Inspection on 28/06/07 for Emmanuel Nursing Home

This inspection was carried out on 28th June 2007.

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

Emmanuel Nursing Home 08/08/06

Emmanuel Nursing Home 25/04/05

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 Theresa Bryson Unannounced Key Inspection 28th June 2007 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Emmanuel Nursing Home DS0000000932.V344759.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. Emmanuel Nursing Home DS0000000932.V344759.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Emmanuel Nursing Home Address 17 Southfield Hessle East Yorkshire HU13 0EL 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) 01482 649749 01482 649418 Dove Care Homes Limited Mrs Catherine Hayes Care Home 44 Category(ies) of Dementia - over 65 years of age (44), Old age, registration, with number not falling within any other category (44), of places Physical disability over 65 years of age (44), Terminally ill over 65 years of age (44) Emmanuel Nursing Home DS0000000932.V344759.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following categories: Dementia - Code DE; Old Age not falling within any other category - Code OP; Physical disability - Code PD, Terminally Ill - Code TI The maximum number of service users who can be accommodated is: 44 To admit one named service user under 65 years 2. 3. Date of last inspection 8th August 2006 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 professionals as necessary. The home provides comprehensive documentation about the services it offers, which is given to all prospective service users and is on display in the main entrance. The range of fees is from £325 to £650, with extra charges made for such items as hairdressing, toiletries and newspapers. Emmanuel Nursing Home DS0000000932.V344759.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit took place over one day in June 2007. Prior to the visit surveys were sent to 14 relatives, of which 9 were returned, 16 staff of which 5 were returned, 4 to health professionals of which none were returned. 5 people living in the home were spoken to and 1 relative plus 5 staff. 4 peoples care plan documentation was tracked on the site visit and 5 staff files. Plus other records and documents. The events history was also tracked prior to the visit and the home submitted a completed pre-inspection questionnaire and supporting documentation. The manager was present through out the inspection and the Company area manager for part of the day. What the service does well: Staff in the home are very approachable and friendly and appeared to have a good working knowledge base of the people living there. They complete the care documentation in a legible manner and ensure it is kept up to date and they record the current needs of service users. There are adequate numbers of staff on duty at all times to ensure the needs of service users can be met. Safe practises are in place to ensure that medication is given correctly and people living there are not put at risk. There is a range of activities on offer, both inside and outside the home and care is taken to ensure people living in the home have their expectations met for their current needs regarding social and cultural activities. A varied menu is on offer and all meals are prepared in a clean and safe environment. Extra care is taken to ensure that fresh produce is used and home baking was being enjoyed by the people living in the home. The home has a robust system in place for recruitment of staff ensuring safety checks are made prior to staff commencing employment and are then trained to do their jobs. The people residing in the home live in a clean and safe environment, which is well maintained and all safety checks completed. Each person can bring into the home personal belongings to help them settle into the home and there was ample evidence to show people living there are able to exercise individual choices. Emmanuel Nursing Home DS0000000932.V344759.R01.S.doc Version 5.2 Page 6 People living in the home and those working there stated they felt confident that any concerns and complaints would be handled in a professional manner and they felt safe. 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. The summary of this inspection report can be made available in other formats on request. Emmanuel Nursing Home DS0000000932.V344759.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 Emmanuel Nursing Home DS0000000932.V344759.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Comprehensive information is available to enable prospective service users to make informed choice about staying in the home. And each person is holistically assessed prior to admission. EVIDENCE: During the course of this inspection Standards 3 and 6 were checked. The Company provides comprehensive information to enable prospective service users to make informed decision about staying in the home. Prior to admission either the manager or her deputy, often accompanied by a senior care assistant, will complete a holistic assessment on each person. This enables the staff to prepare for that person’s admission. Emmanuel Nursing Home DS0000000932.V344759.R01.S.doc Version 5.2 Page 9 Service users stated they felt that staff knew a lot about them prior to admission, which they found comforting. On admission an initial care plan is commenced, which has to be completed within 48hrs. The latest care plan was tracked and all sections of this initial plan had been completed. From this the main programme of care is formed. This gives staff a basis to work from and ensures immediate needs can be met. The home does not provide intermediate care and there fore Standard 6 is not applicable. Emmanuel Nursing Home DS0000000932.V344759.