Inspection on 25/04/05 for Emmanuel Nursing Home

This inspection was carried out on 25th April 2005.

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

Emmanuel Nursing Home 28/06/07

Emmanuel Nursing Home 08/08/06

Emmanuel Nursing Home 23/11/04

Emmanuel Nursing Home 27/05/04

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

CARE HOMES FOR OLDER PEOPLE Emmanuel Nursing Home 17 Southfield Hessle East Yorkshire HU13 0EL Lead Inspector Sarah Sadler Unannounced 25 April 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. Emmanuel Nursing Home J53_s932_Emmanuel Nursing Home_v223440_250405_stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Emmanuel Nursing Home Address 17 Southfield Hessle East Yorkshire HU13 0EL 01482 649749 01482 649418 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) Dove Care Homes Limited Kathleen Carroll Care Home 44 Category(ies) of Dementia - over 65 years of age (DE(E)) 44 registration, with number Terminally ill over 65 years of age (TI(E)) 44 of places Physical disability over 65 years of age (PD(E)) 44 Old age, not falling within any other category (OP) 44 Emmanuel Nursing Home J53_s932_Emmanuel Nursing Home_v223440_250405_stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23 November 2004 Brief Description of the Service: Emmanuel Nursing Home is owned by a national company and is situated in a quiet residential area of Hessle on the outskirts of the city of Hull. It is a short walk to the nearest main road for access to public transport. The nearby village of Hessle gives access to shops, the post office, banks, hairdressers and a train station. The home consists of a large traditional house with a modern extension to the rear. There are two passenger lifts and ramps are in place to assist the people in the home in accessing all areas of the home and the gardens. There are 7 double and 30 single rooms, with some of the single rooms being large enough to be bed/sitting rooms. There are extensive well maintained gardens and a small courtyard area. Visitor car parking is provided. The home is registered for 44 service users over the age of 65 years, of either sex. Service users may have a physical disability and or/terminal illness. All personal care needs are provided by the staff within the home and most of the health needs are met by the nursing staff, accessing other profesisonals as necessary. Emmanuel Nursing Home J53_s932_Emmanuel Nursing Home_v223440_250405_stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was completed as part of the inspection programme for the year April 2005 to March 2006.The inspection was unannounced and undertaken by one inspector over one day. The inspection lasted from 9.00 am until 4.45 pm with approximately half a days preparation also being completed. During the inspection a tour of the premises was completed and a number of people were spoken with. Several of the service users gave details of what they thought of the home and the services provided. One relative and three staff members were spoken with, one being formally interviewed. A reflexologist was also interviewed. Time was spent in individual and communal areas of the home observing the daily lives of the service users. Further time was spent reading service users care plans and files. Discussions were held with the manager and business manager throughout the day. What the service does well: What has improved since the last inspection? More information on service users needs is now written down. The laundry systems have improved. More service user’s wishes for if they become Emmanuel Nursing Home J53_s932_Emmanuel Nursing Home_v223440_250405_stage 4.doc Version 1.30 Page 6 terminally ill or pass away are now written down. The registered manager has developed a good relationship with service users. 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. Emmanuel Nursing Home J53_s932_Emmanuel Nursing Home_v223440_250405_stage 4.doc Version 1.30 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 Emmanuel Nursing Home J53_s932_Emmanuel Nursing Home_v223440_250405_stage 4.doc Version 1.30 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) 3,6 Service users’ needs are assessed prior to them living in the home assuring them their needs will be met. EVIDENCE: Service users recalled the registered manager visiting them and discussing their needs , prior to them entering the home. Individual’s files examined all contained copies of the initial assessment. The initial assessment covered the areas listed within National Minimum Standard 3.3. Intermediate care is not provided. Emmanuel Nursing Home J53_s932_Emmanuel Nursing Home_v223440_250405_stage 4.doc Version 1.30 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, 10,11 Service users’ health and personal care needs are assessed, and met through comprehensive assessment and care planning. EVIDENCE: Service users have nursing and care plans which detail their needs. This includes their health needs. The care plans are reviewed