Inspection on 29/05/08 for Ellesmere House Care Home

This inspection was carried out on 29th May 2008.

CSCI found this care home to be providing an Good service.

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

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Ellesmere House Care Home 9 Nightingale Place London SW10 9NG Lead Inspector Jacqueline Derbyshire Key Unannounced Inspection 29th May 2008 09:00 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 House Care Home DS0000071248.V364390.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 House Care Home DS0000071248.V364390.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ellesmere House Care Home Address 9 Nightingale Place London SW10 9NG 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) 020 7352 6173 manager.ellesmere@careuk.com Care UK Community Partnerships Ltd Therese Laurent Care Home 60 Category(ies) of Dementia (60), Old age, not falling within any registration, with number other category (60) of places Ellesmere House Care Home DS0000071248.V364390.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following categories of service only: Care home with nursing - Code N 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 - Code OP 2. Dementia - Code DE The maximum number of service users who can be accommodated is: 60 1st Date of last inspection Brief Description of the Service: Ellesmere House is a new nursing and residential home for older people that are located in Chelsea, very close to public transport and local amenities and shops. Ellesmere House opened in March 2008. The state of the art building is very modern with a lot of bright open spaces including a sensory garden and a working garden that the people that live at Ellesmere House can plant and grow what they choose. The home has four floors that are accessible by lifts; there are 60 single rooms with en-suite bathrooms in all. Ellesmere house is decorated with fixtures and fittings of an extremely high standard. There is a dinning area and quite rooms on each floor for the people who live there and visitors to have privacy if required. There is a rehabilitation unit that has 10 rooms; there are two nursing floors and a residential floor. The Royal Borough of Kensington and Chelsea have a block contract with Care UK for dementia care for people from the locality. There is a day centre service provided form the building, this is not included as part of this inspection as day centres are not registered with the CSCI. The Royal Borough of Kensington and Chelsea own Ellesmere House and all of the care is managed and provided by Care UK. This flag ship home will be providing (ABC) Activities Based Care, making sure that all of the people living there will be encouraged to participate in activities but primarily be assisted to do the tasks they value most in their lives and stay as independent as is practicable with the assistance of staff. Ellesmere House Care Home DS0000071248.V364390.R01.S.doc Version 5.2 Page 5 Ellesmere house is providing a hostess service that is unique, offering all residents a dining experience that can only be likened to staying in a hotel. The hostess will also work closely with residents in making sure that all of their care needs are met. Ellesmere House Care Home DS0000071248.V364390.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. Throughout this report the word ‘we’ will be used as meaning the CSCI. This unannounced inspection took place on Thursday 29th May 2008; we spent 10.00 hours visiting the home. We spent time talking to the manager, the project manager, staff and people living at Ellesmere House. We checked the care records of four people; all medication and finance records were looked at and were well recorded. 10 of the bedrooms were looked at and all communal parts of the home including the kitchen, laundry, gardens and dining areas on all floors. The home provides an excellent standard of accommodation. The home was seen to be clean and tidy. There were 20 residents living at Ellesmere house at the time of this inspection. We received 8 relatives’ surveys, 4 residents surveys, 1 professional and 10 staff surveys and discussed the home with two relatives; comments from the surveys will be included throughout this report. We will make reference to the Annual Quality Assurance Assessment (AQQA) throughout this report. The weekly charge for Ellesmere House is from £450 to £1100 this will vary depending on the level of care required. What the service does well: People that live at Ellesmere House have access to a multi-professional health care team on-site. The rehabilitation unit has all medical and health issues dealt with by doctors and professional health experts from the Chelsea and Westminster hospital that is located next door to the home. Medication records were checked on two floors and all records were completed correctly with all controlled drugs stored appropriately with the relevant information in place. We discussed recruitment with the manager who stated all staff has been recruited specifically for Ellesmere House having to meet the specification for the unique way care will be provided. All staff is highly skilled with 14 nurses and 19 care staff of different roles including hostess, senior carers and team leaders. 