Inspection on 05/09/05 for Elreg House

This inspection was carried out on 5th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Elreg House 22/01/09

Elreg House 18/03/08

Elreg House 29/05/07

Elreg House 11/04/06

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 Jennifer Wright Unannounced 5 September 2005, 09:00 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 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 H60-H11 S64568 Elreg House V247620 050905 Stage 4.doc Version 1.40 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 Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01243 454201 Miss Angela Louise Brown Mr Anthony Robert Brown position vacant Care Home (CRH) only (PC) 23 Category(ies) of Dementia - over 65 years of age (DE(E)), (23) registration, with number Mental Disorder, excluding learning disability or of places dementia- over 65 years of age (MD(E)), (23) Elreg House H60-H11 S64568 Elreg House V247620 050905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 Only service users age 65 and over may be readmintted. 2 The total number of service users accommodated must not exceed 23. Date of last inspection NA 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 twostorey building with a single storey extension to the rear. Fifteen of the residents bedrooms are single and four have the benefit of en-suite facilities. There is no passenger lift. There is an enclosed rear garden with good access for residents. Elreg House H60-H11 S64568 Elreg House V247620 050905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was the first inspection carried out by the Commission for Social Care Inspection since Mr. and Miss Brown became the owners of Elreg House. Mr. and Miss Brown were present on the day of inspection, as was the newly appointed Manager. During this inspection the Inspector toured the building, visiting every room. As well as talking to Mr. and Miss Brown, the Inspector spoke at length to all of the staff members on duty about how they find working at Elreg House. The Inspector also chatted to several of the residents, but due to their mental frailty, not all were able to tell the Inspector what it was like living at Elreg House, however the residents were seen to be comfortable, well cared for and appeared happy. In addition, the Inspector examined records about care being provided to residents; as well as records of any accidents or concerns or complaints, to make sure that the residents at Elreg House were being taken care of. The position of registered Manager at Elreg House has been vacant for the past two years, and the previous owner of Elreg House sadly passed away relatively recently. These factors have a bearing on the outcome of this report. At this inspection Elreg House was audited against the National Minimum Standards for Older Persons. The majority of elements in each of the standards were met. There are six requirements and two recommendations made in this report. Issues raised in this report will be followed up at the next inspection. The Inspector would like to thank everyone who cooperated with her on the day of this inspection. What the service does well: What has improved since the last inspection? Elreg House H60-H11 S64568 Elreg House V247620 050905 Stage 4.doc Version 1.40 Page 6 This was the first inspection under the new owners, so this section does not apply. 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 H60-H11 S64568 Elreg House V247620 050905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Elreg House H60-H11 S64568 Elreg House V247620 050905 Stage 4.doc Version 1.40 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 standard(s) 3, and 6 Prospective residents, or their representatives have the information they need to make an informed choice about the home, and whether it will meet their needs. Elreg House does not take emergency admissions, or offer intermediate care. EVIDENCE: There is an up to date Statement of Purpose and Service Users Guide that gives residents and their relatives up to date information on the facilities in the home. Elreg House H60-H11 S64568 Elreg House V247620 050905 Stage 4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 and 10 The resident’s health, personal and social care needs are set out in an individual plan of care. Residents make decisions about their lives, with assistance as needed. EVIDENCE: Several care plans were inspected and were up to date in many areas, however it was seen that some recordings had ceased when the previous Manager left. The Inspector was assured that that with there now being a new Manager at Elreg House, this matter would be rectified. The Manager informed the Inspector that health professionals are consulted whenever there is a need. The Inspector observed staff members assisting residents where necessary in a sensitive and caring manner. A requirement is made in this report for all staff members to sign each time they administer medication. Elreg House H60-H11 S64568 Elreg House V247620 050905 Stage 4.doc Version 1.40 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15 People living at Elreg House are not always able to make the day-to-day decisions about how they want to live their life. Where this is so, then their relatives or representatives are consulted. There are activities for those who wish to participate, including art and music. EVIDENCE: Residents are encouraged to maintain contact with friends and family wherever possible. It was seen that the home offers a choice of menu, with people able to eat with other residents in the dining room, or on a table in front of them in the lounge. The Inspector observed residents clearly enjoying their midday meal. The Inspector was told that a record is kept of resident’s likes and dislikes, and that the food used is fresh daily. The Manager informed the Inspector that she is to introduce new activities at Elreg House shortly. Elreg House H60-H11 S64568 Elreg House V247620 050905 Stage 4.doc Version 1.40 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 There is a complaints book at Elreg House for residents, relatives, visitors and staff members to use. Each resident has an advocate to act on his or her behalf. EVIDENCE: The Inspector was assured that all residents have someone to