Inspection on 28/06/06 for Emerson Court

This inspection was carried out on 28th June 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Emerson Court 14/10/09

Emerson Court 27/10/08

Emerson Court 07/02/06

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 Emerson Court 129 Wingletye Lane Hornchurch Essex RM11 3AR Lead Inspector Mr Roger Farrell Unannounced Inspection 28th June 2006 12:00 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 Emerson Court DS0000066195.V302199.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. Emerson Court DS0000066195.V302199.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Emerson Court Address 129 Wingletye Lane Hornchurch Essex RM11 3AR 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) 01708 442 351 01708 437 338 Mr Peter George Warmerdam Mr Peter George Warmerdam Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Emerson Court DS0000066195.V302199.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th February 2006 Brief Description of the Service: Emerson Court is a privately owned care home for older people that now offers seventeen places, fifteen of which are in single rooms. Some bedrooms have en-suite wcs. It is a large detached property on a corner plot with forecourt parking. It is set well back from a busy road, in a pleasant residential area not far from the shops and transport links of central Hornchurch. The buildings layout means that it is not suitable for people who use wheelchairs or have significant problems with mobility. In November 2005 the registered manager bought the home. A lack of investment by the previous owners means that parts of the premises are quite tatty, including the state of the exterior decoration. However, the new owner has quickly started to improve the building, including increasing the lounge space by adding a conservatory. A major strength of the home is that it has a dedicated and caring team, including two deputies – many of whom have worked at the home for a long time. Emerson Court DS0000066195.V302199.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 28 June 2006 and covered all the core standards. Peter Warmerdam, the owner and manager was away on holiday. The two deputies were efficient and competent in responding to the inspector’s questions and presenting the paperwork he asked to see. Peter Warmerdam became the owner on 30 November 2005, having managed the home for over a year under the former proprietors. Inspection reports last year described a service experiencing considerable problems, largely attributable to how it was being run as a business - including cash-flow difficulties and a lack of investment in maintaining and modernising the building. Nevertheless, a consistent positive factor was a core of dedicated staff who continued to make sure residents’ day-to-day needs were met. Questionnaires were sent out to the families of over half the residents. Just over 50 were returned. The inspector would like to thank those who sent comments, and the residents, visitors and staff who made comments during the visit. These views have influenced the positive conclusions described in this report. What the service does well: The last inspection report in February 2006 following the change of ownership spoke about the home having been turned around, with a range of positive changes being evident. The main headline of this recent inspection is that this trend has continued at a steady pace. Highlights include – an excellent standard of care planning and monitoring; much more accountable management systems such as on safety issues; good staff vetting and training records; extra time dedicated to keeping residents stimulated; and the programme of improving the building. The overall atmosphere within the staff team is considerably more relaxed, and staff take a pride in making sure they work as a team to provide high standards of personal care. One relative told the inspector how staff are alert to changing needs. He said – “(My relative) doesn’t complain. They do follow through even minor ailments and make sure she is seen… if they think anything is wrong, like once when she had a bit of weight loss, she was seen straight away by the doctor. I have no worries at all about her welfare, and it is a comfort to know she is well looked after.” The caring attitude of this team is demonstrated by the following example. One resident who did not speak English and had no family was linked up with a Polish befriender. He had recently passed away after a lengthy stay in hospital. The manager had liaised with the health authority on the funeral Emerson Court DS0000066195.V302199.R01.S.doc Version 5.2 Page 6 arrangements. The funeral cortège left from the home, with most of the team and the befriender attending, having arranged for the deceased resident’s ashes to be spread at his wife’s burial lawn. 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. Emerson Court DS0000066195.V302199.R01.S.doc Version 5.2 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 Emerson Court DS0000066195.V302199.R01.S.doc Version 5.2 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): 1, 2, 3, 4 and 5. Quality in this outcome area is ‘good’. This judgement has been made using available evidence including a visit to the service, asking to see core documents, and looking at recent assessments. Updates of information documents done by the new owner give better specific details, such as how many staff are on duty and the size of bedrooms. A check on how assessments are being carried out showed that good information is being collected at an early stage. This is being used to quickly draw up the initial care plans. A who moved in recently said – “I haven’t got any grumbles. It’s comfortable and they are looking after me, such as having a flask and snack in my room. I have been made to feel welcome.” The most recent resident to move in said – “It’s very good. My room is very comfortable. All the staff are fine.” EVIDENCE: Homes must have a main legal document called a ‘statement of purpose’ that says which category of resident they can care for; describe the facilities and level of service provided; and set out the values they promise to promote. A revised ‘statement of purpose’ was