Inspection on 10/05/05 for Engelberg

This inspection was carried out on 10th May 2005.

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

Engelberg 06/11/07

Engelberg 04/07/06

Engelberg 17/09/04

Engelberg 28/04/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Engelberg Ash Hill Compton Wolverhampton WV3 3DR Lead Inspector Ian Harris Unannounced 10 May 2005 09:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Engelberg E56 000030104 Engelberg V225046 UI 100505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Engelberg Address Ash Hill, Compton, Wolverhampton, WV3 3DR Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01902 420613 01902 713587 Methodist Homes for the Aged Angela Jeavons Care Home Only 32 Category(ies) of Old Age (30) registration, with number of places Engelberg E56 000030104 Engelberg V225046 UI 100505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1) Category old age not falling within any other category including females over the age of 60 years. Date of last inspection 17/09/2004 Brief Description of the Service: Engelberg is registered to care for 32 older people. The building has been adapted to provide for the needs of physically frail older people A new extension provides additional accommodation. There are thirty-two single rooms, twelve of which have an en suite facility. The home is situated in a very peaceful area of Compton in Wolverhampton, but is within easy reach of the city centre and local facilities. The home has a large dining room and communal lounge in addition to a second lounge that is used for worship. There is a large and very well maintained garden that is accessable to all the residents.. Engelberg E56 000030104 Engelberg V225046 UI 100505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 5 hours. The main purpose of the inspection was to check the progress made by the home regarding the recommendations and requirements made in the last inspection report. The fullest co-operation was given to the inspection officer by the Care Manager staff and residents’. During the inspection a tour of the premises took place and staff and care records were inspected. Also staff rotas and general records regarding the maintenance of the home were checked. 6 of the 17 staff were on duty, and 10 of the 29 residents were spoken to. On the day of inspection the atmosphere within the home was found to be warm, friendly and comfortable with contented residents. What the service does well: What has improved since the last inspection? There have been considerable improvements made to the home’s environment since the last inspection. The hall, stairway, Music room and Television lounge have all been redecorated. All the resident’s bedroom windows have been Engelberg E56 000030104 Engelberg V225046 UI 100505 Stage 4.doc Version 1.30 Page 6 replaced by double- glazed units. Also the hall and reception area has been re-carpeted and the provision of radiator covers throughout the home has now been completed. 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. Engelberg E56 000030104 Engelberg V225046 UI 100505 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Engelberg E56 000030104 Engelberg V225046 UI 100505 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 The home provides good clear accurate information regarding the service provided, which is available in the reception area of the home EVIDENCE: The statement of purpose and the service user’s guide are available in the hall. Also a copy of the last inspection report is available to anyone interested. It was noted the staff at the home are proactive in inviting prospective residents and their families to visit the home and ask any questions they may have regarding the services provided in order to make an informed choice. Engelberg E56 000030104 Engelberg V225046 UI 100505 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, and 9 Each resident has a comprehensive, individual care plan that is reviewed on a monthly basis. The home has good contact with local G.P. s. local hospitals and paramedical services, which ensures that resident’s health needs are met. The systems for the administration of medication are good with clear and comprehensive recording arrangements being in place to ensure resident’s medication needs are met. EVIDENCE: The home provides a comprehensive Care Plan for each individual resident based on the initial assessment. The Care Plans are drawn up by the Care Staff in consultation with the resident and their family. There was evidence on the files to show the care Plans are being carried out and reviewed on a monthly basis. The home is well supported by local G. P. s. and all of the paramedical services. Wherever possible, the residents are encouraged to retain their own G. P s, Opticians, and Dentists. It was noted that if the resident has moved out of their area the Care Manager ensures that, these services are provided by Engelberg E56 000030104 Engelberg V225046 UI 100505 Stage 4.doc Version 1.30 Page 10 local practitioners. The records indicate that resident’s medical needs are being met. Medication is administered by means of a Boot’s monitored dosage system. The system appears to be working very well. The home receives good support from the Boot’s pharmacist who does a three monthly audit of the homes medication. All care Senior Staff have been trained to use the system before they are allowed to administer medication. The home has very good policies and procedures, which are used as an integral part of the staff induction programme. Engelberg E56 000030104 Engelberg V225046 UI 100505 Stage 4.doc Version 1.30 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 standard(s) 12 and 15 The home provides a stimulating experience for the residents where they are encouraged to maintain their independence as much as possible The home provides a good range of social activities within and outside the home designed to the capabilities of the residents The meals in the home are good offering both choice and variety and also catering for special dietary needs EVIDENCE: The routines and activities within the home are flexible and are built around the needs of the residents. There was also evidence to show that staff consult the residents regarding the choice of meals and activities within the home. There are regular residents meetings and the cook consults the individual residents on a daily basis regarding the menu and their personal preferences. The key-workers also identify interests that the residents wish to pursue. A regular programme of musical evenings, Art and Craft sessions, board- games and sing-a-longs is organised within the home. There are monthly church outings, where residents have the opportunity to visit country churches where tea is provided. Outings to the theatre and a canal trip have been arranged. During the inspection many of the residents were delighted is telling me about the wonderful V. E. celebration party they and their visitors had all enjoyed at the weekend. Engelberg E56 000030104 Engelberg V225046 UI 100505 Stage 4.doc Version 1.30 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 The home has a good complaints procedure with some evidence that resident’s views are listened to and acted upon. The home has good policies and procedures regarding protection from abuse, which includes a whistle blowing policy, and the staff have a good understanding of their responsibilities. EVIDENCE: The home has a very good complaints procedure and all complaints are recorded in a, complains book. Residents and their families are given a copy, of the complaints procedure at admission and there are copies readily available in the reception area. It was noted that no complaints have been recorded since the last inspection. The home has good policies and procedures regarding Restraint, dealing with Aggressive Behaviour and Prevention of Abuse, which includes a Whistle-Blowing policy. These issues are also covered in the N.V.Q. training, which the Staff are undertaking. Engelberg E56 000030104 Engelberg V225046 UI 100505 Stage 4.doc Version 1.30 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 22, 23, 24 and 26 The standard of the environment within the home and the garden is very high providing the residents with a very attractive, comfortable, homely and safe place to live. The home was found to be clean tidy and free of unpleasant odour. EVIDENCE: The home is long established and has undergone alterations over the years in order to provide appropriate accommodation for older people. The home is maintained to a very high standard, as are the gardens and grounds and provides a very comfortable homely and safe atmosphere. It was noted that all the residents’ rooms have been fitted with replacement double glazed windows. All of the homes radiator covers are now fitted. The resident’s bedrooms have been personalised with the residents’ own personal possessions. This gives the appearance of a very comfortable environment. The home is furnished to a high standard throughout. All the bedrooms are well furnished and close attention has been paid to detail. Engelberg E56 000030104 Engelberg V225046 UI 100505 Stage 4.doc Version 1.30 Page 14 It was noted that the home has not been assessed by an Occupational Therapist. However they do provide specialist equipment to meet the needs of the residents Engelberg E56 000030104 Engelberg V225046 UI 100505 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 ,28, 29, and 30 The home is well staffed with adequate numbers and skill mix of staff. The staff have a very good understanding of the resident’s support needs this is evident from the positive relationships which have been formed between staff and residents’. The home has good policies and procedures regarding the recruitment of staff, which include all the appropriate checks and references. There is a good training programme in place that ensures that the staff are competent to do their job. EVIDENCE: The inspection of staff rotas and discussions with staff indicated that the home is well staffed. There is a good balance within the staff group, which includes experience, mature and younger staff who are embarking on a new career. The home operates an acceptable procedure and has registered with the Social Care Association in order to complete the appropriate checks on staff. There was evidence within the home that all the checks are being carried out. All staff, at the home, are committed to developing their knowledge and skills through training and have regular opportunities to do so through external and internal training activities. The home has introduced a programme of N.V.Q. training in order to meet the minimum standard. Also the care staff have attended courses on Safe handling of medication, Risk assessment, Dementia care, and Moving and lifting. It was noted that there are no copies of Birth certificate, passport or a current photograph of each member of staff on their Engelberg E56 000030104 Engelberg V225046 UI 100505 Stage 4.doc Version 1.30 Page 16 files. Also the staff have not received a copy of the General Social Work Council Code of Practice in preparation for registration. Engelberg E56 000030104 Engelberg V225046 UI 100505 Stage 4.doc Version 1.30 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35, 37, and 38 The home is operating a good system to assist residents with the safe handling and keeping of their personal finances and good records are being kept of all transactions made. All the general records that was inspected, were found to be well ordered and maintained. The home has good policies and procedures regarding Health and safety and the care manager and staff demonstrated that they are aware of their responsibilities to promote health and safety. In regards to accidents these have been minimal and dealt with appropriately. EVIDENCE: All the records and administrative procedures within the home that were inspected, were found to be well maintained. The home has a good heath and safety policy and all staff are aware of their responcibilities regarding these issues and a number of staff have received training. However it was noted that there are a number of requirements Engelberg E56 000030104 Engelberg V225046 UI 100505 Stage 4.doc Version 1.30 Page 18 made in the Fire Prevention Officer report dated 15th March 2005 have not yet been carried out. Also the extractor fan filter and hood must be regularly cleaned. In regards to any accidents, they are all recorded in an appropriate book. Engelberg E56 000030104 Engelberg V225046 UI 100505 Stage 4.doc Version 1.30 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 x x 3 3 x 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x 3 3 x x x x 3 x 2 2 Engelberg E56 000030104 Engelberg V225046 UI 100505 Stage 4.doc Version 1.30 Page 20 YES 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 OP22 Regulation 16(1)4(3) Requirement Timescale for action 01/07/05 2. OP38 3. OP38 4. OP29 5. Schedule 2 Facilities and equipment must be assessed by a suitably qualified person i.e. an occupational therapist ( