Inspection on 24/05/05 for Emsworth House

This inspection was carried out on 24th May 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 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

Emsworth House 24/06/08

Emsworth House 29/06/07

Emsworth House 15/11/06

Emsworth House 27/09/05

Emsworth House 15/02/05

Emsworth House 26/10/04

Emsworth House 09/03/04

Emsworth House 18/02/04

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Emsworth House Emsworth House Close Havant Road Emsworth Hampshire Lead Inspector Gina Pickering Unannounced 24/5/05 10:00am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Emsworth House H54 S37245 Emsworth House V228156 240505.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Emsworth House Address Emsworth House Close, Havant Road, Emsworth, Hampshire, PO10 7JR Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01243 373016 01243 372421 Hampshire County Council CRH 36 Category(ies) of DE(E) -Dementia- over the age of 65 years: 36 registration, with number OP- Old Age: 36 of places Emsworth House H54 S37245 Emsworth House V228156 240505.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15/2/2005 Brief Description of the Service: Emsworth House is a care home registered to provide personal care for upto 36 service users over 65 years of age. At present building work is in progress to extend the home provide 40 nursing beds. As a result of the building work the home is at present accomodating no more than 28 residents. The home is registered to provide care for residents with a diagnosis of dementia as well as for the older person. However again due to the buiding work in progress the management team have made an assesment that at the moment the home is not a suitable environment to deliver care to residents with dementia type illnesses. The home is being managed by an acting unit manager with the support of an assistant manager team. A new unit manager has recently being appointed and was in the process of her induction programme at the time of the inspection. She is in the process of applying to the Commission of Social Care Inspection for registration as manager of the home. The home is situated in a residential area of Emsworth within easy access of local community facilities and local health care faciities. Emsworth House H54 S37245 Emsworth House V228156 240505.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over a two-day period by one inspector. The inspector had the opportunity to meet the acting unit manager and the newly appointed unit manager as well many of the assistant managers, care staff and ancillary staff. For the purpose of this report the acting unit manager, newly appointed manager and the assistant managers shall be referred to as the management team. Discussion with staff at the home evidenced that those who live at the home like to be called residents, this shall be reflected throughout this report. The inspector had the opportunity to have discussion with eight residents, two visitors, and several care staff and ancillary staff. Residents offered such comments as ‘ it’s a good as home’, ‘we can do what we want when we want to’, and ‘staff are lovely and very helpful’. Many residents stated that they had no complaints. Staff commented that they receive the training and support to enable them to provide the care and support for the residents at the home. Much attention is placed on the reduction of risks to any one entering the home with the use of comprehensive risk assessments and risk reduction plans. What the service does well: What has improved since the last inspection? The refurbishment of the communal toilets has been completed. A record of all food provided to the residents is documented, including those on special diets. Emsworth House H54 S37245 Emsworth House V228156 240505.doc Version 1.30 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. Emsworth House H54 S37245 Emsworth House V228156 240505.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Emsworth House H54 S37245 Emsworth House V228156 240505.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3, & 6 Prospective residents and their representatives receive information about the home to enable them to make an informed decision regarding the suitability of the home for them. The home has an assessment process that enables prospective residents to be assured that their needs will be met on moving into the home. No intermediate care is provided at this home. EVIDENCE: A service users guide and statement of purpose is available and forwarded to all interested parties. The statement of purpose is displayed within the entrance hall of the home. The statement of purpose was in the process of being revised at the time of the inspection to reflect the changes in management and service provided by the home. All service users at the home are admitted via social services care management process and thus the home receives a comprehensive assessment of the residents needs prior to admission. If on receipt of this information there are any concerns staff from the home undertake their own assessment of the prospective residents needs. Samples of both assessments were viewed during the inspection process. Discussions with care staff evidenced that they believe they receive enough detailed information to enable Emsworth House H54 S37245 Emsworth House V228156 240505.doc Version 1.30 Page 9 them to meet the needs of a new resident. Residents that the inspector had conversations with also expressed this view. The home does not provide intermediate care, thus this standard is not required to be assessed. Emsworth House H54 S37245 Emsworth House V228156 240505.doc Version 1.30 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 standard(s) 8 & 10 Medications are administered to residents in a safe and appropriate manner, however storage of certain medications requires improvement as well as the documentation of medications not administered to fully ensure the health and well being of the residents. Residents at the home are confident in the knowledge that their privacy and dignity is upheld. EVIDENCE: A medication policy and procedure is in place along with the home having recent guidelines form the Royal Pharmaceutical Society. Inspection of the medication administration charts highlighted that medications not given to residents were recorded with an ‘x’, but no reason for their non-administration was recorded. A reason for medication not administered must be documented on the medication administration record form. A record of all medications received and disposed of is maintained. Inspection of the storage of the medications indicated satisfactory stock control and rotation. The drug fridge was felt to be very cold in temperature; there was no method of recording the temperature of the fridge thus ensuring that medications were being stored at the correct temperature. Fridge temperatures must be monitored and maintained at a temperature to ensure the effectiveness of the medications. It Emsworth House H54 S37245 Emsworth House V228156 240505.doc Version 1.30 Page 11 was noted that some ointments did not have the date of opening recorded on them; this must be recorded on the ointment tube. The inspector observed staff addressing residents courteously and knocking on bedroom doors prior to entering them. Discussions with residents suggested that the staff at the home treat them with dignity and respect allowing them to maintain their privacy. Emsworth House H54 S37245 Emsworth House V228156 240505.doc Version 1.30 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 standard(s) 15 Dietary needs of the residents are catered for with a varied and nutritious menu plan that is flexible to enable residents exercise choice regarding their choice of meals. EVIDENCE: Discussion with the catering staff suggested that resident’s wishes are taken into consideration when developing the four-week rotating menu; this was confirmed in conversations that the inspector had with several residents. Menus are on display on each table in the dining room. Residents expressed satisfaction with the meals provided at the home, especially with regard to the choice and quality of the food prepared. Discussion with the catering staff and management of the home indicate that meals for those with cultural or religious needs could be catered for should the need arise. Residents are encouraged to take their main meals in the large airy dining room, but ultimately they have choice as to where they take their meals, in the large dining room, one of the smaller communal areas or in the privacy of their bedrooms. A record is maintained of all meals taken by the residents. Emsworth House H54 S37245 Emsworth House V228156 240505.doc Version 1.30 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 standard(s) 16 & 18 Some residents are aware that they are able to voice concerns and complaints and those will be addressed, however due to probable short- term memory problems of some residents this information is not always retained. Residents are protected from the effects of abuse with comprehensive polices and procedures in place along with an awareness of the care staff of the process involved in the protection of the residents at the home. EVIDENCE: A complaints policy and procedure is in place and is available for all to view. Each resident has a copy of the procedure in their bedroom as well a complaints form that they can fill in if they wish. Discussions with residents revealed that not all were sure to whom they would address any complaints. Conversation with staff and management at the home indicate that all residents are informed of the process and the complaints process is discussed at residents meetings and on a one to one basis with residents. A decision was made by the new manager that a copy of the procedure would be placed on the resident’s notice board. A complaints register is in place that records the action taken and the outcome of any complaints that are received by the home. Polices and procedures are in place relating to the protection of vulnerable adults. The management team informed the inspector that abuse and the protection of vulnerable adults is explored with care staff during formal supervision sessions. However conversations with care staff revealed a lack of awareness that they had received any training with regard to this subject, but they were able demonstrate in conversation that they were aware of the correct procedure to be taken in a case of suspected abuse. Discussion with Emsworth House H54 S37245 Emsworth House V228156 240505.doc Version 1.30 Page 14 the management clarified that formal accredited training with regard to the protection of vulnerable adults was being organised. The management team were able to clearly discuss the correct action to be taken in the case of suspected abuse. Emsworth House H54 S37245 Emsworth House V228156 240505.doc Version 1.30 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 standard(s) 19 & 26 Residents live in an environment that is well maintained and decorated in a fashion that they are content with. Hygiene and cleanliness of the home contributes to the well-being and health of the residents at the home. EVIDENCE: A tour of the environment revealed that despite several areas of the home waiting upgrading and redecoration the home is in good general decorative order, with décor and furnishings being of a homely nature. A choice of communal areas is available for the use of the residents. There are an appropriate number of toilets and assisted baths. Since the previous inspection the refurbishment of the toilet areas had been completed. Grab rails are situated along corridor areas as well as in the bathing and toileting areas. Residents expressed their satisfaction with décor and furnishing of the home to the inspector. Extensive external grounds are available though at the time of the inspection limited access to these grounds was available due to the building work in progress. Infection control polices and procedures are in place. Infection control training for staff members was being arranged during the course of the inspection. A Emsworth House H54 S37245 Emsworth House V228156 240505.doc Version 1.30 Page 16 team of cleaners are employed to ensure the home is kept clean and tidy. At the time of the inspection the home was clean and free from offensive odours. The laundry was inspected and found to have the required flooring and wall surfaces to ensure the hygiene and cleanliness of the laundry area. Concerns were noted with regard to building contractors accessing their offices through the laundry. This was discussed with the laundry staff and management team. Risk assessments with resulting action to be taken to reduce risks associated with this practice were viewed. Action was taken at the time of the inspection to ensure that the risk assessments were being adhered to. Emsworth House H54 S37245 Emsworth House V228156 240505.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 & 30 An appropriate number of staff are employed to ensure that residents personal, social, emotional and recreational needs are catered for. Residents are confident that staff at the home have the training and skills to enable their holistic needs be met and to ensure their safety and well being. EVIDENCE: Inspection of the staff rota and discussion with the management team evidenced that the home has adequate numbers of staff to enable the present group of residents needs be met. Staffing levels at the home have been determined to meet the needs of thirty-six residents. However at the present time only twenty-eight residents are accommodated due to the building work, with no residents being admitted with dementia type illnesses. This allows for extra support for the residents during the building process as well enabling them to have more one to one or small group activities with the staff members. Discussion with care staff indicated that they felt staffing levels were of a number that enabled them to meet the needs of all residents, this was confirmed in conversations that the inspector held with several residents. Despite a vacancy within the cleaning team the commitment to maintaining the cleanliness of the home was apparent with all areas being clean and tidy. Monthly dependency scoring of residents allow the management team determine required staffing levels that are utilised in the recruitment of staff. Emsworth House H54 S37245 Emsworth House V228156 240505.doc Version 1.30 Page 18 All staff are subject to performance reviews that reflect their personal learning needs as a team and as an individual. Staff are able to access Hampshire County Council training programme to ensure they gain various skills and knowledge to enable them to perform their job. Discussion with staff members indicated that they feel they receive the training to enable them to meet the needs of the residents at the home. Residents discussed with the inspector that they felt the care staff had the knowledge to support them with their daily activities and personal care. Emsworth House H54 S37245 Emsworth House V228156 240505.doc Version 1.30 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 & 38 Staff at the home recognise that Emsworth House is the home of the residents and consequently residents views and wishes are an integral part of the running of the home. The health and safety of the residents, staff and all who enter the home are promoted and safeguarded by the practices at the home. EVIDENCE: Various auditing methods are utilised to ensure the home is run in the best interests of the residents. An annual residents survey gives residents and their representatives the opportunity to comment and suggest alternatives on the management of the home. Regular resident meetings enable residents to voice suggestions regarding the home. Resident’s discussed with the inspector that the management team if possible acts upon comments and suggestions. Financial and health and safety audits are performed. Monthly reports on the service provided at the home are performed in line with Regulation 26. Emsworth House H54 S37245 Emsworth House V228156 240505.doc Version 1.30 Page 20 One member of the management team has responsibility for co coordinating health and safety issues within the home. Risk assessments and action to be taken accordingly are in place for the environment, all working practices and individual staff members. All staff receive the mandatory training with regard to health and safety issues to ensure the safety of all whom enter the home. Service certificates were viewed, evidencing that all equipment and services are maintained as per manufacturers or legislative recommendations to ensure the safety of all t the home. Fire safety checks are performed and recorded as per fire and rescue recommendations. Emsworth House H54 S37245 Emsworth House V228156 240505.doc Version 1.30 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x x x x 3 Emsworth House H54 S37245 Emsworth House V228156 240505.doc Version 1.30 Page 22 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13(2) Requirement The registered person must ensure that the reason for any medication not administered to a resident is documented on the medication administration record chart. The registered person must ensure that all tubes of ointment or creams have the opening date written on them. The registered person must ensure the temperature of the medication fridge is monitored, recorded and maintained at a level as stated on the patient information leaflet supplied with cold storage medications. Timescale for action July15th 2005 2. OP9 13(2) July15th 2005 July15th 2005. 3. OP9 13(2) 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 Good Practice Recommendations Emsworth House H54 S37245 Emsworth House V228156 240505.doc Version 1.30 Page 23 Commission for Social Care Inspection 4th Floor- Overline House Blechynden Terrace Southampton Hampshire 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 Emsworth House H54 S37245 Emsworth House V228156 240505.doc Version 1.30 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. 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