included as part of the new owner’s application. This is helpful as it confirmed the maximum number of registered places as 17; sets out the size of bedrooms and communal rooms; and Emerson Court DS0000066195.V302199.R01.S.doc Version 5.2 Page 9 acknowledges that the home is not suitable for those who have problems with mobility, including needing a wheelchair. It also says that it will accept residents for short stays. Helpfully, it gives other more specific detail compared to earlier versions, such as spelling out the level of staff cover. Each resident has also been given a copy of the updated ‘service users’ guide’. The manager is intending to apply to extend the home’s registration to include people who have been diagnosed with dementia. He will revise the ‘statement of purpose’ to say how staff training and skills will make sure these additional needs can be met. The national minimum standard (NMS) stresses the need to carry out detailed assessments. This is to make sure the home can meet a person’s needs, and also ensure sufficient personal details are recorded at an early stage. What needs to be covered is listed under Standard 3.3 in the NMS. The inspector looked at the files of the last two residents to move in. The manager had completed the five-page tick and brief comment assessment covering 20 headings. There were also discharge letters from ward staff. The main care plan sheets had been completed, including for the person who had moved in only six days earlier. This included doing a Bartel dependency rating, and staring monitoring sheets, such as weighing the person on her first day. At the last visit the inspector said that the manager needed to make sure sufficient personal information is recorded at the assessment stage, particularly where there are not background reports or assessments from a social worker. At this visit the files of both new residents had a good ‘social history’ section and clear personal contacts sheet, including for the person who was paying his own fees. The other person had been referred by Havering Council and had moved in the previous week. The social worker had still not provided the expected reports, but there was evidence of how the manager had been chasing this up. They had made sure that this person’s first review had already been booked to take place at the end of her first month. Residents who pay their own fees have been given a copy of the updated ‘contract of residence’. Copies of all the standard contracts used by councils who use the home are available. Havering Council pay for about half the residents. They carry out their own checks on the service, the last having been in January 2006. Emerson Court DS0000066195.V302199.R01.S.doc Version 5.2 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 and 11. Quality in this outcome area is ‘good’. This judgement has been made using available evidence including a visit to the service that involved looking at a number of service users’ files. This included the care notes for the most dependent resident, and those who had moved in since the last inspection. The major positive finding of this visit is that there is now an excellent care planning and monitoring system in place. In recognition of this, the important Standard 7 covering individual care planning has been scored at the top ‘commendable’ level. EVIDENCE: Setting up and maintaining a system of service user files that meet current standards has been a gradual process in this home. The last report signalled that significant progress had been achieved in introducing improvements. The ‘Care Plan Files’ now in use are neatly arranged in a logical sequence; use well designed formats; and are clearly expressed and up-to-date. In addition to the assessment and personal details sections, there are wellarranged care plans, risk assessments, and monitoring sections. The main care plans are a series of up to 14 individual grid sheets, each dealing with a particular area of support. These have good practical instructions about Emerson Court DS0000066195.V302199.R01.S.doc Version 5.2 Page 11 individual’s care, with each sheet being signed as checked by the key worker, along with a monthly review entry. The inspector tracked through where there had been a recent change of medication, and the relevant sections of the care plan sheets had been updated. Day-to-day sheets have an entry made at the end of each of the three shifts. The deputies who have been responsible for designing and introducing this system are congratulated for this excellent achievement. The inspector had asked the manager to make sure that each resident had a main review at least once a year. There is now a planning chart that forward schedules reviews, including giving the date of the last meeting, which social worker is involved, and when the next meeting should take place. The ‘Care Plan Files’ have a section for medical tracking details, with a separate logging sheet for the GP, community nurse, hospital visits, dentist, chiropodist and so on. Staff find that they now have to push hard to get new residents registered with a local GP, including having to contact the PCT. Nevertheless, one deputy said – “We do not have a main practice anymore, but the PCT sort things out straight away. We are happy with all the doctors. (One) in particular is very helpful, but they are all caring. We also have a ‘community matron’ who provides good back-up and is an information link…we have her mobile number.” Medication is supplied by a local independent pharmacy in monitored dose cassettes with printed recording sheets. The pharmacist provides a two-part training session, and only staff who have completed this course give out medication, and copies of their certificates are on the medication file. There is a two-person signing system. The pharmacist also visits to check on the medication system. One such audit had occurred earlier on the day of the last inspection, the feedback being that arrangements were satisfactory. A copy of the last inspection by the Commission’s pharmacy inspector is available with updated notes completed by one of the deputies showing how the recommendations are being maintained. Medication is stored in a trolley kept in the carers’ office