Inspection on 04/01/06 for Enbridge House Care Home

This inspection was carried out on 4th January 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 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 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 Mr Ian Craig Unannounced Inspection 4th January 2006 11:25a 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.V272632.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.V272632.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.V272632.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st November 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.V272632.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. One of the proprietors assisted the inspector. Four residents were interviewed and the inspection lasted 4 hours. Records and documents were examined. This report should be read in conjunction with the previous inspection report. Progress on completing the requirements in the last report was checked. Many of the timescales for completing these had not been reached at the time of this inspection. These will be checked at the next inspection. What the service does well: What has improved since the last inspection? What they could do better: The home needs to ensure that for those referred to the home for possible admission that a full assessment of the person’s needs is carried out and Enbridge House Care Home DS0000012200.V272632.R01.S.doc Version 5.0 Page 6 recorded. Persons should only be admitted to the home for those categories of need that it is registered for. The system of assessment and care planning needs to be reviewed and improved. The provision of activities and stimulation for the residents needs to be developed. Whilst records relating to staff recruitment were satisfactory for the majority of staff, there were no records available at all for 2 staff. The home’s policies for quality assurance need to be implemented. 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.V272632.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.V272632.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Residents had been admitted to the home with needs that are not within the home’s conditions of registration and without an assessment of need being carried out and recorded. EVIDENCE: A self-funding resident had been admitted to the home without an assessment of need being carried out and recorded. The proprietor stated that this person’s needs had been assessed and notes taken during this process, but that these had not been transferred to the person’s case records. It was not possible for the inspector to check what the person’s needs were at the time of admission. At the time of the inspection the person’s needs were outside the home’s categories as detailed on the conditions of registration. For another resident, the home had a copy of the social services care management assessment. This indicated that the home had admitted this person with needs not included in the home’s categories of persons it can accommodate. The inspector discussed the process of assessing potential residents needs prior to admission and this also indicated that in future, only those persons for whom the home is Enbridge House Care Home DS0000012200.V272632.R01.S.doc Version 5.0 Page 9 registered to accommodate are admitted. The home must also apply for a variation to the client categories as part of its registration with the Commission for those residents whose needs are outside the conditions of registration. Additional training must be provided for the home’s staff and management in mental health and dementia. Enbridge House Care Home DS0000012200.V272632.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 Whilst residents described their care needs as being met by the care staff, assessments and care plans did not show in sufficient detail many aspects of the resident’s needs and how care should be delivered. EVIDENCE: Assessments and care plans were examined for several residents. These showed that the care plans were reviewed on a regular basis. Details in the care plans were not in sufficient detail for the reader to tell the extent of staff assistance required, and, in regard to residents with dementia or mental disorder the care plans failed to show diagnoses, symptoms and how staff deal with these specialist needs. One care plan did not have a date or signature of the person completing it. For personal care, “needs help” was the only instruction recorded for staff to follow. Social and recreational needs were not assessed in any depth, with “reads newspaper and watches TV” recorded for two residents. Several residents were interviewed who reported that the care staff provide a good level of personal assistance. Medication administration records were examined and showed the system of administration of residents’ medication to be satisfactory. Enbridge House Care Home DS0000012200.V272632.R01.S.doc Version 5.0 Page 11 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 and 14 Individual resident’s social and recreational needs have not been fully assessed and there is insufficient stimulation and activities for the residents. The home maintains links with the local community for the benefit of the residents, and visitors are welcome at any reasonable time. Choice is promoted for the residents. EVIDENCE: The inspector discussed with the proprietor the provision of activities and stimulation for the residents. Several residents were described as enjoying impromptu activities such as cards, dominoes and jigsaws. A record of these activities had not been made. The home has three parties a year for the residents, and at Christmas a visiting choir entertains the residents. The proprietor described how residents are able to access local community activities but have not shown an interest in this. The lack of provision of further activities was said to be because of a lack of interest from the residents. Each of the residents interviewed appeared satisfied with level of activities provided although one resident was unaware that he/she should be entitled to the provision of any activities. Residents were observed sat in the lounge, and several had their own newspaper. The inspector acknowledged that residents may lack motivation to involve themselves in activities, but also highlighted that individual resident’s social and recreational needs should be assessed and a care plan devised for this. In addition, it was highlighted that the home has a duty to arrange regular activities and/or entertainment. Enbridge House Care Home DS0000012200.V272632.R01.S.doc Version 5.0 Page 12 Records should be made of group activities as well as individual daily social and leisure events. Visitors are welcome at any reasonable time and there is a visitors’ book near the front entrance. Residents are able to spend their free time as they wish. Each resident is able to have a key to his or her bedroom. A record is made of this being offered to each person. The home has knowledge of the individual likes and dislikes for food for each person. At the midday meal an alternative is available to the set menu for those that do not like the meal. At the early evening meal there is a more direct choice from a selection of meals; each resident is asked in advance what they would like to eat and the staff record this. Enbridge House Care Home DS0000012200.V272632.