9 of the care staff have professional qualifications from their country of origin and 10 are completing an NVQ level 2 or 3. Ellesmere House Care Home DS0000071248.V364390.R01.S.doc Version 5.2 Page 7 All staff has had a very intense induction that lasted over two weeks covering all mandatory training but also specialised training including Dementia Awareness, Protection of Vulnerable Adults, Palliative Care and a lot more. We were told by staff that they thoroughly enjoyed the training and appreciated the support from the manager in allowing them the time to participate in the training. The food provided is of a very high standard; we spent time with residents at lunchtime and tried all of the meals being offered that was a three-course menu with options if a resident did not want what was being offered. Menus looked at are varied, nutritiously balanced and were of a high standard. There were a lot of positive comments made by residents. We spent time with one of the hostesses who was seen to be very involved with all residents making sure that their mealtime was a pleasant experience. We also spent time with the chef in the kitchen discussing religious and cultural meals that are available when required. The activities provided are not specifically all group activities but person centred and we saw a lot of records of one-one activities being provided. We discussed activities with the main activities coordinator who is very positive about her role and has attended training to enable her to provide activities to residents that have dementia. The home is using (ABC) Activity Based Care that promotes individuals to be as independent as is practicable and promotes residents doing what they value most in their lives. We looked at the staff rotas and staffing is good on all floors making sure that all of the people living at Ellesmere House are provided with the care as stated in their care plans. All staff spoken to on the day of this site visit were very positive about their roles, we spoke to the manager, deputy manager, project support manager, administration staff, nurses, care staff, physiotherapists and rehabilitation staff, domestic staff, laundry staff, the chef, kitchen staff and the activities coordinator. What has improved since the last inspection? This was the first inspection for Ellesmere House. Ellesmere House Care Home DS0000071248.V364390.R01.S.doc Version 5.2 Page 8 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. Ellesmere House Care Home DS0000071248.V364390.R01.S.doc Version 5.2 Page 9 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 House Care Home DS0000071248.V364390.R01.S.doc Version 5.2 Page 10 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): Standards 1, 2, 3, 5 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admissions are not made to the home until a full needs assessment has been undertaken. For people who are self funding and without a Care Management Assessment the assessment is always undertaken by a skilled and experienced member of staff. The assessment is conducted professionally and sensitively and involves the individual, and their family or representative, where appropriate. Where the assessment has been undertaken through care management arrangements the deputy manager will still visit the individual and complete the homes assessment record. EVIDENCE: Comments made by the people who use the service and relatives of people who use the service. ‘ Its like a 5 star hotel with care thrown in’. Ellesmere House Care Home DS0000071248.V364390.R01.S.doc Version 5.2 Page 11 ‘Provides a first class service where even the smallest requirement or detail is attended to with charm and courtesy’. ‘If in the future I need to go into a care home this is the one I would choose’. We looked at the home’s statement of purpose that is very informative and reflects the care that is provided to all residents. There is also a lot of information on how care will be provided to residents with complex needs such as dementia. A copy of the Statement of Purpose was forwarded to the Commission and was on display within the home during the key inspection. We also looked at a lot of other glossaries and information that would be provided to prospective people looking at using the service. We looked at 4 residents files and all included a contract with the home covering the terms and conditions of the organisation. The manager stated that any resident who was not able to fully understand the contract would be referred to an advocate if no other relatives were known. Information received within the Annual Quality Assurance Assessment (AQQA) completed by the Registered Manager, indicated that there is a dedicated person who completes all initial assessments at Ellesmere House. The manager is also very involved in all admissions into the home or dealing with enquires enabling a personalised service. We looked at 4 residents files and all included a full needs assessment using standard assessment tools, including the Activities Based Care (ABC) care plan, Barthel and Waterlow. The assessments were very informative with all of the relevant information in place. On the day of this inspection the manager was in meetings with prospective residents and their families showing them around the home and providing them with all of the information. There