off the main lounge. This is now also anchor locked. A temperature record is maintained. All conditions seen at this visit were satisfactory. The recording file has good guidelines, covering areas such as difficulty swallowing, and what to do if there is an error – though there have been no known mistakes for over two years. Residents’ individual mar sheets have their photo attached. The trolley was neatly arranged, with attention to good practice such as writing on the container when eye-drops were first opened. The deputies’ overview of each person’s support needs showed sensitivity to individual’s needs. This was evident in the description of the transfer of two residents who have needed to move on to a care home with nursing. Emerson Court DS0000066195.V302199.R01.S.doc Version 5.2 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 and 15. Quality in this outcome area is ‘good’. This judgement has been made using available evidence including a visit to the service. This involved looking at the new arrangements for planning activities, which now includes having a main activities organiser. This is another area where this home can demonstrate important improvements. One relative said – “Mum likes the church services, but doesn’t really want to join in other activities. They do try and encourage her. I see Lorna doing the activities and getting people involved.” Another person remarked – “When Peter (the manager) is going out, such as to the shops, he always asks who wants to go along. He has a heart of gold, like all the staff here.” EVIDENCE: The last report asked for better records to be kept covering the help available for residents to take part in social and recreational activities. Two significant improvements have taken place. • One well-regarded long serving carer is now the main activities organiser. She spends three afternoons a week leading activities, each for four-hour slots. Additionally, two other carers have also been freedup to lead activities at other times, including some on Sundays. The deputies described how this time is used and the inspector saw this working during his visit. In discussion with a group of three established DS0000066195.V302199.R01.S.doc Version 5.2 Page 13 Emerson Court residents they confirmed the increased activity, and how ‘quieter’ residents are not left out. The additional twenty hours activity organisers’ time are mainly extra hours, rather than being taken from the overall care hours. • The inspector was sent copies of residents’ individual activity sheets. These log involvement in in-house activity sessions, and the occasional outside event. These include church services; tea party at a local school; theatre productions; nail care and make-up; reminiscence quizzes; gentle exercise; board games; sing-a-longs; music and favourite movie videos; birthday celebrations; and an Easter Bonnet competition. There are occasional visiting entertainers. This had included a Polish entertainer, as this was one resident’s first language. This means that the manager is now able to demonstrate much better compliance with this group of standards. The deputies gave an overview of each resident’s level of contact with family and friends. Over half the residents have regular visits, usually at least once a week. With one exception, all others also have visitors and quite regular contact such as phone calls. One resident who is an accomplished artist, having had his work displayed at the National Portrait Gallery, showed the inspector how he had resumed drawing since moving into the home after a long gap. This included sketches of other residents. Visitors consistently say they receive a warm welcome, and are kept informed. At this inspection one regular visitor commented – “You are always made welcome. I pop in at anytime. You would never see (the previous owners) and they would not speak. Peter is always around, and tells us about the things he is doing and planning for the home. New windows have been fitted in my Mum’s bedroom….. Staff are busy, but always have time to pass the time of day.” The inspector saw the arrangements for meals on the day of this visit. This showed that resident’s individual choices were being taken into account at the main lunchtime meal. At his last visit the inspector joined the residents for lunch. All comments by residents about the standard of meals were favourable. One comment was – “It is very good. Always well cooked…Yes, there is choice…you are asked about preferences.” Another person added – “I would agree, items are well prepared, and the meat is tender.” A further comment was – “They know I like fish. I am asked if I want it coated or steamed.” As on previous occasions, staff were seen to be responsive to individual needs, and encouraging one person who was slow having his main course. At teatime a wide range of options were offered for this lighter meal, residents telling the Emerson Court DS0000066195.V302199.R01.S.doc Version 5.2 Page 14 inspector that this is normally the case. One new resident said – “The food is good. I am diabetic, and they are aware of what that means. They are encouraging me to have some salads.” He showed the inspector how he is given a flask of hot coffee and a wrapped snack for the evening when he watches tv in his room. The pantry had good stocks of quality products, and there was a good range of fresh vegetables. Emerson Court DS0000066195.V302199.R01.S.doc Version 5.2 Page 15 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, 17 and 18. Quality in this outcome area is ‘good’. This judgement has been made using available evidence including a visit to the service that involved looking at the guidelines and records covering these standards. The inspector is satisfied that complaints are taken seriously, including less serious matters. The manager and team have a good awareness of the their responsibilities, and the guidelines that must be followed if a concern is raised about the wellbeing of a resident. One relative commented – “If I felt there was anything wrong, I know I could speak to (either of the deputies). I would also have a word with (the key worker), she is very good. There are also other staff that I would feel comfortable approaching.” Another