regularly, the review includes the risk assessments. Service users had limited knowledge of their care plans, but recalled reading the initial plan and signing to agree to it. Service users were very happy that their needs were being met. Relevant sections of the individual plan of care were in place in service users bedrooms and en-suites. Visits to and by other professionals, for example GP’s were recorded in the care plans. The reflexologist confirmed that instructions regarding health needs were followed. Service users confirmed that the staff support them in accessing their GP and other professionals. Staff discussed the use of Marie Curie and ‘Parkinson’ nurses. The relative spoken with was very happy with the care provided within the home. Daily notes are made of the support provided. Some of these notes are very specific to the areas of need but the quality is variable and some gaps were found. Emmanuel Nursing Home J53_s932_Emmanuel Nursing Home_v223440_250405_stage 4.doc Version 1.30 Page 10 Service users reflected that they received their medication correctly and records of administration are kept. Records that show why a medication was not administered were not always correct and did not always agree with the medication remaining in the home. There is a refrigerator for the storage of medicines, twice daily recordings of the temperature of the fridge were not in place. Service users reflected that staff are always pleasant and polite with them. Staff and service users had a good and relaxed rapport. Service users stated that they receive their own clothes from the laundry and there are no problems. Service users clothes were clean, reflecting their own personality. Service users receive health professionals in the privacy of their own room and may have a telephone. Service users wishes regarding arrangements in the event of terminal illness and death are recorded in their care plans and letters are given to service users and their relatives at the time of admission to the home to request this information. Policies are in place to support service users and staff with this. Emmanuel Nursing Home J53_s932_Emmanuel Nursing Home_v223440_250405_stage 4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,15 Service users social needs are met. Service users enjoy a balanced diet. EVIDENCE: Menus offer a variety of meals and service users’ dietary needs are recorded and catered for. Service users’ nutritional needs are assessed. Service users choose their meals daily. Service users and one relative reflected a high level of satisfaction with the food provided and the food tasted was of a good standard. Service users were given appropriate support with one member of staff attending to one person at a time. Specialist equipment was used to assist service users with their meals, for example, a plate guard and specialist designed cutlery. The dining room was well presented and pleasant . The daily menus are being developed to include that fresh and frozen vegetables are provided and records are kept of foods that have been provided. Service users were happy with the level of activities provided within the home. An activities person is employed three days per week and a timetable of activities is planned. One service user was preparing to visit family. Activities for service users who are more dependent were not assessed at this inspection and will assessed at the next inspection. Emmanuel Nursing Home J53_s932_Emmanuel Nursing Home_v223440_250405_stage 4.doc Version 1.30 Page 12 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) 16,18 Service users complaints are dealt with . Service users are protected from abuse. EVIDENCE: Service users felt able to complain to the registered manager or the staff within the home and felt confident that their complaint would be listened to and acted upon. Records are kept of any complaints and of the actions taken. Service users and their families are provided with details of the complaints procedure upon entering the home. The registered manager confirmed that the home does not handle any service users finances. There is a copy of the Local Authorities policy ‘The Protection of Vulnerable Adults’ (POVA), complemented by the home’s own policy. Staff would refer any concerns regarding abuse to the appropriate authorities.. Staff are due to undertake POVA training. Emmanuel Nursing Home J53_s932_Emmanuel Nursing Home_v223440_250405_stage 4.doc Version 1.30 Page 13 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) 19,20,21,22,23,24,25,26 Service users reside in a safe, clean and well maintained environment. They are able to personalise their rooms and the home is pleasant and comfortable. EVIDENCE: The home was clean and tidy, with no offensive odours. The home has complied with the requirements of the local fire department. The home continues to provide communal space that meets the requirements of the previous regulatory authority. There is a call system that was in use throughout