Inspection on 13/06/06 for Enbridge House Care Home

This inspection was carried out on 13th June 2006.

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

Enbridge House Care Home 07/06/07

Enbridge House Care Home 04/01/06

Enbridge House Care Home 01/11/05

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 Ms Sue Kinch Unannounced Inspection 13th June 2006 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.V290765.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. Enbridge House Care Home DS0000012200.V290765.R01.S.doc Version 5.2 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.V290765.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Two named residents in the categories of MD (E) and DE (E) may be accommodated. 4th January 2006 Date of last inspection 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. Fees range from £318-£540. Information is available for residents and prospective service users in the front hall of the home. Enbridge House Care Home DS0000012200.V290765.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and included visits on the 13th and 14th June 2006. The inspection lasted 10.5 hours and was completed by one inspector. Four residents were spoken with at length and others more generally. Conversations took place with three care staff, the cook, the owner/manager Mrs Plumb and the other owner Miss Bolt-Lawrence. Other aspects of the inspection included a tour of the home and an examination of documents and records. Four comment cards from relative, many feedback forms completed by a member of staff with residents and a pre inspection questionnaire completed by the manager and submitted prior to the inspection were also assessed. This was a key inspection and all key standards were assessed. Some progress had been made in relation to requirements made after the last inspection but some are repeated due to insufficient or no progress. What the service does well: What has improved since the last inspection? What they could do better: Amend the statement of purpose to reflect the new categories of care as required in the last report. Enbridge House Care Home DS0000012200.V290765.R01.S.doc Version 5.2 Page 6 Ensure that residents are aware of the service user guide and contracts and ensure that a system for adequate assessment of private residents is in place. There has been some progress in assessment and care planning procedures although further work is still needed to: fully develop these to include adequate staff guidance; to demonstrate that residents are consulted and included in reviews which reflect the outcomes of the service for residents. More work is still needed improve levels of mental stimulation and a person centred approach is advised. Records of food provided at the home should be maintained regularly and more so that resident’s diet can be assessed. The current system of recording has lapsed and therefore for one person with dietary problems monitoring is insufficient. More work is needed to improve the condition of the home which although is comfortable and nicely decorated in many areas, others are showing signs of wear and tear and need attention. More prompt attention is also needed for some areas of maintenance. Staff training records are incomplete. The current system makes monitoring training difficult. Training is still needed for staff in the area of mental health to enhance the understanding of the specific needs that they are working with More than four staff need to have completed first aid training and infection control and the frequency of fire training needs to be increased. Staff recruitment has not taken place since the last inspection and so progress will be monitored at a future inspection. The manager needs to organise her own regular training and keep evidence to demonstrate that updating is ongoing. The job description of the owner who works at times as acting manager and a carer still needs to be made available for inspection with a training record. An effective quality assurance system is still needed in the home demonstrating that the home has been audited, residents and other consulted and a development plan available. Further work is needed in the home to ensure that health and safety is given adequate attention. An immediate requirement notice was left at the end of the inspection followed by a letter in relation to fire matters. The manager was required to: take action to ensure that all checks are immediately completed as advised by the fire officer; to make arrangements to ensure that all care staff are trained twice a year by a competent person; through consultation with the fire officer make adequate arrangements for evacuation in the event of fire for all persons in the care home; to ensure that the fire protection system is Enbridge House Care Home DS0000012200.V290765.R01.S.doc Version 5.2 Page 7 fully operational; to consult the fire officer regarding mechanisms to hold fire doors open and take action as advised. Some areas of risk such as use of balconies and the fire escape need to be assessed to ensure that all action needed to monitor the risks are identified, with appropriate action taken. 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.V290765.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Enbridge House Care Home DS0000012200.V290765.