relative wrote – “I have not asked for the complaints procedure, but it’s probably in the home’s mission statement of which I have been given a copy.” EVIDENCE: Details on making complaints are on display, and this is covered in the ‘service users’ guide’. The complaints book shows that staff record matters raised with them, including those of a relatively minor nature, and that these are followed through. In one instances it was recorded that a relative was offered a letter explaining the outcome, but they had said this was not necessary. Most recent entries were about minor building faults that could be tackled by the handyperson. The manager is aware of the steps to follow if there were a suspicion of abuse. This includes having available a copy of ‘No Secrets’, and the local protection policy and procedure. In his absence, both deputies knew where to find the right guidelines. All staff have signed to say that they have been briefed on Emerson Court DS0000066195.V302199.R01.S.doc Version 5.2 Page 16 these procedures, and give good responses when asked about this area, including on the ‘whistle blowing’ expectation. This matter has been covered again in supervision. Earlier this year the manager was asked to brief staff on the role of the General Social Care Council, and the phased programme of registration. All staff have now signed to say they have been given a copy of the GSCC’s code of practice – and duty staff showed the inspector the copies kept in the carers’ office. There is a training video on adult protection, with each staff member is listed as having seen this and completed the test paper. This is a further example that shows how requirements set in earlier reports are seen through. Emerson Court DS0000066195.V302199.R01.S.doc Version 5.2 Page 17 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, 20, 21, 22, 23, 24, 25 and 26. Quality in this outcome area is ‘good’. This judgement has been made using available evidence including a visit to the service, which included looking at most bedrooms. The previous owners had a poor track record of keeping this building up to standard. Their approach was one of ‘patch-up and make do’, only carrying out essential work when inspectors had started legal action. The new owner is making good headway with his improvement plan to make sure the facilities catch-up with modern standards and expectations. EVIDENCE: The last owners showed little motivation to maintain the building in a manner that meets modern expectations of quality, or improve working arrangements. For instance, the exterior of the building needs attention as paint is peeling and woodwork shows signs of rot. However, a survey carried out ahead of the change of ownership last autumn found no structural faults. Last year the manager insisted on some essential replacements, such as new laundry equipment, replacement dining chairs, and levelling the floor in one Emerson Court DS0000066195.V302199.R01.S.doc Version 5.2 Page 18 bedroom. Since becoming the owner, Peter Warmerdam has started to upgrade the building and replace old stock such as bedding. Following the last inspection he did a ‘building improvement plan’. At this visit the inspector saw how these works are progressing. This has included adding a new conservatory that extends the main lounge; some window replacements, installing a new side carport/covered refuse area; redecorating a range of bedrooms; painting the new fire doors; and starting work on improving the dining room – and putting up a new front sign. Work was due to start on the kitchen and service area, including laying new flooring; painting the exterior; replacing the side-gate and fencing; and continuing with the rolling programme of internal decoration. This work was progressing according to schedule, being phased in such a way as to minimise disruption to residents. Further, there are plans to convert a set of first floor bedrooms as the final step to achieving all singles. Given the new owner’s progress in improving the facilities, it has not been necessary to set any requirements under these standards. The inspector looked at the majority of bedrooms. As an established home, some fall below modern space standards, but this is pointed out in the ‘statement of purpose’. Those rooms decorated more recently have a more contemporary style. The manager recently bought a range modern prints for around the building, but some residents did ask for the older style pictures to be put back. Of particular note was that all bedrooms were found to be fresh and clean, with good ‘hands of care’ signs, such as nightclothes having been laid out, and fresh towels and flannels. There is a plan to create a new patio area. The garden was well maintained, including the side path having been cleared. Residents told the inspector that they do use the garden. Emerson Court DS0000066195.V302199.R01.S.doc Version 5.2 Page 19 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 and 30. Quality in this outcome area is ‘good’. This judgement has been made using available evidence including a visit to the service, including looking at staff vetting and training records. As stated earlier, the consistent strength of this home is that it has a strong core of committed care assistants and senior staff – most of whom have worked at the home for many years. About half of the team have completed, or are undertaking the main NVQ award. The manager can now show that he is carrying out all the necessary checks before new staff start. EVIDENCE: The normal pattern of cover is - 3 carers on the early shift between 8am and 2pm; 2 carers between 2pm and 6pm, overlapping with a third person between 4.40pm and 8.30pm; and 2 on the late shift from 5pm to 10pm. This allows a generous ‘double cover’ overlap period at teatime. This does not include the manager, or most of the two deputies’ times. The manager and two deputies rotate weekend cover. Additionally, there is a cook between 8.30am and 2pm seven days a week; domestic assistant cover for five hours every day; and a part-time handyperson. Night cover is two waking-staff from 10pm to 8am. The significant increase is that the ‘activity organiser’ slots are additional, representing an increase of nearly 20 hours