Inspection on 11/04/06 for Elreg House

This inspection was carried out on 11th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Elreg House 22/01/09

Elreg House 18/03/08

Elreg House 29/05/07

Elreg House 05/09/05

Similar services:

1 Marten Road

Daubeney House

Three Gables

Deepdene Care Centre

Aldwick House

49 Glendale

Ferndale Residential Care Home

David Gresham House

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

CARE HOMES FOR OLDER PEOPLE Elreg House 58 Rosslyn Road Shoreham By Sea West Sussex BN43 6WP Lead Inspector Mrs Kerry Leppard Unannounced Inspection 11th April 2006 08:00 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 Elreg House DS0000064568.V287148.R01.S.doc Version 5.1 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. Elreg House DS0000064568.V287148.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Elreg House Address 58 Rosslyn Road Shoreham By Sea West Sussex BN43 6WP 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) 01273 454201 01273 453431 Miss Angela Louise Brown Mr Anthony Robert Brown Post Vacant Care Home 23 Category(ies) of Dementia - over 65 years of age (23), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (23) Elreg House DS0000064568.V287148.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Only service users age 65 and over may be readmintted. The total number of service users accommodated must not exceed 23. Date of last inspection 5th September 2005 Brief Description of the Service: Elreg House is a care home registered to provide personal care and accommodation for twenty-three older people who have dementia or a mental disorder. The home is located near to the town centre of Shoreham-by-Sea, West Sussex, with the usual amenities of a small town. Elreg House is a two-storey building with a single storey extension to the rear. Fifteen of the residents bedrooms are single and four have the benefit of ensuite facilities. There is no passenger lift. There is an enclosed rear garden that is accessible to residents. The range of fees charged by the home is £389- £500 per week and additional charges are made for newspapers, chiropody, hairdressing and toiletries. Currently, a copy of the inspection report is provided to prospective residents and their representatives. The registered provider is considering a website as an alternative way of accessing this information. Elreg House DS0000064568.V287148.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the fieldwork visit the manager, who is yet to be registered, provided details of residents relatives to whom comment cards were sent, feedback on three of these has been incorporated into this report. The fieldwork visit was unannounced and was conducted by two inspectors on Tuesday 11th April 2006 between 8am and 3.45pm. During the inspection the registered provider, manager and staff on duty assisted the inspectors. The inspectors met most of the residents and spoke with five during the course of the visit. What the service does well: What has improved since the last inspection? The environment has been subject to some redecoration and finishing touches to make it more homely. A hand sanitizer has been installed outside the laundry as a short-term measure and the garden has also been made secure. Staffing levels on the day of the visit were good and the registered provider has been submitting monthly reports of his visits to the home to the Commission for Social Care Inspection. The inspectors observed that complaint records are being kept in the home and some medication practises have improved. Elreg House DS0000064568.V287148.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Elreg House DS0000064568.V287148.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Elreg House DS0000064568.V287148.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The homes assessment process ensures that the home can meet prospective residents needs and the changing needs of current residents. Intermediate care services are not provided. EVIDENCE: Three residents including the most recent admission were case tracked, the most recent admission had been assessed by the manager prior to her admission to the home. One resident has developed higher level mobility needs since her admission to the home. Evidence was not provided that professional input, such as a social work assessment has been sought to ensure that Elreg House remains a suitable place for all of the individual’s needs to be met. Elreg House DS0000064568.V287148.R01.S.doc Version 5.1 Page 9 Elreg House DS0000064568.V287148.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Residents needs are set out in a plan of care but these do not accurately reflect the level of need and the support required by residents. Residents health needs are met with the support of community professionals but risks to residents health, safety and welfare are not managed. Medication policies and procedures need reviewing to ensure they protect residents. Storage and record keeping are satisfactory. Residents privacy and dignity is respected. EVIDENCE: From case tracking three residents and cross referencing two other care records evidence was found that the model of care planning is good. Relatives/visitors who completed a comment card indicated that they are kept Elreg House DS0000064568.V287148.R01.S.doc Version 5.1 Page 11 informed of important matters affecting their friend/relative and are consulted about their care. However, links are not made between each residents needs and how their care should be provided. Care plans are inadequate and do not accurately reflect the needs of residents and the risks to their health, safety and welfare, including falls and pressure areas. Care plans were not up to date. Despite the inadequacy of care plans, the inspectors observed some good care practises, for example staff responded appropriately and in an understanding and caring way to residents needs and wishes. However there is a risk to residents health, safety and welfare if staff practises are based on instinct rather than the assessment of need and provision for each individual resident at Elreg House. Care records indicate that health input is sought to support the home to meet residents needs including pressure care and medication review. However risk management is inadequate as assessments do not include the action staff must take to minimise identified risks. Observations indicate that medication is stored appropriately and that records are completed accurately. Minor points for improvement are that medication packaging should not be over written by staff, this introduces the potential for medication errors. Also, the medication policy and procedures that are in place to meet the requirement of the pharmacy inspection are in need of review to ensure they reflect the practises at Elreg House. Staff have been trained to understand residents rights to privacy and dignity. Relative/visitors who completed a comment card said they can visit their relative/friend in private. Elreg House DS0000064568.V287148.