is a rehabilitation unit in Ellesmere house that is linked directly with referrals from the Chelsea and Westminster hospital and the local authority (RBKC). There is a multi disciplinary professional staff team based there with support staff from care UK. We talked to a resident on the rehabilitation unit who was extremely happy with the care being provided and was looking forward to returning home. We saw very intensive care plans that had a lot of information in place showing what healthcare and support was being provided. Ellesmere House Care Home DS0000071248.V364390.R01.S.doc Version 5.2 Page 12 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): Standards 7, 8, 9, 10 and 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal support is responsive to the varied and individual needs and preferences of the people who use the services. The delivery of personal care is individual and is flexible, consistent, reliable, and person centred. Staff respect privacy and dignity and are sensitive to changing needs. People who use services are supported and helped to be independent and can take responsibility for their personal care needs. Staff listen to people who use the services and take into account what is important to them. EVIDENCE: Comments made by the people who use the service and relatives of people who use the service. ‘Since my mother was admitted in March, she has taken on a new lease of life’. ‘My mother is French Canadian and the manager and some staff speak French this has helped my mother settle in and she feels quite at home’. Ellesmere House Care Home DS0000071248.V364390.R01.S.doc Version 5.2 Page 13 ‘The home responds to all residents needs’. We looked at four residents’ files and the information on the organisations Saturn computer system that has all of the care plan information in putted within 48 hours of admission. Care plans based on the Activities Based Care did have information in place however there is a requirement that more information is recorded showing exactly what care is being provided as written in the initial assessment. Night care plans were seen on each file setting out the residents care at night, including preferred time for going to bed, and for getting up. The deputy manager undertakes regular audits of care plans and risk assessments. We looked at the risk assessments and not all of the information corresponded with the initial assessment and care plan. We were told by the deputy manager that the format had been changed from the 15th May 2008 and all residents risk assessments will be updated. All risk areas need to work in conjunction with the care plan showing how a risk has been identified with a relevant action plan showing what actions staff must follow to minimise the risk to ensure the safety of the resident and staff. Looking at the healthcare records of the four residents all have a GP this may be there own GP or they may have registered with a new GP in the locality. We were told by the manager that she is in discussion with the local surgery to have a GP available to visit the home in emergency situations. The rehabilitation unit is run differently to the other floors the doctors visit twice a week from the Chelsea and Westminster hospital, they are also responsible for medication that is collected from the hospitals pharmacy. We looked at the medication procedures on two floors; all Medication Administration Records (MAR) were well recorded. The storage of medication was good with the medication rooms having the temperature recorded daily and medication fridges were also checked daily, all records show that the medication is stored at a safe temperature. Controlled Drugs were inspected in the home. All were currently individually prescribed, we checked the amount against the record and the information recorded was correct. Staff were observed to speak respectfully to residents, using their preferred form of address. The residents privacy is respected, for example staff were seen to knock on the doors of residents before entering and all personal care was attended to in the privacy of the residents own room or in one of the communal bathrooms. Ellesmere House Care Home DS0000071248.V364390.R01.S.doc Version 5.2 Page 14 We discussed end of life care with the manager who stated that the policy and procedure of the home states that a resident will be cared for with dignity and respect. All of the relevant care will be provided to make sure a resident is kept comfortable. The manager has collated a document with the local providers of funeral care, this is a very informative document and covers all religions to assist the resident or family members to make a decision about who they would like to provide the service if they do not already have anything in place. Ellesmere House Care Home DS0000071248.V364390.R01.S.doc Version 5.2 Page 15 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): Standards 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use services are involved in meaningful daytime activities of their own choice and according to their individual interests and capability. EVIDENCE: Comments made by the people who use the service and relatives of people who use the service. ‘My mother is provided with support, kindness and is motivated to be kept alert and not just left