Inspection on 15/11/05 for Emmaus House

This inspection was carried out on 15th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Emmaus House 02/01/07

Emmaus House 24/03/06

Emmaus House 18/01/05

Emmaus House 06/07/04

Emmaus House 18/11/03

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Emmaus House 115 Valley Drive Harrogate North Yorkshire HG2 0JS Lead Inspector Kate Shackleton Unannounced Inspection 15th November 2005 09:30 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 DS0000007808.V262420.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 DS0000007808.V262420.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Emmaus House Address 115 Valley Drive Harrogate North Yorkshire HG2 0JS 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) 01423 565932 01423 565964 Harrogate Emmaus Trust Mrs Christine Alice Hornby Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places Emmaus House DS0000007808.V262420.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th January 2005 Brief Description of the Service: Emmaus House is registered to provide personal and social care for 23 older people. The home is situated a short distance from Harrogate town centre and provides good access to services and amenities. The home is on two floors and there is a passenger lift to all levels. There are steps to the front of the building with level access at the rear. There are twenty single bedrooms and two shared. All but one room has en-suite facilities. Emmaus House DS0000007808.V262420.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over six and a half hours. The manager, two care staff and a number of service users were spoken to. Communal areas of the building and some bedrooms were seen. A sample of staff, service users and health and safety records were examined. What the service does well: What has improved since the last inspection? There has been a programme of redecoration to four bedrooms and refurbishment of two .New dining room and lounge chairs and a TV, video and music centre have been purchased. Hot water is delivered at a safe temperature. New fail-safe thermostatically controlled valves have been fitted to taps. Emmaus House DS0000007808.V262420.R01.S.doc Version 5.0 Page 6 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 DS0000007808.V262420.R01.S.doc Version 5.0 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 Emmaus House DS0000007808.V262420.R01.S.doc Version 5.0 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): 3. Standard 6 does not apply to Emmaus House Good quality information about the prospective service user is gathered prior to admission. This enables the manager to decide before a service is offered whether the needs of the person can be met effectively. EVIDENCE: Four case files were examined. They showed that comprehensive assessments are completed prior to and following admission to the home. Assessments cover a range of issues for example personal and social care needs, spiritual needs, medication and mobility. Personal and environmental risk assessments are completed. The home operates a key worker scheme. This member of staff (the key worker) takes a special interest in the service user and does a monthly review of the service users needs. The dates of these reviews are recorded but not all. The manager said that they used to record all review dates and that they would in the future do so. Emmaus House DS0000007808.V262420.R01.S.doc Version 5.0 Page 9 Staff spoken to say that they report any changes to a persons needs and match the delivery of care accordingly. Emmaus House DS0000007808.V262420.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 and 10 Service user needs are met in a kind and respectful manner and they are encouraged to be independent. EVIDENCE: All service users have a care plan. Four plans seen showed the type of care that the person needed. The plans told staff what they have to do so that the person receives the care they need. Doctors, nurses and other health care professionals visit the home. Some service users go out to visit surgeries and attend hospital appointments. Wherever possible service users keep the same doctor they had before admission. Some service users look after their own medicines. A safe place for them to keep their medicines is provided. An assessment is done to make sure that the service user is capable to self medicate safely. Arrangements are in place for the secure storage and safe administration and disposal of medicines. Service users give written consent for staff to give them their medicines. Designated Emmaus House DS0000007808.V262420.R01.S.doc Version 5.0 Page 11 staff who have received training are the only people who can give out medicines. Service users spoken to say that they are treated in a polite and respectful manner. They said staff were very helpful and caring. Staff were seen enjoying the company of service users, involving them in conversations and checking that they had what they needed and were comfortable. Staff training covers staff attitudes about respect and privacy. Emmaus House DS0000007808.V262420.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, and 15 Service users receive a service that they are happy with and meets their needs. EVIDENCE: Service users spoken to said that living at Emmaus House was very enjoyable. They said that they were able to keep themselves occupied and the Christian ethos of the home suited them very well. Some said that is why they had chosen to live here. The home employs someone to organise activities. One service user had “no regrets” and would not want to live anywhere else. Visitors are made welcome and can have a meal with their relative. A visitor was seen during this visit. Service users and staff were able to give a number of examples about the way in which people exercise choice and control in their daily lives. Some situations given were, Rising and retiring time, clothes to wear, bathing times, choice of activities in and outside the home and food. Menus were seen and they offered a choice of nutritious meals. The cook explained that local fresh produce is used and when people first come to live at the home she talks with them to find out what they like to eat. The cook is interested in providing good quality “home cooked” meals and is able to cope with special diets. A member of staff was seen talking with each service user telling them what was on the menu for the following days lunch and making a Emmaus House DS0000007808.V262420.R01.S.doc Version 5.0 Page 13 note of their choice. Good quality biscuits were being offered at the coffee break. Staff sat with service users in the lounge to have their coffee. Meals can be taken in bedrooms and a couple of people choose to eat alone. The majority eat in the dining room in a very attractive setting. Fresh linen tablecloths and napkins and flowers dress the tables. The dining room felt and looked like a place where service users can enjoy taking a meal. Care staff and service users sit together to have their meals. Service users spoken to said that the meals are very good and that drinks and snacks are available anytime. Some service users have a kettle in their bedrooms to make their own drinks. Emmaus House DS0000007808.V262420.