Inspection on 15/08/07 for Emyvale House

This inspection was carried out on 15th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Emyvale House 04/01/06

Emyvale House 11/08/05

Emyvale House 18/01/05

Emyvale House 05/09/04

Emyvale House 02/10/03

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

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 Emyvale House 29 Brampton Road West Melton Rotherham South Yorkshire S63 6AR Lead Inspector Valerie Hoyle Key Unannounced Inspection 09:00 15th August 2007 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 Emyvale House DS0000040187.V314788.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. Emyvale House DS0000040187.V314788.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Emyvale House Address 29 Brampton Road West Melton Rotherham South Yorkshire S63 6AR 01709 874910 NONE NONE 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) Mr Stephen John Oldale Julie Count Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Emyvale House DS0000040187.V314788.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th January 2006 Brief Description of the Service: Emyvale House is situated in the village of West Melton on the northern outskirts of Rotherham. It is near the village facilities such as the shops, public houses, public transport and the Church. Located on the main road, it has the appearance of a large ordinary house and has been converted for this current use. A small car park and garden area are at the front of the building. A further small garden area leads off the conservatory at the side of the house, and this is level, and has seating for residents, bird tables and other decorative features. Emyvale House is registered to provide care for 16 elderly people with accommodation on three floors comprising of 14 single and 1 double room, all with en-suite facilities. There are two bathrooms, one with a special bath to aid people with disabilities. A lift gives access to the first and second floor in addition to a centrally located staircase. There is a lounge that overlooks the conservatory and a ramped passage leading to the conservatory. The home provides information to service users and their relatives prior to admission into the home. Service Users Guides are available in all bedrooms or on request from the manager. The last published inspection report is available on request and a copy is available in entrance for visitors to read. Information gained on the 15th August 2007 indicated the current fees were £343. Additional charges include private chiropody £7 hairdressing from £5, and newspapers. Emyvale House DS0000040187.V314788.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key unannounced inspection took place over 4.5 hours, this included a partial inspection of the building. Two peoples care plans and supporting documentation were examined. Six people who use the service, two relatives and two staff were spoken to during the visit; their views are included throughout the report. Occupancy at the home remains high with all 16 beds occupied. Twelve CSCI service users questionnaires were sent to the home and returned. Three health and social care professional surveys were returned. The information has been collated and their views are contained within this report. Two peoples care plans were examined and policies relating to medication, complaints, protection of vulnerable adults and handling of people’s monies were looked at. Three staff recruitment and training records were examined to ensure people who use the service are protected. The registered manager was present throughout this visit and assisted with the inspection process. The registered manager had completed and returned the pre-inspection questionnaire and the information gained is included in this report. What the service does well: The home had a stable staff group who had worked at the home for a number of years. They were motivated, enthusiastic and well trained, and people who use the service spoke highly of the staff. A manager, who encourages staff to be involved in promoting an excellent service, leads the team. Excellent assessments ensure people who live at the home were receiving appropriate care, from staff who were well trained and motivated. Relative’s praised the home and said the care was excellent. The home provides excellent activities, which keep people who use the service stimulated and involved. People say they enjoyed the outings and the entertainment provided at the home. Relatives said “there is always a ‘buzz’ in the home when they visit, with lots of laughter between residents and staff”. Relatives praised the manager and staff who provide a homely environment for people to spend their time. The environment provides an excellent standard of cleanliness and staff were commended for their efforts. A good refurbishment plan ensures the premises Emyvale House DS0000040187.V314788.R01.S.doc Version 5.2 Page 6 were well maintained, for the safety of people who live in the home. Refurbishment of the conservatory will enhance the environment and give extra communal space, for people who use the service. People said they liked to sit in the conservatory, which overlooks the garden. 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. Emyvale House DS0000040187.V314788.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 Emyvale House DS0000040187.V314788.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): 3. People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service were assessed before moving into the home to ensure their needs can be met. EVIDENCE: All new people receive a full comprehensive needs assessment before admission this was carried out by manager or responsible person who had the required skills and competencies. The service was highly efficient in obtaining a summary of any assessment undertaken by the placing authority, and insists on receiving a copy of the care plan before admission. Two assessments were examined and they focused on achieving positive outcomes for people who use the service. Before agreeing admission the manager and staff carefully considers the needs assessment for each individual prospective person and the capacity of the home to meet their needs. Emyvale House DS0000040187.V314788.R01.S.doc Version 5.2 Page 9 Prospective people who use services were given the opportunity to spend time in the home, before making final decisions about where to live. One person said family had visited several homes before recommending Emyvale as the best home to meet the needs of their relative. One relative said her mother described Emyvale as the nearest thing to her own home, which was important to help her settle. All CSCI surveys received confirmed that people who use the service were provided with clear information about the service before moving into the home. Emyvale House DS0000040187.V314788.