with number other category (28) of places DS0000072092.V373117.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category (OP) 28 Dementia (DE) 28 The maximum number of service users to be accommodated is 28 2. Date of last inspection Brief Description of the Service: Ellesmere House is a care home that is able care for up to 28 older people who have dementia. It is situated on the edge of the small Shropshire town of Ellesmere, overlooking the scenic body of water after which the town has been named. The house is within easy walking distance of the town centre and all of its amenities and is next to a church. To the rear of the building as an ample off road parking for the use of visitors. It is an older building that was converted to its present use some time ago by the inclusion of such things as a shaft lift to aid the mobility of the people who live there. The manager is currently in the process of applying for registration with the Commission for Social Care Inspection. The fees charged by the home range from £337.95 per week to £364.34 per week. DS0000072092.V373117.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A range of evidence was used to make judgements about this service. This includes: information from the provider, records kept in the home, medication records, discussions with the staff team, tour of the premises, previous inspection reports and talking with as well as observing the care experienced by people using the service. What the service does well: What has improved since the last inspection? 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. DS0000072092.V373117.R01.S.doc Version 5.2 Page 6 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 DS0000072092.V373117.R01.S.doc Version 5.2 Page 7 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. Prospective residents have their needs assessed to ensure that the home can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The records of a person who has recently started living in the home were looked at and it could be seen that an assessment had been carried to ensure that the home could meet their needs. This assessment looked at such things as what help, if any, they would require at meal times, how much help they would need with personal care and whether or not they would or could look after their own medication. The assessment also showed how much help the person would need with their mobility, how good their sight and hearing were and their likes and dislikes. DS0000072092.V373117.R01.S.doc Version 5.2 Page 8 Such things as favourite foods as well as hobbies and interests were identified. DS0000072092.V373117.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. The health and personal care, which a resident receives, is based on their individual needs. The principles of respect, dignity and privacy are put into practice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the inspection the records of a number of people who live at the home were looked at and these showed that the care plans for those people had been looked at and changed where necessary each month. The staff had then signed and dated the records to show that they had done this. Care plans contained information about how people coped with eating and drinking, personal hygiene, mobility, using the toilet, activities, going out in community, etc as well as instructions to the staff on how and when to give assistance if necessary. DS0000072092.V373117.R01.S.doc Version 5.2 Page 10 The staff records showed and the manager and the staff confirmed that they were all scheduled to receive updates to their training in manual handling in the near future. Appropriate assessments had been undertaken in relation to manual handling and falls as had a variety of other risk assessments. The home has a medication trolley that is kept secured in the carers office along with the controlled drugs cabinet and records of any drug administration. The records were seen to be appropriately kept. Talking with staff established and looking at records and listening to the manager confirmed that only staff who have received appropriate training are allowed to give out the medication. DS0000072092.V373117.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 are able to choose their life style, social activity and keep in contact with family and friends. Social, cultural and recreational activities meet residents’ expectations. Residents receive a healthy, varied diet according to their assessed requirement and choice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The records for two of the people living in the home were looked at and these were seen to contain information about the individuals’ likes and dislikes and the name by which they wanted to be known. The daily records for each person showed that they have regular visits from friends and relatives. They also showed that they had joined in with afternoon activities such as bingo and sing-alongs. The manager, her staff and some of the service users also talked about hair and beauty activities and a hairdresser visited on the day of the inspection. Some residents were seen coming and going from the home and making there way to and from meetings with groups of friends in the town. Talking to staff DS0000072092.V373117.R01.S.doc Version 5.2 Page 12 established that they knew where people had gone and when to expect them back. Throughout the inspection the staff were seen behaving in a polite and respectful manner towards those that they care for, always talking clearly and knocking on bedroom and bathroom doors before entering. Bedrooms were seen to contain lots of personal items such as pictures and other ornaments. The meal being served during the inspection was seen to be well presented and in ample portions. Looking at the past menus and talking to some of the people living in the home showed that they receive a balanced and varied diet. Before lunch a member of the care staff was seen going around everybody asking them what they would like for dinner and talking to the manager, the cook and care staff showed that people are regularly offered a hot snack as a second meal in the evening along with a cooked lunch. Staff were seen giving discrete help to those that needed it during meals. DS0000072092.V373117.