the inspection and service users stated that staff respond well to this, taking slightly longer at busier times, for example, meal times. Service users are able to furnish their rooms with their own possessions, this includes electrical items, which service users confirmed that the home assess for safety prior to use. Service users are notified by letter prior to entering the home if their room does not contain all of the items required within National Minimum Standard 24.2. Service users may also decorate their rooms to their own tastes. Rooms are well lit with adequate natural lighting and ventilation. Hot water is regularly checked and on the day found to be close to 43 degrees Emmanuel Nursing Home J53_s932_Emmanuel Nursing Home_v223440_250405_stage 4.doc Version 1.30 Page 14 centigrade. The hot water will at times run above the recommended temperature for a matter of seconds when first turned on. Warning notifications and risk assessments are in place for this. Service users laundry continues to be washed in a dedicated laundry room with commercial washers and dryers. Emmanuel Nursing Home J53_s932_Emmanuel Nursing Home_v223440_250405_stage 4.doc Version 1.30 Page 15 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) None of these standards was assessed at this time. EVIDENCE: Emmanuel Nursing Home J53_s932_Emmanuel Nursing Home_v223440_250405_stage 4.doc Version 1.30 Page 16 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) 31,32,33,35,38 Service users reside in a well run home which ensures their Health and Safety. Service users are not formally involved in the quality assessment and development of the home. EVIDENCE: The registered manager confirmed that she is continuing with her National Vocational Qualification level 4 in management and has also undertaken specific training concerning ethics and dying, and motor neurone disease. The registered manager had a good rapport, and positive relationship with service users. The registered manager was observed responding appropriately to any concerns raised. Service users felt able to approach the registered manager if they required additional support or confirmation on a matter and did so during the inspection. Emmanuel Nursing Home J53_s932_Emmanuel Nursing Home_v223440_250405_stage 4.doc Version 1.30 Page 17 The registered manager confirmed that the home continues to hold the Local Authorities QDS award, but have not yet developed a quality assurance system that meets the recommendations of National Minimum Standard 33. Service users are not involved in a formal system of development of the home. The registered manager has commenced assessment of the home and a questionnaire has been sent to individuals and their representatives. Service users’ finances are not handled within the home. There are policies in place to assist staff with safe working practices and training is undertaken. On the day of the inspection staff were undertaking an examination in Health and Safety. The registered manager has developed the training and has implemented a plan to ensure compliance with the Care for Skills standards. Maintenance is undertaken on the fire alarm, fire extinguishers, emergency lighting, electrical wiring, baths and lifts. Regular fire drills and hot water checks are undertaken. A Control of Substances Hazardous to Health file is in place; records of accidents are kept alongside a policy for RIDDOR. Emmanuel Nursing Home J53_s932_Emmanuel Nursing Home_v223440_250405_stage 4.doc Version 1.30 Page 18 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 2 8 3 9 1 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 3 1 x N/A x x 3 Emmanuel Nursing Home J53_s932_Emmanuel Nursing Home_v223440_250405_stage 4.doc Version 1.30 Page 19 Yes 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. Standard 9 Regulation 12,13 Requirement Timescale for action 9.5.05 2. 9 12,13 3. 33 24 The registered person must ensure that records of medication are up to date and correct. The registered person must 9.5.05 ensure that the medication fridge temperatures are taken and recorded twice daily. The registered person must 25.5.05 ensure a quality assurance system that meets the recommendations of standard 33. This requirement has been brought forward with a previous attainment date of 23.1.05. 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 7 31 Good Practice Recommendations The registered person should ensure accurate records with no gaps. The registerd manager should achieve NVQ level 4 in management by 2005. Emmanuel Nursing Home J53_s932_Emmanuel Nursing Home_v223440_250405_stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection First Floor Unit 3 Hesslewood Country Office Park Ferriby Road, Hessle HU13 0QF 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 Emmanuel Nursing Home J53_s932_Emmanuel Nursing Home_v223440_250405_stage 4.doc Version 1.30 Page 21 - 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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