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Work has taken place to improve the system of assessing residents needs before admissions to the home but in instances where the home relies on it’s own assessment more information is needed to demonstrate that the home can meet specific needs. EVIDENCE: In the last inspection report a requirement was made of the manager apply to CSCI to vary the conditions of registration for those residents whose needs were not included in the homes category of registration. This has been completed and the variation relates to two residents. This has yet to be added to the Statement of Purpose and was advised to be completed. Admissions to the home since the last inspection have been appropriate. Records made or obtained before admission were viewed during the inspection. The records for one person included care management assessment identifying the main reason for admission and a hospital report. The homes own record Enbridge House Care Home DS0000012200.V290765.R01.S.doc Version 5.2 Page 10 prior to admission is brief but as the other information was available in this instance there was enough information. For the second person there was a brief home record only. Other records are started on admission. Attention will be needed to ensure that the homes pre admission assessment tool is adequate to demonstrate that all needs are identified before admission. Residents spoken with were unsure about whether there was written contract or service use guide .Two thought that their relatives might know. In two files sampled there was evidence of contracts having been issued. Although there is a folder in the hall containing the service user guide, more steps could be taken to improve residents’ awareness of information in the home. Residents spoken to mostly felt that their needs were met. Enbridge House Care Home DS0000012200.V290765.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. While residents described their care needs as being met by the care staff, assessments and care plans although improving do still not show enough detail of residents health and care needs and how they will be met or show enough evidence that residents have been involved in reviewing their care. Residents benefit from a service in which dignity and privacy is promoted. Medication practices in the home are managed well. EVIDENCE: Care plans were raised at the last inspection to ensure that details of particular needs were documented. At this inspection the manager said that a new system of assessment and care planning was being developed and all of the files viewed contained the new format. Some examples of the way the care plans were being developed were viewed and these included clearer and more detailed guidance. From observation of care provided, discussion with residents and staff it was clear that more information needed to be recorded and this was discussed with the manager. Some needs had been partially Enbridge House Care Home DS0000012200.V290765.R01.S.doc Version 5.2 Page 12 identified but the support required was unclear. This included areas such as social stimulation, verbal aggression, personal care, and support at night. One resident was often up at night and reluctant to get up in the daytime, how staff should provide support was not documented. There was evidence of care plans being reviewed and staff said that they could be changed at any time if needed. However the review process does not show how the resident’s views have been sought or any details of outcomes of the service to them. None of the four residents case tracked were aware of care plans although one had been signed. The requirement has been repeated. Some moving and handling risk assessments were in place, another was for smoking but some areas of risk were not assessed and minimised or monitored. This was discussed with the manager and related to the balcony and fire escape on the first floor, which the manager said were not in use. All were found to be accessible, one had a key in the door, another was open and a member of staff said that relatives opened the door to the fire exit and the key was hanging beside it. One balcony door was open and the other two doors were accessible with available keys. Health care needs are identified in care-plans and residents mostly felt that their care needs were met. Staff saw that their role included monitoring health needs and are able to contact the doctor if necessary. Health recording does take place although it would be easier to monitor if the health records were separated out from other daily records. In respect of one resident case tracked staff were aware of the dietary needs and were supporting the person but records were insufficient to demonstrate that effective monitoring was taking place. Aspects of medication were assessed. Residents case tracked said that they had their medication regularly provided by staff and were happy with it being held by the staff. The medication was seen to be stored securely in the homethis included controlled medication. It was well organised into individual sections for residents. Two staff spoken to confirmed that key holders only administered the medication and had been trained in medication practices. Records of administration were accurately recorded and a member of staff described the process of administering to each resident in turn. Some checks of stocks were made and these mostly corresponded to the records. There was one minor exception to this and one ‘as required’ medication that needed clearer guidance for staff. Records were also in place for controlled drugs and correct procedures, where sampled, had been followed. Dignity, respect and privacy are promoted in the home and all residents agreed with this. Personal care is provided at the residents’ pace and staff are seen as kind and friendly. This was seen during the inspection and staff were aware of their roles in privacy and confidentiality. Enbridge House Care Home DS0000012200.V290765.R01.S.doc Version 5.2 Page 13 Enbridge House Care Home DS0000012200.V290765.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some resident’s lives could be more stimulating as a result of a person centred approach to their individual social and recreational needs through assessment and planning of activity based on individual preferences and interests. Residents mostly like the food provided in the home but a record of food provided to show that it is varied and balanced is needed. EVIDENCE: At the last inspection issues were raised about the level of social stimulation in the home for residents. At this inspection through observation of interactions, the viewing of care plans and verbal discussion with staff, residents and the manager, insufficient evidence of social and recreational needs being met was noted. Staff said that ‘they were there for the residents’ and that there was time in to sit and talk with them. Some residents have clear preferences on a day-to-day basis and pursue their own interests. The mobile library visits and some residents have daily