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 and 18 Service users can be confident that complaints are taken seriously and acted upon. Proper procedures and staff training protect service users from harm. EVIDENCE: The complaints record was looked at and showed that any concerns raised are responded to quickly and in a manner that seeks to resolve the issue to everyone’s satisfaction. Service users spoken to knew how to make a complaint and felt comfortable about approaching the manager if they needed to. Service users and relatives are given a copy of the complaints procedure. The home has an adult protection procedure in place. Staff are given training in abuse awareness. Staff training files examined confirmed this. Staff spoken to knew to pass on any suspicions or allegations of abuse to the manager. There have been no incidents of abuse reported since the last inspection. The manager is aware that staff that are deemed to be unsuitable to work with vulnerable adults are referred for inclusion on the Protection of Vulnerable Adults register. Every month a Trust member visits the home to carry out checks to ensure the safety and well being of service users and staff. At this visit service users are spoken to, to make sure that they are being cared for in a manner that suits them. Reports of these visits are sent to the Commission for Social Care Inspection. Emmaus House DS0000007808.V262420.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 and 26 Service users live in a clean safe environment. EVIDENCE: The home is ideally situated close to the centre of Harrogate and with a range of shops and facilities nearby. It is opposite the towns famous “Valley Gardens”. There is an ongoing programme of routine maintenance and a maintenance man is employed to do the routine safety checks. Bedrooms are redecorated as needed and always between lets. New chairs have been bought for the lounge and dining room. The home is spotlessly clean with no offensive odours. Domestic staff are employed for daily cleaning and outside contractors are used for bigger jobs for example cleaning the lounge carpet and window cleaning. Emmaus House DS0000007808.V262420.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 and30 There are sufficient numbers of well-trained staff to meet service users needs. Some aspects of the recruitment process have the potential to place service users at risk. EVIDENCE: Rotas examined showed that there is four care staff on duty during the morning and two on in the afternoon, evening and throughout the night. Additional staff are employed to do the cleaning, catering and maintenance work. There is a comprehensive staff-training programme. The training covers general aspects of care as well as specialist training for example, diversional therapy and dementia care. Staff are encouraged to do National Vocational Qualifications and 42 of staff have already completed NVQ with a further two enrolled to start in January 2006.Staff spoken to say that the training is good and provides them with the knowledge and skills to do the job. Service users spoken to said that staff are competent and care for them in a sensitive manner. Generally the staff recruitment process is rigorous enough to prevent the employment of unsuitable staff. However in two recent cases care staff have been employed without having been checked through the criminal records bureau. The manager has relied on the previous employers CRB check and this Emmaus House DS0000007808.V262420.R01.S.doc Version 5.0 Page 17 is not acceptable. Since July 26 2004 no one can be employed if they are on the Protection of Vulnerable Adults list. This list is checked as part of the CRB checking or in an emergency through POVAfirst. The POVA list lists people who are unsuitable to work with vulnerable adults. Emmaus House DS0000007808.V262420.R01.S.doc Version 5.0 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): 31,33,35 and 38 The home is well managed. The risk of harm or injury to service users and staff is minimised through safe systems of working, staff training and risk assessment. EVIDENCE: The registered manager is a registered nurse and has over seventeen years management experience. She also has the NVQ level 4 qualification in management and care and shows a commitment to providing a good quality service. She has a good understanding of the individual needs of the people who live at the home and both service users and staff say she is very approachable. There is an effective quality assurance process, which asks for the views of service users and their families about the service provided. A trustee completes monthly checks of the home. Satisfaction surveys are sent to Emmaus House DS0000007808.V262420.R01.S.doc Version 5.0 Page 19 relatives and others. The manager has to produce a report and attend the Trustee committee meetings. Twice yearly service users meetings are arranged. The manager sends a monthly report to the Commission. Arrangements are in place to keep money held by the home on behalf of service users safe. Systems used make it difficult for financial abuse to take place. There are a range of policies, procedures and systems in place to promote the health safety and welfare of service users and staff. Staff receive training in safe working practices and there is always a trained first-aider in the house. Gas and electrical appliances are serviced regularly and water temperatures checked to ensure the delivery of safe hot water. Risk assessments are carried out and the findings recorded. Accidents and injuries are recorded and reported. Emmaus House DS0000007808.V262420.R01.S.doc Version 5.0 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 X X 2 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 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 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Emmaus House DS0000007808.V262420.R01.S.doc Version 5.0 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 OP29 Regulation 19 Requirement Staff must not commence employment until a CRB or POVAfirst check has been obtained. Timescale for action 16/11/05 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 Refer to Standard OP3 Good Practice Recommendations Where the care plan document asks for the date of the review, it should be recorded. Emmaus House DS0000007808.V262420.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Emmaus House DS0000007808.V262420.R01.S.doc Version 5.0 Page 23 - 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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