CARE HOMES FOR OLDER PEOPLE
Emmaus House Walkmill Close Moresby Parks Whitehaven Cumbria CA28 8XR Lead Inspector
Nancy Saich Unannounced Inspection 12 January 2006 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 Emmaus House DS0000022550.V259623.R01.S.doc Version 5.0 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. Emmaus House DS0000022550.V259623.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Emmaus House Address Walkmill Close Moresby Parks Whitehaven Cumbria CA28 8XR 01946 591362 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) office@emmaustrust.co.uk Cumbria Emmaus Trust Mrs Patricia Margaret Davies Care Home 24 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (22) of places Emmaus House DS0000022550.V259623.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The home is registered for a maximum of 24 service users to include: up to 24 service users in the category of OP ( Old age, not falling within any other category) up to 2 service users in the category of DE(E) (Dementia over 65 years of age) The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 20th July 2005 2. Date of last inspection Brief Description of the Service: Emmaus House is a purpose built home that caters for up to twenty-four older people, two of whom may have dementia. The home is owned and operated by the Emmaus Trust, a charitable organisation set up by the Christian Brethren Church. Some, but not all residents are members of this church. The home is managed by Mrs Patricia Davies who has been in post since April 2005.The home is in a residential area of Moresby, a village approximately three miles from Whitehaven, and is within walking distance of village amenities. The home has its own grounds and car parking. Emmaus House DS0000022550.V259623.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The lead inspector Nancy Saich was accompanied by another inspector, Diane Jinks on this unannounced inspection of Emmaus House. The visit started just after nine in the morning and they toured all areas of the home, spoke to residents, staff and visitors. They also spent time with the manager and with the chair of the Emmaus Trust, who is the person who takes the responsibility for the running of the home. They also checked on documents that supported what people said and what they saw during the day. They enjoyed lunch with the residents and left the home mid afternoon. What the service does well:
This is a well managed home with a dedicated staff team who deliver extremely high standards of care and services to the older people who choose to live in the home. The home makes sure that they only take new residents who they are really sure that they can care for and who will fit in with the other residents. The staff give good levels of care to residents and the residents feel that the staff team are “dedicated”, “caring”, “polite” and “kind”. Residents were aware that the staff keep records of their needs and preferences. These ‘care plans’ were very detailed and helped staff to understand any difficulties residents might have. The home arranges for outings and activities on a regular basis. Residents can go out to religious services or attend the service in the home. They can go out shopping or to entertainments or appointments. Residents said they enjoyed the services and the weekly craft sessions and said that the Christmas party and trip out were “really lovely…. just made Christmas for me…”. Residents said they could get up or go to bed when they wished. Some people spend a lot of time in their rooms, while others like the company of the main lounge. Residents said they could eat in their room if they wished. All of the residents said the food was “excellent”, “very nicely prepared” and there was “plenty of choice”. The inspectors enjoyed a very nice meal and saw a good range of food available in the kitchen. One resident summed it all up by saying, “…the manager, the trust and the staff make sure we have everything we want or need. They are good at the small things as well as the bigger problems…but it’s the attention to detail that makes this place so good…” The home makes sure that residents can voice anything that concerns them. Members of the trust visit the home almost on a daily basis and residents said
Emmaus House DS0000022550.V259623.R01.S.doc Version 5.0 Page 6 they would speak to the manger first but could discuss any difficulties with members of the trust. Staff were able to tell the inspectors how they would protect residents from any harm or potential abuse. The home has good policies and procedures about this. The home was clean, warm and tidy on the day. The residents said their rooms were always “spotless” and it was easy to see that the staff launder clothes and bed linens properly. The staff were aware of how to prevent cross infection. The main living area has comfortable furniture and is set out to encourage residents to sit in small groups. Each bedroom has a toilet and wash hand basin ensuite. The staff help residents to personalise their rooms and residents are encouraged to bring in their own furniture and personal items. Each room also has a telephone and residents are given their own telephone number. The staff said that there were enough people on duty to give residents the care they needed. In the morning there are four people who care for the residents and three in the afternoon. There are two waking night staff. The manager and the deputy both work full time. There is a team of housekeeping and catering staff and a handyman. This means that everything runs smoothly and staff don’t need to rush and can spend time with residents. Staff had received lots of training in the past year and more was planned. They all thought that this helped them care for people properly. Most staff have National Vocational Qualifications in care at levels 2 or 3. New staff are only taken on once they have been checked and proven to be the right kind of people to care for the residents. The home has very good systems that allow things to operate smoothly. The Trust has a system that ensures that good standards are met at all times. The inspector was given a report of this ‘quality assurance’ system. This showed that the trust had asked everyone involved with Emmaus house about how it could be made better. It also made sure that all the management systems in the home were working as they should. The chairman of the trust had also sent a copy of the home’s account and a business plan for the coming year. These were both in order. The home is planning to do some building work that will give a new lounge and office and increase the size of two bedrooms. The home’s manager has been in post for less than a year but is proving that she is more than capable of maintaining good standards, leading the staff team and in developing the home for the benefit of the residents. There was plenty of evidence to show that she really cared about the residents and made sure the home was run for their benefit. Emmaus House DS0000022550.V259623.R01.S.doc Version 5.0 Page 7 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. Emmaus House DS0000022550.V259623.R01.S.doc Version 5.0 Page 8 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 Emmaus House DS0000022550.V259623.R01.S.doc Version 5.0 Page 9 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): 3 This home is good at only admitting people they know will fit in and they can care for. EVIDENCE: The inspectors spoke to new residents who said that the manager or her deputy had visited them and they had made sure they understood what the person wanted from the home. The residents’ files contained details of what the manager found at this assessment visit. The manager and her deputy went out in the afternoon to meet with a social work manager to make sure that they worked well together so that the right people were placed in the home. Emmaus House DS0000022550.V259623.R01.S.doc Version 5.0 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 The home is very good at making sure that residents’ personal and health care needs are met fully. EVIDENCE: The inspectors met with alert and well cared for residents. This showed that the staff team take time and effort to support people to have the best care and attention possible. There was lots of evidence to show that residents got personal care and they said that staff did this and helped them retain their dignity and privacy. They felt that the staff approached this with just the right level of sensitivity and care. Residents’ files showed that their health care was managed properly. They said they could see the doctor or nurse when they needed. Some doctors come to see all their patients on a regular basis and make sure that their care is as good as possible. One resident spoke very highly of the way the doctor, the manager and the staff were helping with a major health problem. This person said “I could not wish for better care and attention than this…and I am very grateful that they work together so well…”