papers. Some residents are more able to provide their own stimulation and choose to do puzzles, read and go in the garden. Some Enbridge House Care Home DS0000012200.V290765.R01.S.doc Version 5.2 Page 15 spoke of going out with relatives. However there was no clear plan of mental stimulation and little guidance in the care plans. The manager said that there was a lack of interest in activities and some activities tried had not been wanted. Two residents spoken to said that there was nothing to do, one person did not feel well enough to do anything and a fourth was more active and independent but said that there were no activities and people watch the TV all of the time. The manager said that a garden party was planned. There no written evidence of planned events or activities although the owners said that some were arranged. Recording was advised, as was the outcome of support given to residents in the area when their care needs are reviewed. Feedback from relatives and residents during the inspection and from comment cards indicated that contact with friends and a relative is encouraged. Visitors are welcomed to the home and refreshments are offered. Elements of choice are promoted in the home. Residents are able to choose when to get up and go to bed, where to be and where they want to eat and what to have for tea. Staff spoke of choice and residents needs coming first. Some aspects of choice could be explored further such as over bedroom keys. Residents are given the option of a key only at the beginning of their stay .It is recorded. It advised to review this regularly when care is reviewed individually with the residents to ensure that choice continues to be promoted. Feedback about the food was varied. Comments received were that it was mostly liked and enough in quantity, although there was no choice at lunchtime. Residents said that their likes and dislikes were known and alternatives could be provided. More choice was available over tea. Staff said that residents could have food other than at meal times and drinks were freely available .One person did not think there was a menu and one was not prominently placed for residents. Residents said that there was variety. Food provided at the time of the inspection was attractive and snacks were provided between meals for those who wanted it. A four-week menu was in the kitchen but the food records were poor and incomplete. None had been completed since January 2006 some since July 2005. Food intake was being insufficiently monitored for one person. Although staff recorded how much of a meal was eaten and whether a supplement was given with no food records there was an inadequate trail. Therefore it was not possible to record whether the diet was satisfactory specifically for that person or for anyone else. Enbridge House Care Home DS0000012200.V290765.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are confident that they will be listened to and their wishes acted upon. Residents benefit from staff awareness of potential abuse and willingness to respond to it but further work is needed to ensure that correct procedures would be followed at all times. EVIDENCE: Through conversation with residents, staff and from feedback with relatives, sufficient evidence was noted to confirm that residents feel able to talk to raise issues and ask for help in the home. There had been no recent complaints at the home. In the ten comment cards from residents nine said they always knew how to make a complaint and who to speak to if not happy. One said usually. All said that the staff listen. Three of the four relatives on the comment cards said that they knew the complaint procedure and none of them had needed to make a complaint. At the inspection the four residents case tracked had no complaints to raise and all felt that they could talk to staff, the manager a friend or care manager if they needed to. One person specifically said that they anticipated a positive response if a complaint was made. Staff are being trained in adult protection but still need to be clear about local procedures for responding to suspicions or allegations. Some certificates were available but the staff training record did not reflect the level of training Enbridge House Care Home DS0000012200.V290765.R01.S.doc Version 5.2 Page 17 provided and this is advised. The manager said that training had taken place on 10/4/06 on recognising abuse and all staff had attended. The manager had developed file of information regarding abuse and this contained a flow chart for responding and referring in instances of abuse. However the local policy was not available and although staff were: aware of the potential for abuse; aware of whistle blowing; and willing to report to the manager, but they were not aware of the locally agreed reporting policies. The manager is aware of these procedures and needs to ensure that all staff are fully aware so that they are clear of the limits of their roles. Enbridge House Care Home DS0000012200.V290765.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents experience a clean, hygienic and comfortable environment and pleasant garden but this would be enhanced by: redecorating some areas of the home; being more prompt with maintenance; and moving old furniture in the garden from sight. EVIDENCE: The home is situated in well-maintained and attractive gardens appreciated by residents. The home is pleasantly furnished and residents are able to bring their own furniture for their rooms. Some rooms have French windows leading to the garden. Two bedrooms have balconies and another has a fire escape taken out of action by the home on which the resident can put flowerpots. All have either ensuite facilities or bathrooms easy to access. Equipment is provided to ease movement in the home and residents said that it worked. The shaft lift and the call bell system were reported to work regularly. Assisted bath seats are used and a mobile hoist is available. Enbridge House Care Home DS0000012200.V290765.R01.S.doc Version 5.2 Page 19 The home is cleaned five days a week and was fresh during the inspection. Residents said that the home is always clean. At the inspection on 1st November 2005 comments were