in bed’. ‘The manager and staff are very good at keeping in touch with me over my mothers care’. ‘I enjoy reading poetry unfortunately my sight has deteriorated but the lovely activities lady reads it for me’. ‘We have afternoon tea together and I do so enjoy meeting with the other people’. Ellesmere House Care Home DS0000071248.V364390.R01.S.doc Version 5.2 Page 16 We looked at four residents files and care needs assessments. All of the files contained a lot of information regarding the resident’s likes, dislikes, hobbies and leisure interests. We looked at daily records for the four residents and there was information written daily about what activities an individual had done including going for walks, gardening, art, cooking, poetry reading and attending any community centres. The activity coordinator makes sure that all residents are supported daily to participate in activities they enjoy. The Activities Based Care (ABC) is about being person centred and providing an activity not specifically in a group but in one-one sessions if required. The (ABC) plans are also in place to encourage residents to be as independent as is practicable and doing activities that they value. We were told by the manager that family and visitors are welcome at Ellesmere House, on the day of the Inspection residents’ families were seen on each floor. We spoke to two relatives who were very positive about the care provided to their relative and stated that the manager and staff made them feel very welcome. We spoke to the activity coordinator who is very positive about her role and promotes (ABC) plans. Residents were participating in activities on all floors including poetry, reading their newspaper in the garden, and doing a quiz that was set by the activities coordinator. We received a plan of all of the activities that are planned in June 2008; the manager and activity coordinator stated that this does change to suit residents. Photographs were looked at showing residents cooking, gardening, designing hats and taking part in a lot of other activities. Night care plans indicate that residents are assisted to go to bed at whatever time they wish to, there is no set time. Meals are prepared in the main kitchen and transported to the floors in trolleys. A hot choice is available at breakfast, lunch and supper when a range of dishes are available. All of the residents spoken with confirmed that they were very happy with the food provided, one resident was not so happy with the choice made on the day of this inspection and was very vocal to staff about it. We had lunch on one of the floors and all of the choices were tried, the food was very tastefully served and all was of a good quality. We looked at the menus that were varied, nutritiously balanced and were of a high standard. We spent time with the chef who is very passionate about what food is provided to residents and plans the menus in advance. The food was served by a hostess and assisted by care staff, staff are encouraged to make sure that meal times are a pleasant experience, on the day of the inspection the residents were seen to enjoy their lunch. Ellesmere House Care Home DS0000071248.V364390.R01.S.doc Version 5.2 Page 17 The chef spends time with residents talking about what food they like and dislike, in discussion the chef she stated that any resident that required a special diet or had religious or cultural food requirements would be provided with whatever they wanted. The chef stated that if she were not aware of how to prepare or cook a certain way she would ask residents or their relatives for the information or would seek the relevant information herself. The four files looked at contained a copy of a dietary assessment, with action taken where concerns were identified. We were told by the manager that food and fluid intake is recorded for all residents. Ellesmere House Care Home DS0000071248.V364390.R01.S.doc Version 5.2 Page 18 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): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has a complaints procedure that is clearly written and easy to understand. It is available on request in a number of formats, to help anyone living at, or involved with, the service to complain or make suggestions for improvement. EVIDENCE: Comments made by the people who use the service and relatives of people who use the service. ‘We were given a copy of the homes complaint procedure before mum moved in, however we do not have any complaints’. ‘I have no complaints about my care all of the staff are very kind to me’. ‘I would speak to the manager if we had an issue about the care provided’. We looked at the homes complaint procedure that was given to all residents and their families. The complaints procedure is easy to follow and give clear information and timescales for dealing with a complaint. There have been no complaints since the home opened in March 2008. Ellesmere House Care Home DS0000071248.V364390.R01.S.doc Version 5.2 Page 19 We looked at the homes safeguarding policy and procedure that is directly linked to the Royal Borough of Kensington and Chelsea procedure as the commissioning local authority. We were told by the manager that all staff attended training provided by the local authority on Safeguarding Vulnerable Adults. Training records show that