Inspection on 01/11/05 for Enbridge House Care Home

This inspection was carried out on 1st 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 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

Enbridge House Care Home 07/06/07

Enbridge House Care Home 13/06/06

Enbridge House Care Home 04/01/06

Enbridge House Care Home 19/10/04

Enbridge House Care Home 17/06/04

Enbridge House Care Home 19/01/04

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 Enbridge House Care Home Church Road Woolton Hill Nr Newbury Hampshire RG20 9XQ Lead Inspector Drew Gurney Unannounced Inspection 1st November 2005 10:00 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 Enbridge House Care Home DS0000012200.V261937.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. Enbridge House Care Home DS0000012200.V261937.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Enbridge House Care Home Address Church Road Woolton Hill Nr Newbury Hampshire RG20 9XQ 01635 254888 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) kblwork@tesco.net Mrs Mandy Ann Plumb Miss Karen Bolt-Lawrence Mrs Mandy Ann Plumb Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Enbridge House Care Home DS0000012200.V261937.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th September 2005 Brief Description of the Service: Enbridge House is registered to provide a service for 17 older persons. The home is situated in Woolton Hill village, near to Newbury and is a large property. Set in well-maintained grounds the home reflects the era of building, offering comfortable, tasteful surroundings to service users. Accommodation is offered over three floors and access is available via a central staircase or via a passenger lift. The accommodation consists of two shared double rooms and thirteen single rooms. One of the single rooms is offered for respite accommodation, the home having built up a regular clientele who visit the home for holiday periods. There is ample car parking space available to the front of the property. Enbridge House Care Home DS0000012200.V261937.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place during a period of five hours. The inspector was able to talk with the majority of service users either during a tour of the building, or when several were relaxing in the lounge. All service users looked well cared for, and spoke well of the care that they receive at the home. The inspector also spoke with several members of the care staff from both the morning and afternoon shift. Records were viewed for both service users and staff. The inspection was undertaken with the registered manager, Mrs. Mandy Plumb. Five requirements were placed on the establishment as a result of the inspection. What the service does well: What has improved since the last inspection? All service users have been provided with an updated contract of terms and conditions. The internal building work has been completed and now provides additional accommodation for two persons. New carpeting has been provided for one bedroom and the room has also been re-decorated. Compliance with Water Regulations has been adhered to since the previous inspection. Training issues have been addressed. Enbridge House Care Home DS0000012200.V261937.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. Enbridge House Care Home DS0000012200.V261937.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 Enbridge House Care Home DS0000012200.V261937.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): 2, 3, and 6 All service users are now in receipt of an updated contract of terms and conditions in response to the previous inspection. Pre-assessment procedures for admission to the home are adequate and are maintained within service user files. EVIDENCE: During the previous inspection, it was noted that not all service users had received the same contractual agreement of terms and conditions and files looked at had contained old style contracts. The inspector observed on files viewed, that in response, the home has now provided all service users with updated contracts and these include all aspects suggested within the standards. The new contracts had been signed and dated by both service user or representative and the home. Files were viewed for two service users admitted to the home since the previous inspection. The content provided sufficient information to enable decisions to be reached about the suitability of the home for the person involved. Following admission, the information is transferred to a cardex system, this being completed with the further assistance of service users and the family. The cardex system is referred to three times daily by staff, when Enbridge House Care Home DS0000012200.V261937.R01.S.doc Version 5.0 Page 9 staff on duty record information about individual service users prior to shift changes. A handover period of ten minutes is allocated between shifts for exchange of information. No intermediate care is offered by the home. One single room, unless permanently allocated, is offered as holiday or respite accommodation for service users. Enbridge House Care Home DS0000012200.V261937.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 and 9 All service user files contained updated care plans that are regularly reviewed on a monthly basis. Care plans would benefit from evidence of service user involvement. Medication procedures are appropriate and correct procedures followed. EVIDENCE: Files were viewed for two service users admitted since the previous inspection. These contained appropriate care plans that had been generated from the preadmission assessment and provided the basis for the care to be delivered. Signatures and dates indicated that these care plans are regularly reviewed on a monthly basis as required. Care plans had not been signed by either a service user or a representative, according to the abilities of individual service users. Care plans must be signed initially and again, whenever a change in care is agreed. Risk assessments were not written in sufficient detail to outline clearly what the actual