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Activities based on lifestyle and past experience are not provided. Resident’s relatives are consulted and contact with residents is encouraged. Residents are supported to make choices and decisions. A varied diet is provided but times are not always suitable. EVIDENCE: Structured activities were not provided during the fieldwork visit, residents were observed sitting in lounge areas with a television on or music playing. Meaningful activity based on individual residents lifestyles and past experiences is not planned and this was supported by conversations with two residents and the registered provider. Feedback from relative/visitor comment cards indicates that they are consulted and welcomed into the home. Elreg House DS0000064568.V287148.R01.S.doc Version 5.1 Page 13 It was observed that the morning was relaxed and residents ate and received support with personal care throughout this time. From observation and discussion with residents, the food provided is fulfilling, residents were seen taking breakfast individually throughout the morning in the dining room, lounge and bedrooms. Lunch was observed and staff were available to provide support. Meal times are being reconsidered to ensure they are appropriately timed. Dietary needs are not considered satisfactorily in the care planning process and a good example of how the link should have been made between a particular residents diet and care needs was brought to the registered persons attention. Elreg House DS0000064568.V287148.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Complaints are listened to, recorded and acted upon. Risk assessment processes do not protect residents from abuse. EVIDENCE: Complaint records were inspected and showed that complaints are listened to and acted upon. A theme was laundry management and the inspectors noted that two new machines have recently been purchased. Residents/visitors who completed a comment card said they had not had to make a complaint, although two said they were not aware of the homes complaints procedure. The inspectors observed staff respond appropriately to residents, however risk assessments in relation to challenging behaviour have not been developed to ensure other residents are protected and that staff understand and know how to respond appropriately to aggression from residents. Two of the three staff who spoke with the inspector knew about whistle blowing and their responsibility to do so. Elreg House DS0000064568.V287148.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22 &26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents live in a safe, well-maintained environment. Specialist equipment is not provided to meet resident’s mobility needs with safety and dignity. The home is clean and hygienic but unpleasant odours are noticeable at times. EVIDENCE: Redecoration and refurbishment is ongoing and requirements in relation to the environment have been addressed at least in the short term, for example a hand sanitizer outside the laundry where a sink needs to be installed. There are issues with the environment that may be addressed within the long term plans for the building. Elreg House DS0000064568.V287148.R01.S.doc Version 5.1 Page 16 A hoist is provided to assist staff to support residents mobility however inadequate appropriate equipment is in place to enable the same resident to be transported around the home safely and with dignity. The home employs domestic staff to maintain cleanliness, variances in warmth and ventialtion around the home lead to less than fresh odours at times. Elreg House DS0000064568.V287148.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Staffing has been improved to ensure it meets residents needs. The home’s recruitment policy and practices do not protect residents. Training for staff does not ensure that residents are in safe hands at all times EVIDENCE: Staffing levels during the visit were good and ensured residents needs were met. The home must not use care staff for domestic tasks to the detriment of residents care and welfare. Recruitment records were either not stored at the home or did not demonstrate that the home had followed a robust recruitment procedure that protects residents. Two staff had begun unsupervised employment without receipt of satisfactory checks including CRB and PoVA checks. Staff records show that staff are experienced and have previous training. Staff also indicated that they have received training and records show that an induction process is in place and training for staff secured. Records show that health and safety training and NVQ achievement need work to meet the National Minimum Standards and ensure residents are in safe hands at all times. Elreg House DS0000064568.V287148.R01.S.doc Version 5.1 Page 18 Elreg House DS0000064568.V287148.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The homes manager is not currently registered to carry on the service. A formal Quality Assurance system that ensures the home is run in the best interests of residents has not been devised. Residents financial interests are safeguarded. Staff are supervised. The health, safety and welfare of residents and staff are not promoted and protected through auditing and risk assessing. EVIDENCE: Elreg House DS0000064568.V287148.R01.S.doc Version 5.1 Page 20 The manager will be submitting an application for registration in the near future. A formal quality assurance programme has not been implemented. The registered provider has submitted monthly reports of visits to the home and has informal processes for consulting with residents and their relatives and reacting to their requests. The inspectors discussed with the registered person his responsibility for quality audit of the service and provision of this information to the Commission for Social Care Inspection. The homes policy on residents money and belongings indicates that the management will ensure that service users retain effective control of their own money except where they state they do not wish to, or they lack capacity to do so, an advocate would then be involved. The inspector was advised that no money is being stored for safe keeping on behalf of resdients and a few belongings are being securely stored. Staff said they receive supervision and records indicate that there is a system for this, some sessions are overdue. Fire safety is maintained through training and servicing of the necessary equipment. Some equipment checks and servicing is overdue. Poor moving and handling practise was observed that puts residents health, safety and welfare at risk. Accidents are recorded but not audited and linked to risk asessments or the care planning process. Elreg House DS0000064568.V287148.R01.S.doc Version 5.1 Page 21 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 X X 2 X X X 2 STAFFING Standard No Score 27 3 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 2 Elreg House DS0000064568.V287148.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? yes 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 15 (1&2) Timescale for action Unless it is impracticable to carry 11/07/06 out such consultation, the registered person shall, after consultation with the service user, or a representative of his, prepare a written plan as to how the service user’s needs in respect of his health and welfare are to be met.The registered person shall keep the service user’s plan under review; where appropriate and, unless it is impracticable to carry out such consultation, after consultation with the service user or a representative of his, revise the service user’s plan. The registered person shall 11/07/06 ensure that the care home is conducted so as to promote and make proper provision for the health and welfare of service users. The registered person shall 11/07/06 ensure that the care home is conducted so as to promote and make proper provision for the health and welfare of service users. DS0000064568.V287148.R01.S.doc Version 5.1 Page 23 Requirement 2 OP8 12 (1) 3 OP18 12 (1) Elreg House 4 OP29 19 (1) Staff records must include the information and documents specified within Schedule 2. (Previous timescale of 30 September 2005 not met) 23/05/06 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 Elreg House DS0000064568.V287148.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Elreg House DS0000064568.V287148.R01.S.doc Version 5.1 Page 25 - 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!