all staff has attended the training. There have been no protection incidents at the home since it opened in March 2008. Ellesmere House Care Home DS0000071248.V364390.R01.S.doc Version 5.2 Page 20 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): Standards 19,20,21,22,23,24,25 and 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The environment is fully able to meet the changing needs of people who use the services, along with their cultural and specialist care needs. It is fully accessible throughout to people with physical disabilities, adaptations and specialist equipment would be designed to fit in with the homely environment. EVIDENCE: Comments made by the people who use the service and relatives of people who use the service. ‘Excellent home, bright clean and friendly and accessible staff’. ‘The home is so lovely and bright, I really like my room I am very comfortable’. Ellesmere House Care Home DS0000071248.V364390.R01.S.doc Version 5.2 Page 21 We had a full tour of the home and 10 resident rooms were looked at, the standard of decoration and fixtures and fittings is excellent a lot of time has been spent getting it ‘just right’. The residents’ rooms all had personal items including photographs, ornaments and pictures. The residents spoken with were all very happy with their rooms. The floors are all decorated with different colour schemes along corridors, this was done in line with professional input for residents to be able to find their rooms and not get disorientated. There are communal bathrooms on all floors that have specialist equipment in them if required including different types of hoists and baths. All of the residents’ bathrooms have a shower and some residents do prefer a bath. There are dinning rooms on all floors that are very tastefully done; all of the dinning areas have large windows allowing a lot of natural light in the areas. There is also a lounge area in each dining room with televisions and music systems in each. There is a designated cinema room on the lower ground floor that residents go and watch a film, the activity coordinator makes sure cinema nights have sandwiches and drinks provided to all that attend. There is a sensory garden that has a lot of wonderful items in place and residents are encouraged to plant and grow things if they wish. There are two rooms available for the hairdresser to use, one of the rooms is also available for any massages or beauty treatments requested by the residents The home has a security system that has cameras outside the building and a monitor is on floors. Fobs are used to gain access onto all floors. The home was very clean and tidy on the day of this inspection. We spent time talking to the manager of the domestic staff who stated that all staff assist in keeping the home clean and tidy and free from any odours. Ellesmere House Care Home DS0000071248.V364390.R01.S.doc Version 5.2 Page 22 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): All of the above standards were inspected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service ensures that all staff receives relevant training that is focussed on delivering improved outcomes for people using the service. The service puts a high level of importance on training and staff report that they are supported through training to meet the individual needs of people using the service. EVIDENCE: Comments made by staff, the people who use the service, relatives and professionals. ‘Providing the right hand picked staff including nurses to provide the care’. ‘ All of the staff are very helpful and are always polite’. ‘ I have been very impressed with the overall standard of staff at Ellesmere House’. ‘Our company provided a full range of training that has helped me to develop my skills and improve my knowledge’. Ellesmere House Care Home DS0000071248.V364390.R01.S.doc Version 5.2 Page 23 We looked at the staffing rota for all floors; the staffing levels are good and are meting the care needs of all residents. We were told by the manager if a care package changed and more input was required this would be dealt with immediately. We looked at four staff files; the recruitment of new staff is co-ordinated by the manager. All relevant checks were seen to be in place including CRB’s on all staff, pin numbers were up to date on nurses, all copies of original documentation seen had a date and signature showing that original documents had been seen. A copy of all original qualifications and training is kept on the staff file. Looking at the references in staff files there were three references that had not been checked for validity. We were told by the manager this is part of the recruitment procedure and she will make sure that all references are checked before a member of staff is employed. We looked at the training and development records of all staff since working at Ellesmere House. There has been an intense induction training covering all mandatory training but also specialised training including Dementia Awareness, Protection of Vulnerable Adults, Palliative Care and a lot more. We were told by staff that they thoroughly enjoyed the training and appreciated the support from the manager in allowing them the time to participate in the training. There are 14 nurses employed including the deputy manager and head of nursing. We were told by nurses that they attended the full induction training and are nominated by the manager to attend specialist training. All care staff spoken with was very positive about their roles and one hostess commented ‘they were the best trained staff in the organisation’. 