Emmaus House DS0000022550.V259623.R01.S.doc Version 5.0 Page 11 . Their was a lot of spoken evidence to show that this person was getting complex social, personal, health and psychological care. The person’s very detailed file described all the needs but didn’t really show all how the needs were met. Several other files didn’t describe all of the planned work staff were doing. The inspectors thought that the staff needed to be more specific about how they help residents overcome difficulties. This is so they can show that the action will be planned and the staff will all approach things in the same way. The inspectors checked on the way medicines were being handled. These were in order. Some residents looked after their own medicines and the staff made sure they had the support they needed to do this. Emmaus House DS0000022550.V259623.R01.S.doc Version 5.0 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, 13,14,15 Residents in this home said they had the kind of life that they wanted and were happy and content with the way things were arranged. EVIDENCE: Many of the residents in this home chose it because of the focus on faith and religious belief. Many of the residents are not members of the Christian Bretheren church but do consider themselves to be Christians. Ministers form other churches are very welcome in the home and give communion to anyone in the home. Residents said they also enjoyed the regular activities on offer and that they had the chance to go out to services or to shop or to local events or entertainments. Residents also liked the fact that they could spend their time as they wanted. Some people spent a lot of time in their rooms and other people preferred the “friendship and fellowship” of the shared areas. They said that their visitors were made very welcome and that lots of people from the congregation came to visit the home. Residents said they had plenty of choice and could influence things as much as they wanted. There was evidence to show that the manager was trying to encourage residents to be involved in decision making.
Emmaus House DS0000022550.V259623.R01.S.doc Version 5.0 Page 13 Residents said the food was always very good, properly cooked and that they had lots of choice. The inspectors sat and enjoyed a relaxed lunch with residents. Tables were properly set and the food was served hot and it looked attractive and was tasty and nutritious. The stores of food showed a wide range of healthy options and lots of homemade treats. Residents said that the home baking was ‘wonderful’. Emmaus House DS0000022550.V259623.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 This home is very good at making sure residents are protected from harm and that their concerns are listened to and acted on. EVIDENCE: Residents had no complaints and said there was nothing of concern going on in the home. They said that if anything was wrong they trusted the manager and her deputy to deal with it. They knew how to approach other people if there was a problem. Staff understood how to help people complain and understood how to protect vulnerable people. They knew how to contact people outside of the home if necessary. Emmaus House DS0000022550.V259623.R01.S.doc Version 5.0 Page 15 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): 19,26 Emmaus House is a safe, comfortable house where the residents feel relaxed and at home. EVIDENCE: The inspectors toured the building and found the home was clean, warm and well maintained in all areas. Residents said that the home was always clean and tidy and that things were kept in a good state of repair. The home was purpose built over ten years ago and provides a suitable environment for people who may have problems with their mobility. The trust has plans to update some areas of the home to make sure it continues to do this. Emmaus House DS0000022550.V259623.R01.S.doc Version 5.0 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 home has enough well trained staff to provide high levels of care for residents. EVIDENCE: The inspectors checked on the rosters and spoke to residents and staff about the staffing levels. Everyone felt that there were enough staff available to make sure that residents get all the care and attention they deserve. The staff team all have qualifications in care and continue to update their training. The manager has a training plan in place for the staff team. The inspectors checked on the files of the last two new staff to be taken on by the home. The manager had made sure she had checked that these were the right kind of people to be trusted with the care of residents. Emmaus House DS0000022550.V259623.R01.S.doc Version 5.0 Page 17 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 This is a well managed home where all of the team make sure that good quality care and services are provided for the residents. EVIDENCE: The registered manager has been in post for less than a year. She has had a number of years of experience in caring for older people and has just finished a training course about managing residential homes. This will give her a national vocational qualification in care management at level 4. The inspectors saw lots of evidence to show that she had maintained and developed all the systems that keep the home running smoothly. Staff and residents were happy with the way she was managing the home, as was the Emmaus Trust. The Trust had reviewed the management of the home as part of a wider exercise to measure whether quality was being achieved. The trust used someone external to the home to come in and look at all aspects of the way
Emmaus House DS0000022550.V259623.R01.S.doc Version 5.0 Page 18 the home was working. This audit of the home was completed and a report prepared. This showed that the home was operating very well and that residents and their families were very happy with the level of care and services provided. It highlighted some developments that they hoped to make to ensure the residents well being is as good as it possibly can be. Emmaus House DS0000022550.V259623.R01.S.doc Version 5.0 Page 19 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 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 4 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 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X X X X X Emmaus House DS0000022550.V259623.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? NA 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. 1 Refer to Standard 7 Good Practice Recommendations It is recommended that the manager introduce more strategic planning into residents individual care plans. Emmaus House DS0000022550.V259623.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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