speak on their behalf where necessary. There is a complaints book by the front door at Elreg House, although there were no complaints recorded in it at the time of the inspection. A requirement is made in this report for all complaints to be recorded. Elreg House H60-H11 S64568 Elreg House V247620 050905 Stage 4.doc Version 1.40 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 23, 24 and 26 Elreg House is suitably located for its purpose, being close to the town of Shoreham-by Sea. The home is set in a residential area with a large frontage suitable for car parking. Radiator covers have been fitted throughout the building. Communal areas consist of a large lounge, separate dining room and lounge/diner on a different level. On the day of inspection Elreg House was seen to be clean and free from offensive odours. Policies and procedures were available for staff regarding control of infection, and the safe disposal of clinical waste. The rear garden is accessible to the residents of Elreg House. EVIDENCE: Parts of the home, which includes the laundry, are due for a total refurbishment. The garden to the rear of the property is quite large, and divided into sections by the design of the property, making it an interesting garden for the people who live at Elreg House to use. There are trees, lawn and patio areas, and residents were seen to be making use of the garden on the day of inspection. Parts of the garden are to be tidied, and some areas to Elreg House H60-H11 S64568 Elreg House V247620 050905 Stage 4.doc Version 1.40 Page 13 be fenced in. Fire doors are to be adjusted, locks fitted on all resident’s bedroom doors, and a fire screen door fitted to the kitchen door leading to the front of the home, to allow air in, but which will be kept locked to ensure that residents are not able to use it. Elreg House H60-H11 S64568 Elreg House V247620 050905 Stage 4.doc Version 1.40 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 Many of the staff members have worked in the home for some time. Elreg House does not use agency staff, thus ensuring that the residents always know the person who is taking care of them. There are times when there needs to be more staff members on duty, and paperwork with regard to recruitment is to be looked at. EVIDENCE: Staff members told the Inspector that since the previous Manager had left, this had left the home understaffed, and they were unable to attend to the residents as well as they would like. A requirement is made in this report that there be sufficient staff members on duty to meet the needs of the residents at all times. The Manager informed the Inspector that now she was in post, there would always be sufficient staff members on duty to meet the National Minimum Standards, and that if she were ever engaged in tasks such as supervision, assessing new residents, attending meetings or off sick or on holiday, then additional staff would be brought in. Mr. and Miss Brown confirmed that this would be the case. Not all the paper work relating to the recruitment of staff members was available on the staff member’s file for the Inspector to see on the day of inspection, and a requirement is made in this report for this matter to be addressed. Every member of staff that the Inspector spoke with, said how much they liked working with the residents at Elreg House, and commented on what a friendly home it was. Some staff members said they would welcome training on record keeping and dementia. Elreg House H60-H11 S64568 Elreg House V247620 050905 Stage 4.doc Version 1.40 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 35, 37 and 38 The position of registered Manager of Elreg House is currently vacant. Elreg House is run in the best interests of the people who live there. The health, safety and welfare of residents and staff are promoted and protected. Policies and procedures are available for staff members to refer to, to ensure the safety of the people who live and work at the home. EVIDENCE: Records are kept of all accidents, and the Commission for Social Care Inspection are kept informed of any significant events. The Manager informed the Inspector that she has started supervising the staff members, and the people that the Inspector spoke with confirmed this, and said how much they welcomed it. There is to be a photo of every resident, on record. A requirement is made in this report that monthly reports on the responsible individual’s visit to the home are to be kept, and a copy forwarded to the Commission for Social Care Inspection. Elreg House H60-H11 S64568 Elreg House V247620 050905 Stage 4.doc Version 1.40 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 x x x 2 3 x 3 STAFFING Standard No Score 27 2 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 3 x 2 3 x 3 x 2 3 Elreg House H60-H11 S64568 Elreg House V247620 050905 Stage 4.doc Version 1.40 Page 17 Are there any outstanding requirements from the last inspection? 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. 2. 3. 4. 5. 6. Standard OP 26 OP 29 OP 27 OP 9 OP 16 32 Regulation 23 19 18 13 17 26 Requirement That a sink be installed in the laundry to enable staff to wash their hands That all paperwork relating to staff be complete, and retained in the home Staffing levels must be increased to take account of residents assessed needs All staff members must sign each time they administer medication That all complaints be recorded in the complaints book That monthly unannounced visits to the home be undertaken by the responsible individual, and their report be sent to the Commission Timescale for action 31.03.06 30.09.05 30.09.05 05.09.05 05.09.05 31.10.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 19 19 Good Practice Recommendations That parts of the garden identified as being a hazard, be fenced off. That a fly screen door be fitted to the kitchen door. H60-H11 S64568 Elreg House V247620 050905 Stage 4.doc Version 1.40 Page 18 Elreg House Elreg House H60-H11 S64568 Elreg House V247620 050905 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection 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 H60-H11 S64568 Elreg House V247620 050905 Stage 4.doc Version 1.40 Page 20 - 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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