risk was for service user or staff, did not describe the possible eventuality and did not clearly identify, specific measures to overcome risk factors. A separate moving and handling risk assessment was also not Enbridge House Care Home DS0000012200.V261937.R01.S.doc Version 5.0 Page 11 available on records. A risk assessment coding system is being introduced; this system is not however supported by clear information for care staff to follow. Discussion took place about risk assessment recording and it is felt that the registered person responsible for recording risk assessments should undertake a training course to improve risk assessment recording practices. Risk assessments must be very specific with clear instructions indicating procedures to follow to protect the safety of both service user and staff. A very responsible approach to medication practices is observed by the home. Six members of staff have undertaken a safe handling administration course on a distance-learning basis from Newbury College. Recorded specimen signatures were available on file. A senior member of staff on duty who has undertaken medication training, holds the keys to medication cupboards. Medication is maintained under satisfactory circumstances in a locked, dedicated room. Records were viewed and had been recorded well. The G.P. who attends all service users at Enbridge House, undertakes a monthly check of all medication records and signs and dates each individual record as being correct. A medication check was undertaken for two service users by the inspector and records and contents proved accurate. Enbridge House Care Home DS0000012200.V261937.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): 15 A nourishing diet is provided to service users. The lunch meal provided looked appetising and well presented. EVIDENCE: Planned menus for a four-week period were viewed and found to offer a nourishing dietary balance for service users. Menus are adapted to suit specific needs. Kitchen staff has a list of service user likes and dislikes and will offer an alternative if required. Access to the kitchen is not restricted so snacks are available at all times. Several service users were observed to choose to have their meals served in the dining room, the lounge area or in their bedrooms. During conversation, service users confirmed to the inspector that they were asked where they wished to have their meals. All said that they found the food was excellent and were happy with the range of meals provided. The lunch provided was excellent in presentation and content and enjoyed by those service users observed by the inspector. Enbridge House Care Home DS0000012200.V261937.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 A satisfactory complaint procedure has been developed by the home and staff are provided with whistle blowing procedures. Service user safety is observed including staff training, and POVA and adult protection procedures being available. All staff must have access to a copy of the home’s adult protection procedure that has been developed in a user-friendlier format. EVIDENCE: The home has developed an appropriate complaint procedure and this has been made available to all service users, staff and visitors. Staff have been provided with information regarding whistle blowing procedures and during conversation with several members of staff, this was confirmed and it was also established that staff were aware of the role of CSCI and the address from where CSCI operate. Adult protection procedures are discussed one a one to one basis with new members of staff as part of induction training and when available, study days on this topic are accessed. Hampshire Social Service adult protection information is available. The home has developed adult protection information in a shortened, user-friendlier version for staff but has yet to provide this to everyone. The home does not hold personal finances for service users. All service users are either supported by family with regard to financial arrangements or are able to conduct their own affairs. Power of Attorney is held by a number of service users’ relatives. Enbridge House Care Home DS0000012200.V261937.R01.S.doc Version 5.0 Page 14 Enbridge House Care Home DS0000012200.V261937.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, 21, 22, 24, 25 and 26 Adequate measures appear to have been taken to provide a safe environment for service users, by staff observing health and safety and the inclusion of specialist equipment. Carpeting throughout the establishment is of reasonable quality and rooms decorated to a tasteful standard. Paintwork throughout the building is looking chipped and worn and a programme must commence to renew paintwork. Bedrooms are personalised and reflect individual tastes. The home was clean and no offensive odours were detected throughout the visit. EVIDENCE: Various measures have been taken to provide a safe environment for service users and care staff and include the provision of two hoists, two assisted bath seats in two of the three communal bathrooms , five wheelchairs, and four electrical raising beds. Several service users were observed to be using various walking aids. All rooms have smoke alarms, window restrictors and Enbridge House Care Home DS0000012200.V261937.R01.S.doc Version 5.0 Page 16 radiators have been covered for safety purposes. Appropriate safety notices were displayed in kitchen areas. The home also has a clinical waste disposal contract. All but four bedrooms have been fitted with showers and all but four service users have are en-suite facilities. All bedrooms have been fitted with washhand basins; those service users without a personal toilet, share an easily accessible toilet adjacent to bedrooms. Additionally, there is a staff toilet and a separate toilet situated on the ground floor. There is a bathroom on each floor of the establishment. All bedrooms were viewed by the inspector and proved to be large, light, airy and comfortable. Some rooms have french windows leading to the garden or an upstairs balcony