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans provide staff with sufficient information to meet the needs of people who use the service. Medication policies and procedures were well managed ensuring the safe administration of medication. EVIDENCE: Two care plans were examined; these were well written and provided sufficient information to enable staff to meet the needs of the people who use the service. The care plans include regular evaluations, and daily records assess the individual’s progress. Comprehensive risk assessments ensure people can maintain their independence, while remaining safe. All CSCI surveys received confirmed that people’s needs were always met by staff that was well trained. Surveys say that staff always listen to people who use the service, and people said staff were excellent, well trained and always provided a good service. Relatives said staff always kept them informed about any changes to their relatives care needs. “staff are very kind and always make me feel welcome”. Emyvale House DS0000040187.V314788.R01.S.doc Version 5.2 Page 11 Records examined and discussion with the staff confirmed people’s healthcare needs were met. An audit of medication stocks and records was examined and were found to be correct ensuring the health and safety of people who use the service. Senior carers had responsibility for administering medications and they had attended training to ensure medicines were administered safely. The local pharmacist is contracted to undertake periodic checks to ensure the stock levels are maintained and procedures are followed. Medication was stored securely, there were separate, locked rooms for storing medication that contain a locked fridge and a controlled drugs cabinet. Throughout this visit staff were seen interacting with people who use the service in a kind manner, they spent time talking to people and were observed knocking on bedroom doors before entering. All people were referred to by their first name and this was agreed in the care plans examined. CSCI service user surveys received confirmed that staff always treated people who use the service with respect and maintain their dignity at all times. Emyvale House DS0000040187.V314788.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Excellent social activities were organised which were appropriate to the needs of the people who use the service. Mealtimes were well managed and people were encouraged to make choices and control over their own lives. People who use the service could maintain contact with family and friends, and have good opportunities to maintain links with the local community. EVIDENCE: There was a warm and friendly atmosphere on entering the home and a sense of wellbeing throughout the home. Staff were commended for creating a pleasant ambiance in the lounges. People who live at the home said activities and outings were very good. One person said they liked sitting in the entrance, watching all the children go to school, while others said games of bingo were their favourite pass-time. Activities were arranged to meet the needs of the people who live at the home and staff frequently ask people what they want to do and where they want to go. Mobile library and newspapers were available and the more independent people could access local shops. CSCI surveys received confirmed that people who use the service were happy with the Emyvale House DS0000040187.V314788.R01.S.doc Version 5.2 Page 13 activities provided at the home. One relative said resident’s are encouraged to join in the numerous activities provided and there is always plenty of laughter and enjoyment at the events. The home employed a staff member who had responsibility to organise activities, she said the summer fayre was the main focus of everyone’s attention. Making crafts, extra large board games, sing-a-longs and memory games were also popular amongst most people. Visiting relatives said they were always made to feel welcome and staff were very caring. They also said that they were confident in staff’s ability to provide the care needed for their relative. Staff asks people what foods they liked and the meals were included in the menus. The meals were served directly to the dining room via a serving hatch. Mealtimes were well managed by staff who have a good understanding of peoples dietary needs. Staff were seen giving assistance in an unobtrusive way, and meals served to people in their bedrooms were accompanied with a drink. People said they had enjoyed their meal of meat pie with fresh vegetables and mashed potatoes, followed by milk pudding. The quality was very good and plentiful. People said the food was excellent, one person said they had put on weight in the short time they had lived at the home, because they enjoyed the food so much. Emyvale House DS0000040187.V314788.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service could access the complaints procedures and the manager ensures any concerns were recorded and investigated appropriately. Adult protection policies, procedures and training of staff promote the protection of service users from abuse. EVIDENCE: There was a complaints procedure that was available to people who use the service and visitors. The procedure was also referred to in the service users guide, identifying the stages to follow; this included the time scales to respond to complaints. The address and telephone number of the Commission for Social Care Inspection is included in the procedure. Examination of the complaints records showed that there were no complaints recorded since the last visit to the home. People who use the service said that they are confident that the manager or the responsible person would deal with any concerns they may have. Commission for Social Care Inspection surveys received confirmed that people who use the service know what to do if they had any concerns, and relatives said although they had never had to make a complaint they were confident that the manager would deal with any complaints. Emyvale House DS0000040187.V314788.R01.S.doc Version 5.2 Page 15 There was a comprehensive Adult Abuse and Whistleblowing policy and staff follow the procedures to those standards. The registered manager would investigate fully any allegations of abuse and would follow the necessary procedures if any were substantiated. The registered manager holds discussions with staff to talk over issues and how to recognise different forms of abuse. Emyvale House DS0000040187.V314788.