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): None of the standards in this section were assessed at this inspection. EVIDENCE: Enbridge House Care Home DS0000012200.V272632.R01.S.doc Version 5.0 Page 14 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): None of the standards in this section were assessed at this inspection. EVIDENCE: Enbridge House Care Home DS0000012200.V272632.R01.S.doc Version 5.0 Page 15 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 The home deploys sufficient staff to meet the residents’ needs. The home was not able to demonstrate that each staff member has undergone the required checks; this was also a requirement in the previous inspection report. EVIDENCE: Residents described the staff as ‘friendly’, ‘helpful’ and ‘kind.’ Of those residents interviewed, staff were said to be provided in sufficient numbers. The staff rotas confirmed that at least two care staff are on duty at any given time and that additional staff are deployed for the purposes of catering and cleaning. Recruitment procedures were examined for 6 staff, and were found to be satisfactory for 4. There were no records available at all for two staff members. The home was therefore unable to demonstrate that checks had been carried out on these staff as required by the regulations. The proprietor stated that she had left the staff records at home. Training for staff was briefly inspected. There are training plans for staff and these need to be expanded to include the following areas: adult protection and working with residents who have dementia and a mental disorder. Enbridge House Care Home DS0000012200.V272632.R01.S.doc Version 5.0 Page 16 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 and 35 Whilst the manager is registered with the Commission there are several areas indicating that management procedures in the home need to be improved. The management and role of one of the proprietors working in the home needs to be clarified. Additional measures need to be taken gain feedback from residents and relatives, to use this as a basis to plan the home, and to audit and plan for the home’s future. EVIDENCE: The home’s manager is registered with the Commission. At the time of the inspection the registered manager was on leave and the management of the home was the responsibility of the one of the owners who is not the registered manager. There was a discussion about the role of the owner, the process of decision-making and accountability. The inspector concluded that the owners need to review and clarify the role of the owner who acts as manage, Miss Enbridge House Care Home DS0000012200.V272632.R01.S.doc Version 5.0 Page 17 Karen Bolt-Lawrence, during the absence of the registered manager, and when working as a member of the care staff team as detailed on the rota. The owner, who also works in the home, stated that she attends various training courses but records of this are not maintained. It was not possible to verify that the owner, who acts as manager, has received the necessary training to confirm her competency in working as a care staff member or in her capacity as acting manager. The home has a quality assurance system procedure, which has not yet been fully implemented. Feedback has been sought from some of the residents. Questionnaires are available in the home’s entrance hall for visitors to make comments about the service provided by the home. These are a reflection of the Commission for Social Care Inspection ‘Comment Cards.’ The inspector considered that that the home could devise a more expansive and useful survey pro forma for residents and visitors. A maintenance logbook is used to record the need for any repairs to the building, but the home does not have a plan of redecoration and refurbishment. A system of audit has not yet been introduced and the home does not have an annual development plan, although there are training plans for the staff team. The home does not manage or handle any of the resident’s finances. Enbridge House Care Home DS0000012200.V272632.R01.S.doc Version 5.0 Page 18 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 1 X X X 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 2 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 3 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X X Enbridge House Care Home DS0000012200.V272632.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? N/A 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 OP3 Regulation 14 Requirement Timescale for action 04/02/06 2 OP1OP3 Care Stand Act 2000 3 OP7 15 The home must ensure that for residents who are self funding that an assessment of need is carried out and recorded in order to ascertain if the home can meet the person’s needs and that the person’s needs are within the home’s categories of registration. The home must review the needs 04/02/06 of the individual residents and apply for a variation to the home’s conditions of registration for those residents whose needs are not included in the home’s conditions of registration such as dementia and mental disorder for older persons. The Statement of Purpose and Service Users’ guide must be amended accordingly. The system of written 27/02/04 assessment and care planning should be reviewed to ensure the following: • Specific details of how staff are to provide personal care • Details of diagnoses of dementia and mental DS0000012200.V272632.R01.S.doc Version 5.0 Enbridge House Care Home Page 20 4 OP12 12 5 OP29 19,17 Sch 2 and 4 6 OP30 18 7 OP31 9 disorder, including symptoms and behaviour and how staff are to deal with these • Details of any plans for treatment by mental health practitioners and circumstances when they should be contacted Care plans must be signed and dated by the person completing them. The home 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 a care plan devised to show how those needs are being met. The home must be able to demonstrate that recruitment checks have been carried out each staff member by the availability of staff records in the home. This was also a requirement in the previous report. Arrangements must be made for staff and management to receive suitable training in working with residents’ who have dementia and mental disorder. A job description for the owner who works in the home, as an acting manager and care staff member must be available for inspection. This must give details of the responsibilities and management accountability in the home. The acting manager must attend training courses and a record of this training must be maintained to demonstrate that the owner has the competencies to manage DS0000012200.V272632.R01.S.doc 04/02/06 04/02/06 04/04/06 15/02/06 8 OP31 10 04/04/06 Enbridge House Care Home Version 5.0 Page 21 9 OP33 24 the home and to work in a care setting, especially in the absence of the registered manager. The home must implement their own quality assurance procedure to include the following: • Surveys of residents’, relatives and involved professionals • A system of audit • An annual development plan 04/04/06 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 18 and 30 Good Practice Recommendations Staff and management should attend training in adult protection procedures. Enbridge House Care Home DS0000012200.V272632.R01.S.doc Version 5.0 Page 22 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. 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