made about the need redecorate some areas of the home. At the last inspection progress was commented on, however there are still areas such as bedrooms and bathrooms that require attention and they detract from the otherwise well presented home. A system is available for staff to record maintenance issues and staff asked, said that attention was given to things that needed to be fixed but a few maintenance issues were brought to the manager’s attention at the inspection including the need to replace a light bulb, in an otherwise totally dark corridor outside resident’s rooms and to fix a magnetic door holder. Attention was also needed to a lock on a bedroom door, which could be locked from the inside without a system of access for staff in an emergency. The manager was unaware of this and was advised to address it. Nothing had been recorded in the maintenance book since April 06. Through observation of practice in the home and discussion with the staff and manager the inspector noted that there was sufficient evidence to demonstrate that infection control is addressed in the home and five out of twelve staff have been formally trained. Staff spoke of washing procedures and showed the facilities. They were aware of the equipment available in the home and confirmed that they used it. They also confirmed that there was clinical waste contract and that it was adequate to ensure that bins did not over flow. Enbridge House Care Home DS0000012200.V290765.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home employs sufficient staff to meet residents’ needs. The home does provide staff with some regular training but more evidence is needed to demonstrate that residents receive support from adequately trained staff. EVIDENCE: Residents spoke positively about staff throughout the inspection. Comments received included ‘wonderful’, ‘good to me’, ‘friendly’, ‘alright’, ‘can talk to them’ and ’respectful’. Acceptable staff levels found at the last inspection have been maintained. Evidence of this was obtained through discussion with staff and observation of the rota. Senior carers known as key holders lead the shifts, which include one other carer. Waking night staff provide care at night. Domestic staff complete catering and cleaning tasks. The owner and the manager complete care tasks when staff are on holiday or training. Through written and verbal information from the manager about NVQ levels obtained by staff it was concluded that more staff would benefit from NVQ training. The manager stated that 30 has been achieved and that there are plans for three staff to start courses in September 2006. Enbridge House Care Home DS0000012200.V290765.R01.S.doc Version 5.2 Page 21 Inspectors have raised issues about recruitment procedures at the last two inspections at which records have been incomplete. The manager reported that no staff had been recruited since the last inspection. Therefore it was not possible establish whether the process is now robust. Two files of staff previously recruited were sampled and it was noted that CRB checks and POVA checks had been completed after recruitment. The requirement will not be repeated on this occasion but this key standard will be reviewed at the next visit. Training levels were raised at the last inspection and a requirement was made for staff to be trained in dementia and mental disorder. Adult protection was also highlighted as needed in the report. At this inspection from conversations with staff and viewing some records there was evidence that some training had taken place on these topics on 10/4/06. The manager said that all staff had that day, completed training in recognising abuse and dementia. However mental disorder still needs to be covered. Staff records were: not up to date; did not include dates and duration of training; and the frequency was not possible to assess. Training issues are also raised in the next section regarding fire and first aid. Enbridge House Care Home DS0000012200.V290765.R01.S.doc Version 5.2 Page 22 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): 31,33,35,38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents would benefit from clarity in management roles fulfilled by managers updated in training. Additional measures need to be taken to gain feedback from residents and relatives, to audit the home and use findings establish a development plan. Residents should be safeguarded by a more rigorous approach to the management of health and safety in the home. EVIDENCE: The registered manager has the required qualifications and experience for running the home but there was no record of recent training. The manager needs to ensure that she is updated regularly through training and other Enbridge House Care Home DS0000012200.V290765.R01.S.doc Version 5.2 Page 23 methods. As found at the last inspection the other owner, who acts as manager in the absence of the registered manager, does not yet have a clear job description and training records need to be held to demonstrate competence for this role. Systems in the home need development to ensure that practices in the home are fully monitored and that quality is assured. Some feedback has been obtained from residents informally and using questionnaires but there is no clear system in place for monitoring the outcomes of the service provided or to audit the home against the regulations. Although the manager expressed some ideas on improvements planned for the home, as found at the last inspection, there is no annual development plan to outline plans for the home for residents, relatives and staff to see or evaluate progress against. The manager agreed that she needed to spend more time on management tasks. Areas covered in some other sections of the report have shown that clearer monitoring and measurable action plans are needed. From discussion with residents and the owner it is evidenced that the management of the home is not generally involved in residents’ money. However a cheque had been received in the week of the inspection for one resident and the owner was aware of the required procedures to follow. Safeguards taken to promote the health and safety of residents need more attention. Staff have training