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Detailed care plans are kept on each service user, which are regularly evaluated to ensure all their needs are being met and they are free from risk. EVIDENCE: During the course of this inspection Standards 7,8,9 and 10 were checked. Prior to the site visit 14 surveys were sent to service users and their families, of which 9 were returned. 4 sent to health professionals, of which none were returned. 5-service users and a relative were spoken to during the site visit. 4 care plans were tracked in depth. Each set of documents had been well written and gave a detailed picture of the needs of each person. An initial set of records are provided by the Company and also supplementary sheets to enable special needs to be recorded, such as those who have been admitted Emmanuel Nursing Home DS0000000932.V344759.R01.S.doc Version 5.2 Page 11 with pressure sores and those requiring a more in-depth psychological function test. The home also takes into consideration those who may require special help because of reading difficulties and the daily living section is also in picture format and the records showed those who needed an oral assessment, where each section is read and explained. The daily reporting section was legibly written and gave a good overall picture of the daily care delivered to each person. One relative was assisting their family member to read a care plan during the site visit, which they stated, “was useful for them to see, as their family member could not always remember events”. A service user also stated, “the staff help me a lot, which I like and they are always pleasant”. Staff were observed through out the day assisting service users in a variety of tasks, such as personal hygiene, meals and activities. This was always done in a calm and dignified manner and they spoke to service users quietly and with respect. A senior member of nursing staff escorted the inspector when the drug records were being checked. Safe practises appeared to be in place and all records appeared correct. Emmanuel Nursing Home DS0000000932.V344759.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A varied activities programme is provided to meet service users expectations and all food is prepared in a clean environment. EVIDENCE: During the course of this inspection Standards 12,13,14 and 15 were checked. The inspector was able to speak to the activities organiser at length and also see a reminisce session in progress. Service users present at the session said how much a session like that helped them rekindle memories about the town they live in and as one person put it “ it’s helped me form friendships with like minded people in the home”. The activities organiser keeps interaction sheets on each person, which helps to keep a track of what sort of activities each person likes, how they interact with other people and to plan any future events to meet changing needs. Emmanuel Nursing Home DS0000000932.V344759.R01.S.doc Version 5.2 Page 13 The records showed a large variety of activities, which had taken place over the previous months. This included group activities such as art, basket weaving and flower arranging. To one to one sessions such as reading and painting. There is good access to the local community, with service users being able to go out to local events, in the near by vibrant town and also to have visits from groups from the local church, library and Historical Society. The Activities organiser works in conjunction with the key workers for each service user, and a social needs assessment is written in each care plan. The ones tracked were very detailed and also gave a life story of each person prior to admission. This helps staff to plan events around individual needs and also see where some may benefit from group sessions. The head cook escorted the inspector on a tour of the kitchen. This was cleaned to a very high standard and there appeared to be good stock control. The varied menu had been submitted prior to the inspection and showed a balanced diet was available. At the time of the site visit the kitchen was dealing with special diets for diabetics, soft diets and 1 kosher diet. There was evidence of fresh fruit and vegetables being used and home baking, including homemade chocolates. Service users made such comments as “I get enough to eat” and “I like being asked what I want to eat” and “I am thankful someone is helping my relative to eat a more balanced diet”. Emmanuel Nursing Home DS0000000932.V344759.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. A robust system to deal with complaints ensures service users are protected from harm and systems are in place to protect them from abuse. EVIDENCE: During the course of the inspection Standards 16 and 18 were checked. Since the last inspection the Company now has a more robust system in place to ensure any concerns are dealt with promptly and outcomes are recorded. The events history for CSCI showed that since the last inspection 4 concerns, 1 complaint and 1 allegation had all had satisfactory conclusions recorded for the parties involved. Service users, relatives and staff spoken to and surveyed all stated that they had confidence in the current management team and felt any concerns would be professionally looked at and responded to quickly. Most staff have received training safe guarding adults and the rest are booked to attend sessions. The local authority policy manual was in place as well as the Company policy, which was in the process of being reviewed. Emmanuel Nursing Home DS0000000932.V344759.R01.S.doc Version 5.2 Page 15 These processes, alongside the risk assessment policy documentation seen in the individual care plans ensures that service users are protected from harm and staff can identify any abusive situations and know how to refer issues. Emmanuel Nursing Home DS0000000932.V344759.