Inspection on 08/08/06 for Emmanuel Nursing Home

This inspection was carried out on 8th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 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 OEL Lead Inspector Ann Day Key Unannounced Inspection 8th August 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.V296016.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.V296016.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Emmanuel Nursing Home Address 17 Southfield Hessle East Yorkshire HU13 OEL 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 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.V296016.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To admit one named service user under 65 years Date of last inspection 25th August 2005 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. Fees £390-£675 Emmanuel Nursing Home DS0000000932.V296016.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection included preparation, collation of information received, questionnaires completed by service users and comment cards completed by relatives; a pre inspection questionnaire completed by the providers of this service and fieldwork. The fieldwork included a tour of the premises, case tracking individual residents following their experience of the care provided; examination of statutory records; observation of and meeting with residents; interviewing staff members, the home’s administrator and the manager. The site visits to the home took place on 18th May & 8th August 2006 and was unannounced. Fieldwork took a total of 8.25 hours to complete. What the service does well: Service users said, “Happy well cared for”. “Very kind girls and boys! Always polite”. “ Very happy with this home”. “If anybody has to come into a home, then this one I would recommend”. “Room always clean and tidy, the home itself is bright and airy”. A relative said, All aspects of the home are excellent”. A member of staff said “Best home I have worked in”. Members of staff were able to explain how they ensured individual resident’s dignity and privacy whilst providing personal care. The interaction and rapport between members of staff and residents was seen to be very good. All activities are individually care planned and recorded; members of staff promote the continuation of regular visits, and hobbies e.g. church, wood work; particularly where these visits or activities were established patterns before an individual’s admission to Emmanuel Nursing Home. A relative said, that the activities coordinator was excellent and often spent time with individual service users. Meals were observed to be unhurried and the convivial atmosphere provided an enjoyable social occasion. The home was very clean, comfortable and homely in appearance. The home is developing a memorial and sensory garden within its extensive well-maintained grounds. The home has an ongoing maintenance and redecoration programme. Members of staff interviewed were clear about their role, knew what was expected from them and showed a good understanding of the actions they needed to take to meet and promote independence, equality, diversity and choice. Emmanuel Nursing Home DS0000000932.V296016.R01.S.doc Version 5.2 Page 6 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. Emmanuel Nursing Home DS0000000932.V296016.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.V296016.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): 1,2,3,5,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service have good information about the home in order to make an informed decision about whether the service is right for them. The personalised needs assessment means that people’s diverse needs are identified and planned for before they move to the home. EVIDENCE: Written admission documentation was adequate and included a copy of the care management assessment. Basic information was available to staff to ensure they could meet the social, emotional and care needs of new service users. The written contract and terms and conditions of residence were on each service user’s file. The newest service users had a copy. The current fees were included and clearly laid out. This means that service users have the information they need about the service they will receive and how much it will cost them. The home does not provide intermediate care. Emmanuel Nursing Home DS0000000932.V296016.R01.S.doc Version 5.2 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 the following standard(s): 7,8,9,10,11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Practice regarding the planning and delivery of care means that all service users can be sure that their health and personal care needs will be fully met. EVIDENCE: Service users said, “They look after me very well at this home.” Members of staff were able to explain how they ensured individual resident’s dignity and privacy whilst providing personal care. The interaction and rapport between members of staff and residents was seen to be very good.Care staff said, how nurses explained the care needs of the individual residents and that they were encouraged to read through the care plans. Four service users were case tracked, following the care needed and provided for these individual service users. In addition care records for residents, who had or were currently receiving pressure area care from nursing staff in the home, were examined. Care records were found to be comprehensive, including risk assessments, detailed care plans, which are evaluated and regular reviews of individual care needs are documented. Emmanuel Nursing Home DS0000000932.V296016.R01.S.doc Version 5.2 Page 10 The home has a nurse call system that records response times. Members of care staff were observed responding immediately in response to calls. The home has Safe Handling of Medication procedures in place and safe practices are adhered to. The home uses a monitored dose system, for the administration of