17 staff has an NVQ or above, there is 9 staff that has professional qualifications from their country of origin. 10 staff is currently registered to do an NVQ level 2 or 3. The manager has a training programme in place and nominates staff to attend as required. Ellesmere House Care Home DS0000071248.V364390.R01.S.doc Version 5.2 Page 24 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): Standards 31, 33, 35, 36, 37 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager has the required qualifications and experience and is competent to run the home. She works continuously to improve services and provide an increased quality of life for residents with a strong focus on equality and diversity. EVIDENCE: Comments made by the people who use the service, relatives and staff. ‘The manager is very approachable and is always available to talk to me when I request it’. Ellesmere House Care Home DS0000071248.V364390.R01.S.doc Version 5.2 Page 25 ‘The manager is very supportive and goes onto each floor a number of times a day to make sure everyone is alright’. ‘ My mother was made very welcome by the manager and staff from the initial visit to the home, she always keeps me informed about my mothers progress’. The manager is extremely qualified and has a Diploma in nursing and a Degree in Medical –Social and hospital Sciences. In 2000 the manager became an infection control nurse. We spent time with the manager who is very positive about her role and is dedicated to making sure that a quality service is provided to all residents. Ellesmere House opened in March 2008; we were told by the manager that all residents are liaised with on a regular basis to make sure they are happy with the care and support provided at the home. There is a quality assurance procedure that is followed by all Care Uk providers and all residents will attend regular reviews with relevant professionals and family included if required. We were told by the manager that all information received will be actioned and improvements will be made in any area that is required. We were told by the manager that a residents and relatives forum is being set up, as this will be invaluable to get information directly. There were no complaints or issues at Ellesmere House since the opening in March 2008. We looked at the finances of four residents, all records were correct showing what had been purchased with receipts in place. The balance of money kept in the safe for each resident was correct. The residents are encouraged to keep their own money, as there are lockable draws in each room. The manager is requested by relatives to keep money for residents if they need to purchase any toiletries or to get their hair done by the hairdresser. We looked at records kept by the home that are either locked away in lockable storage cabinets or are on the Saturn computer system where a password is required to gain access. All records looked at were up to date and legible with the relevant information in place. We looked at all health and safety records including fire safety, water temperatures, safe water checks (legionella), and maintenance records, all records were well recorded and up to date. We spent time talking to the maintenance officer who told us he does daily and weekly checks in most areas. All staff is fully trained in infection control, the home has a strict admissions criteria and no individuals are admitted with any infectious disease that could have a health impact on other residents living at the home. All staff has completed moving and handling and is familiar with the equipment in the home. The AQQA had all of the information on health and safety showing that the home is a safe environment for people to live and work. Ellesmere House Care Home DS0000071248.V364390.R01.S.doc Version 5.2 Page 26 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 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 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 4 4 4 3 4 4 4 4 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 3 3 Ellesmere House Care Home DS0000071248.V364390.R01.S.doc Version 5.2 Page 27 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 OP7 Regulation 13 Requirement The manager must make sure that all risk assessment records are up to date and work in conjunction with the original assessment and care plan. The manager must make sure that all care plans are linked to the original assessment and there is as much information as possible to show how they are meeting the residents care needs. The manager must make sure that all references are checked for validity to protect the people living at the home. Timescale for action 29/06/08 2 OP7 15 29/07/08 3 OP29 19 29/06/08 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 House Care Home DS0000071248.V364390.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 House Care Home DS0000071248.V364390.R01.S.doc Version 5.2 Page 29 - 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. 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