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are able to live in a safe and clean environment suitable to meet their needs. EVIDENCE: During the course of this inspection Standards 19 and 26 were checked. Due to recent abnormally bad weather in the area the cellar had been flooded, but the home had coped very well and liaised with local emergency services, so as not to put service users at risk. The manager and visiting area manager accompanied the inspector on a tour of the home. The home appeared well cared for and clean and tidy. There were adequate methods for service users to be able to simmon assistance in Emmanuel Nursing Home DS0000000932.V344759.R01.S.doc Version 5.2 Page 17 communal areas as well as their rooms. A maintenance plan is in place to ensure that all areas of the home are covered and planned redecoration is in place. There was ample evidence to support that service users could personalize their own rooms. One service user spoken to had moved in “because I want to be cared for and I can bring my own furniture”. An inspection of the laundry area showed two dryers out of order, but the Company had ensured a temporary dryer was in place and staff spoken to stated they felt there was no backlog. A good system appeared to be in place to combat cross infection when handling soiled linen. The linen was in ample supply and of a good standard. Emmanuel Nursing Home DS0000000932.V344759.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Adequate staff are employed to ensure the needs of service users are met at all times by staff who have received safety checks prior to employment and are trained to do their job. EVIDENCE: During the course of this inspection Standards 27,28,29 and 30 were checked. Staff rotas had been submitted prior to the inspection and were checked on the site visit. There appeared to be adequate staffing levels in the home and service users and families did not indicate any problems with needs always being met. This was ascertained through the examination of rotas, looking at dependency levels and speaking to staff and service users. One service user stated “they come and answer my buzzer immediately, even at night” and “ all staff are approachable” and “ they look after me well”. 16 survey forms were sent to staff prior to the site visit and 5 were returned. 5 staff were also spoken to on the day of the site visit. Staff spoken to said they had every confidence in the home management team and “felt happy to come to work”. Emmanuel Nursing Home DS0000000932.V344759.R01.S.doc Version 5.2 Page 19 5 staff files were tracked in depth and found to contain all the relevant information to support that all safety checks had been completed prior to commencement of employment. These files also contained relevant information about the topics covered in training sessions attended by staff. This has covered all mandatory training and a variety of service specific topics such as wound care, phlebotomy, ear care and promoting urinary continence. 50 of staff have also completed their NVQ level 2 awards. The manager needs to ensure that all staff groups are covered and that a training matrix is in place to keep a track of training completed and needed. Emmanuel Nursing Home DS0000000932.V344759.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a safe and secure environment, which is constantly monitored by the Company. EVIDENCE: During the course of this inspection Standards 31,33,35,36 and 38 were checked. Since the last inspection the current manager has been registered with CSCI and is the process of completing her Registered Manager’s Award. There was also evidence to support that she had attended clinical training days in such Emmanuel Nursing Home DS0000000932.V344759.R01.S.doc Version 5.2 Page 21 topics as wound care, phlebotomy and administration of drugs. This has given a good basic knowledge base for the manager to lead the staff. The supervision records have also improved and the home has developed a system of line management to enable sessions to be kept up to date and also acted upon promptly. The records tracked showed how each session is planned, items discussed and outcomes. This enables the management team to address any lack of knowledge base with staff and to monitor how the actual care is being delivered to ensure service users are not put at risk. The quality assurance system has also improved since the last inspection and the last complete audit by the company was in May 2007. Visits are frequently made by Company personal and Regulation 26 notices completed, which were seen by the inspector. A variety of other audits take place such as accident analysis, consultation with service users and also staff and other stakeholders. This ensures that the home is being run for the service users; it meets their needs and is safe to live and work in. A selection of other documents were also seen to ensure that the building is safe and all equipment has been maintained and relevant safety certificates are in place. Emmanuel Nursing Home DS0000000932.V344759.R01.S.doc Version 5.2 Page 22 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 3 Emmanuel Nursing Home DS0000000932.V344759.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP30 Regulation 18.1.c.i. Requirement A training matrix must be in place to ensure that all staff are trained to do their jobs and have the skills to deliver the care to service users. Timescale for action 20/10/07 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. Refer to Standard OP31 Good Practice Recommendations The registered manager should finish the registered Manager’s Award. Emmanuel Nursing Home DS0000000932.V344759.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Emmanuel Nursing Home DS0000000932.V344759.R01.S.doc Version 5.2 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. 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