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service were provided with a clean, comfortable environment, although some refurbishment was planned to improve furnishings and carpets. There were sufficient staff to maintain good hygiene standards. EVIDENCE: The registered providers continues to make improvement to the decoration and a number of bedrooms have been fitted with new carpets, the registered manager said the rolling programme is to continue and a number of other carpets have been identified to be replaced. A partial tour of the building found bedrooms to be homely and personalised to individual taste; people said they liked their bedroom and have things around them to remind them of family and friends. One person said they loved their bedroom with all of their belongings around them “it really felt like home”. Emyvale House DS0000040187.V314788.R01.S.doc Version 5.2 Page 17 The registered manager said a government grant had recently been awarded and the grant was to be used to improve communal areas throughout the home. The registered providers had also arranged for some refurbishment to the conservatory. People said they were looking forward to a new roof being fitted in the conservatory to improve the room, as people liked to spend time looking out into the garden. Moving and handling equipment has been obtained since the last inspection, which ensures the safe transfers of some people who use the service. Emyvale House DS0000040187.V314788.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff have the skills and knowledge to fulfil their roles within the home, a stable staff group ensures continuity of care by staff that knows the people who use the service. Recruitment policies are followed ensuring the safety and protection of people who live at the home. EVIDENCE: Training records examined show the staff have the required skills and competencies to deliver a good service. Discussion with the manager and staff confirmed that there was a stable staff group who had worked at the home for a good number of years. Staff said they enjoy working at the home, and feel supported. There was a robust induction and probationary package, which is service specific. The manager only confirms permanent employment when satisfied that competence and progress has been shown to be satisfactory against their high standards. Staff rotas and observation during this visit showed there were sufficient staff to meet the needs of people who live in the home. People said there was always enough staff. Emyvale House DS0000040187.V314788.R01.S.doc Version 5.2 Page 19 Staff had the required skills to meet the needs of people, and they are commended for meeting the requirement of 50 NVQ level two qualified staff. A number of staff are progressing with or completed NVQ level three There were robust recruitment and selection procedures that ensure people who use the service are safe and protected. A number of staff recruitment files were examined, and there was evidence that all the required employment checks have been undertaken prior to commencing work at the home. Evidence confirmed all staff had a CRB check. The manager should check the date on all existing CRB’s as good practise suggests that a new CRB check should be carried out every three years, to ensure the information is up to date. Emyvale House DS0000040187.V314788.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service were protected by sound management practises, and their views were actively sought to improve the service. The financial interests of people were safeguarded, and good health and safety procedures ensured they are protected. EVIDENCE: The registered manager has a wealth of experience and knowledge and was able to demonstrate her ability to manage the home. She had achieved the required management and care qualifications. She operated an open door policy to ensure she was accessible to staff and people who use the service. People spoke highly of the manager and said she was very caring. Staff rotas Emyvale House DS0000040187.V314788.R01.S.doc Version 5.2 Page 21 examined show that the manager is sometimes called upon to cover in the absence of the cook, and on occasion’s works as a carer. Staff and group meetings ensured that staff were informed about training opportunities and the day to day running of the home, they were also encouraged to be involved in decision making. Residents meetings were used to ensure they play an active part in making decisions about how the home is run. The manager consults with people on an individual basis to gain their views. Formal quality assurance systems also ensure that relative’s views were actively sought. The last quality assurance surveys were sent to relatives and people who use the service in May 2007. Relatives said, “if I had to go into a home it would be this one”. “Quality of care is excellent, staff are always there when needed”. Residents said, “there room was always clean and tidy”, staff are friendly, “I like to join in the activities”. To improve the quality assurance system the manager should collate the surveys received and produce an action plan, which addresses shortfalls in services delivered. People who use the service are able to manage their own finances, although most prefer the manager to assist with dealing with their personal allowances. A number of peoples personal allowance records were examined and checked, the records were accurate and there were clear auditing procedures. Accident reports were analysed by the manager to ensure risk assessments were developed where required. Maintenance and service records examined were up to date and current to the services provided. The manager had the required Health and Safety policies and procedures and displays the relevant notices. Fire safety procedures were in place and service records were examined and were current, ensuring the safety of people who live at the home. Emyvale House DS0000040187.V314788.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 4 X X X 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 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 4 3 X X X X X X 4 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 3 Emyvale House DS0000040187.V314788.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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. Refer to Standard Good Practice Recommendations Emyvale House DS0000040187.V314788.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Emyvale House DS0000040187.V314788.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!