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. Residents have access to a robust, effective complaints procedure, are protected from abuse and have their legal rights protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Looking at the complaints book and talking with the manager established that no complaints, other than those linked to the allegations referred to below, had been received since the home had been re-registered. A complaints procedure was seen and this contained the information that someone might need if they did wish to make a complaint. Since registration one issue had been referred through the local policies and procedures for the protection of vulnerable adults. The home had co-operated fully with the investigations that were carried out within those local policies and procedures and by the Commission for Social Care Inspection. No evidence was found to support the allegations. Talking with the staff and looking at their training records showed that they had received training in the adult protection procedures. DS0000072092.V373117.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. The physical design and layout of the home enables residents to live in a safe and comfortable environment, which encourages independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Looking around the home it was seen to be in good decorative order, clean and tidy although some of the empty rooms were undergoing a facelift one of which was as a result of water damage from a fault in the roof. Talking to the manager and her staff confirmed that improvements to the structure of the roof and the rest of the building were planned. DS0000072092.V373117.R01.S.doc Version 5.2 Page 15 There was a large lounge and two dining areas one of which was a conservatory. The conservatory led out to a secure garden where people could relax in pleasant surroundings. Some of the bedrooms that were being used as such were looked at and they were also seen to be clean and acceptably decorated. Most contained personal items such as pictures and small pieces of furniture. A number of bathrooms were seen to be available and the temperature of the hot water was found to be appropriate. The home has a laundry area that is clean and well equipped. There was a large parking area to the rear of the home. DS0000072092.V373117.R01.S.doc Version 5.2 Page 16 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. Staff in the home are trained, skilled and in sufficient numbers to fill the aims of the home and meet the changing needs of residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Looking at the staff rota as well as talking with the residents, the manager, shift leaders and other staff showed that there are enough staff on duty to make sure that the needs of the people living in the home are met. There were three staff on duty during this and the previous inspection on 22nd September 2008. On both occasions this included a senior member of the care staff who was responsible for the staff team on that shift. During the inspection a lot of conversations between residents and staff were seen and heard. The staff were always clear and polite when they spoke to the people that they care for. Talking with a number of the staff confirmed that they have received the training that would ensure that they are able to meet the needs of the people living at the home. This was confirmed by talking with the manager and DS0000072092.V373117.R01.S.doc Version 5.2 Page 17 looking at the training records. The training included an induction programme for new staff that was based on a recognised training package. Talking to staff, the manager and looking at records confirmed that 6 of the 11 staff had achieved National Vocational Qualification level 2 or above in care. The employment records of two of the staff were looked at and these showed that appropriate back-ground checks had been obtained before people had access to service users as part of the procedure that ensures that they are fit do so. DS0000072092.V373117.R01.S.doc Version 5.2 Page 18 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. The management and administration of the home is based on openness and respect, has effective quality assurance systems developed by competent managers. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of this inspection the home’s manager was in the process of completing her application for registration with the Commission for Social Care Inspection. DS0000072092.V373117.R01.S.doc Version 5.2 Page 19 Talking with the residents and the staff it was clear that the proprietor visits the home on about once a week and records of more formal monthly visits were seen to be kept in the office. The home does store cash for some of the people living there. The system for recording this was seen to be transparent and accurate. Equality and diversity for the service users were seen to be promoted throughout the home within the assessments, care plans and activities. Various records were seen to be kept that monitored systems and the environment in order to make sure the people living in the home are safe. These were found to be kept up to date. Hazardous materials such as some cleaning fluids were seen to be kept securely and instructions about how they should be used safely were also available. DS0000072092.V373117.R01.S.doc Version 5.2 Page 20 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 x 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 DS0000072092.V373117.R01.S.doc Version 5.2 Page 21 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 DS0000072092.V373117.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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. 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