in this area including: general health and safety, moving and handling, fire and first aid and further training is planned for some of this. However there is insufficient evidence that all of these are carried out within the right frequency and that all staff receive the training. Only four staff have received first aid training and fire training is planned for once a year instead of twice. Whilst there is some evidence of checks and services of equipment taking place, gaps exist in some servicing records such as the in house fire checks, hoists and central heating. The system of monitoring this and ensuring that checks are completed within appropriate timescales are not yet robust. The matters relating to fire records were reported in a letter of serious concern to the manager after the inspection. This also included: the need to assess the risk and take action regarding two chairs on front of a fire escape and the use of wedges; and attention to the self-closing mechanism on the mezzanine fire door. Some attention has been given to risk assessments in the home and those covering control of water and radiator surface temperatures were viewed and discussed with the manager. A programme of covering radiators has been underway for some time and most have been covered but some were not covered on the first floor. These were risk assessed by the manager as needing to be covered but there was no clear action plan for this. The manager said Enbridge House Care Home DS0000012200.V290765.R01.S.doc Version 5.2 Page 24 that work was taking place to achieve this. The radiators did not pose an immediate risk to residents as they were switched off due to the weather. However, plans could be included in the development plan. Use of balconies and the fire escape were not included in the household risk assessment or individual risk assessments and are referred to in the health and personal care section above. Enbridge House Care Home DS0000012200.V290765.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 3 x x 1 Enbridge House Care Home DS0000012200.V290765.R01.S.doc Version 5.2 Page 26 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 OP7 OP8 Regulation 15 Requirement The registered manager must review the system of written assessment and care planning to ensure that: all residents needs are recorded in adequate detail and risks are assessed; that adequate guidance is contained in the plans to ensure that staff support residents consistently; to show that care plans are reviewed with the residents or relative where appropriate. This is an amended requirement repeated from the inspection of 4/1/06 The registered manager must be able to demonstrate that residents’ social, leisure, recreational and educational needs are being met. Each resident’s social, recreational, educational and leisure needs must be assessed and included in the care plan to show how those needs are being met. This is a repeated requirement from the inspection of 4/1/06 DS0000012200.V290765.R01.S.doc Timescale for action 13/09/06 2. OP12 12 16 (m)(n) 13/09/06 Enbridge House Care Home Version 5.2 Page 27 3. OP15 4 OP19 16(i) Regulation 17 Schedule 4 ,13 23(2)(b)( d) 5. OP30 OP18 18, 17 Schedule 4 6. OP31 9 The registered manager must ensure that records of food provided are adequate in detail to determine whether the diet is satisfactory. The registered manager must take action to ensure that a programme of redecoration and maintenance is planned and acted upon. This is an amended requirement from the inspection of 1/11/05 The registered manager must ensure that adequate arrangements are made for staff to receive suitable training in areas such as working with residents’ who have a mental disorder, first aid, adult protection procedures and fire matters and maintain an adequately detailed record of training. This is an amended requirement from the inspection of 4/1/06 The registered manager must provide a job description for the owner who works in the home, as an acting manager and care staff member and it must be available for inspection. This must give details of the responsibilities and management accountability in the home. This is an repeated requirement from the inspection of 4/1/06 The registered manager must identify her own training needs and records training completed to demonstrate that updates are taking place. The registered provider must ensure she attends training courses and a record of this DS0000012200.V290765.R01.S.doc 13/08/06 13/08/06 13/08/06 13/08/06 8. OP31 10 13/08/06 9 OP31 10 13/08/06 Enbridge House Care Home Version 5.2 Page 28 training must be maintained to demonstrate that she has the competencies to manage the home and to work in a care setting, especially in the absence of the registered manager. This is an amended but repeated requirement from the inspection of 4/1/06 10. OP33 24 The home must implement their 13/09/06 own quality assurance procedure to include the following: a survey of residents’, relatives and involved professionals; a system of audit and an annual development plan. This is an repeated requirement from the inspection of 4/1/06 14/06/06 The registered manager must: take action to ensure that all checks are immediately completed as advised by the fire officer; to make arrangements to ensure that all care staff are trained twice a year in fire matters by a competent person; through consultation with the fire officer make adequate arrangements for evacuation in the event of fire for all persons in the care home; to ensure that the fire protection system is fully operational; to consult the fire officer regarding mechanisms to hold fire doors open and take action as advised. 11 OP26 OP38 23(4),(a)(e) Enbridge House Care Home DS0000012200.V290765.R01.S.doc Version 5.2 Page 29 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 It is advised that a system is in place to record more information for privately funded residents prior to admission. Enbridge House Care Home DS0000012200.V290765.R01.S.doc Version 5.2 Page 30 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.V290765.R01.S.doc Version 5.2 Page 31 - 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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