and all have a pleasant view to the mature garden areas surrounding the property. Service users are able to bring an agreed amount of personal furniture when admitted to the home and all rooms reflect their owners’ interests and tastes. During conversations with many service users, all stated that they were happy in their surroundings and found staff to be helpful and to respond in good time if they called for assistance. The home throughout, presented a pleasant and hygienic appearance. All staff undertake a structured distance-learning course in infection control. Access to the laundry is gained outside the building. In response to a previous requirement, an impermeable covering has been provided in the laundry room. The home has also responded to the previous inspection and now complies with Water Supply Regulations. Enbridge House Care Home DS0000012200.V261937.R01.S.doc Version 5.0 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 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, 29 and 30 Staffing levels were found to be adequate on the date of inspection. Staffing levels were found to be adequate on the date of inspection. EVIDENCE: Staff complement includes the registered manager, six care staff shift leaders, three care staff and two cooks who work 25 hours and 10 hours respectively. Night duties are undertaken by one wake and one sleep member of staff. Shift patterns are from 8 a.m. until 3 p.m. (three staff on duty), 3 p.m. until 9 p.m. (2 staff on duty) and 9 p.m. until 8 p.m. (2 staff on duty). The home does not pursue robust recruitment procedures. A requirement was placed at the previous inspection that CRB procedures had to be pursued for all members of staff. The home has complied with this requirement and all files were observed to contain CRB information, apart from one. The home was also advised that no new employee was to commence work without all current schedule 2 details being held and a CRB check being carried out and a response received by the home. Since the last inspection, correct procedures have not been pursued. The registered persons were reminded that current procedures include having processed and received two references and a clear POVA 1st check being obtained before a care worker is able to work under the supervision of an experienced member of staff until satisfactory full CRB verification is received. During the course of the inspection, POVA 1st procedures were put into practice, the home is required to obtain two written Enbridge House Care Home DS0000012200.V261937.R01.S.doc Version 5.0 Page 18 references and to follow other responsible procedures until the situation has been remedied. In response to the previous inspection, the home has developed induction procedures that include moving and handling training, fire safety, infection control, food hygiene, and health and safety. Certificates were viewed for all staff holding qualifications. Two members of staff remain to receive first aid training and this must actioned. Five members of the team hold an NVQ qualification including levels 2,3 and 4. Other training undertaken by staff includes continence management and Care of the Dying. Enbridge House Care Home DS0000012200.V261937.R01.S.doc Version 5.0 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 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): 36, 37 and 38 All staff receive one to one supervision sessions and annual appraisal. Servicing documentation, accident recording and health and safety measures are recorded regularly and were available for viewing. EVIDENCE: Recorded staff supervision sessions were viewed by the inspector and during conversations, care staff confirmed that they regularly meet with the registered manager and discuss aspects of practice and career development needs. Information was also available on file, showing that the registered manager also undertakes annual appraisal for all staff. During the course of the inspection, up to date servicing information was viewed for the maintenance of the home’s various equipment; the fire safety Enbridge House Care Home DS0000012200.V261937.R01.S.doc Version 5.0 Page 20 training records were viewed; the accident book was viewed and records were viewed of indicating that measures had been followed for recording temperatures of refrigerators, freezers and meal preparation. The certificate of registration was available in the hallway. The home is also aware of its responsibilities to submit Regulation 37 information to CSCI. Enbridge House Care Home DS0000012200.V261937.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x 3 3 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 1 X 3 3 x 3 3 3 STAFFING Standard No Score 27 3 28 x 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x x 3 x 3 Enbridge House Care Home DS0000012200.V261937.R01.S.doc Version 5.0 Page 22 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 OP77 Regulation 13{4}{c} Requirement Risk assessments must clearly identify the level of risk for the health and safety of both service user and staff; risk assessment training should be undertaken by the member of staff responsible for risk assessment Timescale for action 01/02/05 2 OP1818 13{6} 3 4 OP1919 OP2929 23{2}{d} 19{4} Schedule 2 {1}{5} {8} Staff must be provided with 01/12/05 access to written information describing adult protection measures. All areas in need of re-decoration 01/12/05 are made good. Recruitment practices must be 01/12/05 followed; confirmation of 2 references and CRB information for a recent appointment are to be forwarded to CSCI. All files must contain a photograph of the staff member First aid training must be provided for two members of staff 5 OP3030 18{c}{i} 01/02/05 Enbridge House Care Home DS0000012200.V261937.R01.S.doc Version 5.0 Page 23 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 Enbridge House Care Home DS0000012200.V261937.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Enbridge House Care Home DS0000012200.V261937.R01.S.doc Version 5.0 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!