since the last inspection. Emerson Court DS0000066195.V302199.R01.S.doc Version 5.2 Page 20 Last year the registered persons were served with an ‘Immediate Requirement Notice’ for failing to carry out the necessary checks on staff. They were told that not having the documents asked for in Regulation 19(4)/Schedule 2 would result in further legal action, which can include prosecution. Soon after that visit the manager did an audit of all staff files, identifying the gaps and introducing a tracking sheet, and gave an undertaking to follow-up each item. At the visit in February 2006 the inspector was shown the tracking matrix setting out how these responsibilities were now being dealt with, , including doing fresh CRB checks. The necessary checks had been completed for the person who had started the previous week. Therefore the requirement on that important standard was recorded as achieved. This good level of compliance is being maintained. At this recent visit the inspector saw the up-to-date ‘Staff Vetting Record Tracking Sheet’. This has columns logging when each check is completed, such as receiving CRB certificates and copies of documents that prove identity, including a recent photo. The random sample of staff folders checked showed that the expected documentation was on file. Those for staff who had started in the last year had a signed copy of their induction programme. A number of staff who had started recently were those who have previously worked at the home and had rejoined since the change of ownership. The deputies gave an update on training and qualifications. The ‘staff details’ sheet shows that the home has achieved the 50 target for qualified care staff. Last year’s report said – “That so many staff have completed their professional qualification against the backdrop of uncertainty that existed last year is a further sign of their resourcefulness. One of the deputies was instrumental in making sure this result was achieved. In turn the manager restated his commitment to support NVQ training.” He has honoured this commitment by supporting a number of staff progress onto Level 3. Positive comments were made about the ‘Profit from Learning/Meridian’ scheme currently being used, which included providing some free places. The inspector was also sent copies of the ‘Training Tracking Sheets’. There is a good range of training videos. The training log sheets show when each person has completed core topics such as fire safety; first aid; safe food handling; manual handling; risk assessment and general health and safety. These list when each person has watched the training video, completed a test paper, and when a refresher is due. Most recently staff had been working their way through the series of three training videos on care for people with dementia. Emerson Court DS0000066195.V302199.R01.S.doc Version 5.2 Page 21 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, 32, 33, 34, 35, 36, 37 and 38. Quality in this outcome area is ‘good’. This judgement has been made using available evidence including a visit to the service, including checking safety certificates. The new owner did an audit of all the safety documents and booked the required checks. One of the deputies and a senior carer takes a lead on internal safety checks, and their records are very well arranged and are kept up-to-date. This home can now demonstrate much better operational systems, reflecting the benefits of a strong on-site management team of the owner and his two deputies, and seniors who take on responsibilities in some key areas. EVIDENCE: One of the senior care workers takes a lead on in-house fire safety checks. There is a well set-out fire log showing regular equipment checks, drills, and contractor servicing of the alarm system and extinguishers. The record of general safety checks shows the same high standard. The required certificates and paperwork covering gas, electrical and water safety were available. There Emerson Court DS0000066195.V302199.R01.S.doc Version 5.2 Page 22 is also a file of worthwhile risk assessments covering household arrangements, including the recent building works and installation of the higher standard electric consumer unit. The only outstanding items from the last environmental health inspection was to improve the flooring and sink arrangements in the kitchen and service area, and this work is scheduled to go ahead. The last inspection of the premises by a fire safety inspector is logged as October 2004, with satisfactory conditions reported following the work they and the Commission had asked to be completed. The deputies described the system used to help residents with their personal money. In nearly all instances it is the family who receive benefits. The inspector saw the individual account sheets, which have receipts attached for all spends such as hairdressing, chiropody and toiletries. The amount of cash held for any one person is generally limited to £50. Relatives are given a photocopy of the completed account sheets, and sign to say they have checked the balances. If a resident runs out of cash, items are paid for through pettycash and a debit sheet is given to a family member when convenient. The account sheets and cash balances are checked regularly, and no discrepancies have been found over the past year. The manager has carried out resident and relatives’ satisfaction surveys. When requested, he has made information on budgets and financial planning available to inspectors. There is a tacking sheet showing regular supervision. Emerson Court DS0000066195.V302199.R01.S.doc Version 5.2 Page 23 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 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 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 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 3 Emerson Court DS0000066195.V302199.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes. No requirements have been set at this 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. 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 Emerson Court DS0000066195.V302199.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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. 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