medication. Only registered nurses employed in the home administer medication in the home. Medication Administration Record sheets were examined and were found to be accurate. The home has policies and procedures in place to care for the dying and their relatives, care records examined contained service users’ individual wishes, and members of staff confirmed that both service users and their family members are well supported at this difficult time. Emmanuel Nursing Home DS0000000932.V296016.R01.S.doc Version 5.2 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 the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A range of activities within the home and community mean the service users do have a range of opportunities to participate in stimulating and motivating activities. Meals and mealtimes are not rushed and are an enjoyable, social occasion for all of the service users. EVIDENCE: The home employs a part-time activities coordinator, and there is a published varied programme of activities made available for residents to participate in. All activities are individually care planned and recorded; members of staff promote the continuation of regular visits, and hobbies e.g. church, woodwork; particularly where these visits or activities were established patterns before an individual’s admission to Emmanuel Nursing Home. A relative said, that the activities coordinator was excellent and often spent time with individual service users. The home is developing a memorial and sensory garden within its extensive well-maintained grounds. Emmanuel Nursing Home DS0000000932.V296016.R01.S.doc Version 5.2 Page 12 The home encourages open visiting, observation and service users confirmed that family and friends are made welcome. Service users said, “ Nursing staff very helpful, keep my family informed”. A male carer on the staff team enables male residents to choose to have care provided by a carer of their own gender, increasing their choices. The home has a Primary nurse and Key worker system in place, that works well. Service users and staff confirmed that they are encouraged to make choices about the time they get up, retire to bed, the clothes they wear and the activities/pastimes they take part in. Service users confirmed that they liked the food, service users can choose to eat a cooked breakfast, and the home’s main menus are varied. The home has an assisted dining room and a waitress is employed to attend to the more able residents in a separate dining area. Meals were observed to be unhurried and the convivial atmosphere provided an enjoyable social occasion. Service users said, “I always have a selection of good food available to me when I need it”. “Very good selection and choices”. Emmanuel Nursing Home DS0000000932.V296016.R01.S.doc Version 5.2 Page 13 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): 16,17,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users feel safe and listened to. Formal processes have been developed and the home’s procedures are available to every service user, and understood. However, complaints records were not easily accessible for inspection. EVIDENCE: The home has policies and procedures in place; service users, relatives and members of staff know to whom they speak if they have any concerns. The complaints procedures are provided as apart of the Service User Guide to every resident of the home. The complaints records/log was available only after a protracted search. Three complaints have been received by the Commission, with regard to care provided, assistance at meal times, the marking of clothing and management of the home. The home has not recorded any formal complaints received this year. Service users are enabled to use their postal vote. Members of staff have attended adult protection awareness training, and are clear, about their responsibilities, with regard to the reporting of any incident, occurrence or concern. Emmanuel Nursing Home DS0000000932.V296016.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,22,24,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The maintenance and renewal of equipment and facilities mean that service users live in a safe environment. The very good condition of the décor, and fixtures and fittings means that service users live in a good environment. EVIDENCE: A tour of the premises was undertaken, aids and adaptations are in place to promote residents independence. The home was very clean, comfortable and homely in appearance. Residents eat in a convivial atmosphere. The home has an infection control policy in place; the home is free from malodour. Emmanuel Nursing Home DS0000000932.V296016.R01.S.doc Version 5.2 Page 15 A new walk in shower has been provided on the ground floor to aid those less mobile service users. The home has an ongoing maintenance and redecoration programme, which is recorded. The home has extensive well-maintained grounds, and a memorial/sensory garden is being developed. The rooms of those service users whose care was case tracked (individual experience of care provided was followed) showed individuals had been able to personalise their rooms, and they were satisfactorily clean and well presented. Service users felt their rooms were comfortable. Aids and equipment were provided in the home, all of these were of a satisfactory quality. New hospital beds and pressure relief mattresses have been purchased recently for the home. The stock of general aids, were in a good condition. The hoists were serviced regularly, which ensures the safety of and minimises risk for people who use the service. Emmanuel Nursing Home DS0000000932.V296016.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The quality rating for this outcome group is adequate. This judgement has been made using available evidence including a visit to this service. The home’s staff, are competent and appropriately trained, however service users are not sufficiently supported and protected by the home’s recruitment practices. EVIDENCE: There were sufficient numbers of staff on duty on the day of the visit, the manager said, that she is hoping to develop a “Bank”, she confirmed that the home uses one agency to provide staff, enabling the home to provide some continuity during shortages. Members of staff interviewed were clear about their role, knew what was expected from them and showed a good understanding of the actions they needed to take to meet and promote independence, equality, diversity and choice. A care worker confirmed that all the statutory checks had taken place before she started work at Emmanuel Nursing Home. The home’s business manager explained that there had been a delay with Criminal Records Bureau checks (CRB) for new starters since the change in the home’s ownership; and one staff file examined did not contain two written references. Emmanuel Nursing Home DS0000000932.V296016.R01.S.doc Version 5.2 Page 17 Training records are currently being separated from the personnel staff files to better facilitate the location of individual records. Some of the changes are currently delaying searches. Currently 42.86 of the care staff group have achieved NVQ Level 2 or equivalent. Four members of care staff are currently undertaking NVQ Level 2, one member of staff undertaking NVQ Level 3 and one member of staff is undertaking NVQ Level 4. The home does not currently meet the target of 50 of care staff with NVQ Level 2. Emmanuel Nursing Home DS0000000932.V296016.R01.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,34,35,36,38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Management arrangements are not currently meeting the needs of the service. EVIDENCE: The current manager was appointed to the post in May 2006. The Home Manager is a registered nurse and has worked in the position of deputy manager previous to her appointment. The Home Manager is yet to apply to be registered with the Commission, but has identified a college to undertake the Registered Managers Award, later in the year. Emmanuel Nursing Home DS0000000932.V296016.R01.S.doc Version 5.2 Page 19 The home does not have a comprehensive quality assurance programme in place; the home has received the first part of an external quality award, and is working towards the second part. Members of staff and the Business Manager confirmed that the Responsible Individual does visit the home regularly, however no report (Reg 26) was available; this was brought to the attention of the Home Manager. The home does not hold personal monies for individual service users. The home provides locked cabinets in bedrooms and service users are discouraged from keeping large sums of money in the home. Items such as hairdressing and chiropody are invoiced directly. The inspector was provided with up to date, detailed budget accounts for the home. The Home Manager has not formally supervised or appraised any of the home’s staff since her appointment in May. She has not delegated this duty to her deputy who is Registered Mental Health Nurse or the senior carer, who has achieved NVQ Level 4. However, members of staff and records confirmed that they had regularly received formal supervision from the home’s previous registered manager, in spring of this year, and were in receipt of informal supervision. Members of staff confirmed that they are invited to attend regular staff meetings where they are enabled to raise issues and voice any concerns. The Business Manager is in the process of moving his office space to share the downstairs office with the newly appointed Home Manager. The Home Manager and Business Manager experienced some difficulty finding documentation and records for the inspection. The home has been vigilant in its obligation to notify the Commission of accidents, medication errors, injuries, illnesses and deaths. All maintenance and servicing documentation was up to date, available for examination and met legislation and regulations. Service users, relatives and members of staff described the managers as approachable. Emmanuel Nursing Home DS0000000932.V296016.R01.S.doc Version 5.2 Page 20 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 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 2 17 3 18 3 3 X X 3 X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 3 3 1 X 3 Emmanuel Nursing Home DS0000000932.V296016.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP16 Regulation 22 Requirement The Registered Person shall ensure that every complaint/concern received is thoroughly investigated and that a complaints log/records are made available for inspection. The Registered person shall not employ a person to work at the care home unless he has obtained in respect of that person the documents and checks specified in Paras. 1-7 of Schedule2 The Registered person must 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.) and document monitoring visits to the home, making reports available to the Commission. The Registered Person must ensure that persons working at the care home are appropriately supervised and in receipt of annual appraisal, and that such supervision and appraisals are DS0000000932.V296016.R01.S.doc Timescale for action 30/09/06 2. OP29 19 Sched.2 30/09/06 3. OP33 24 &26 30/09/06 4 OP36 18 30/09/06 Emmanuel Nursing Home Version 5.2 Page 22 documented. 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 OP28 OP31 Good Practice Recommendations The Registered Person should ensure that 50 of care staff achieve NVQ Level 2 The Home Manager should apply to the Commission to be registered and undertake and achieve NVQ level 4 in Management or equivalent by 2007. Emmanuel Nursing Home DS0000000932.V296016.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Hessle Area Office 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 DS0000000932.V296016.R01.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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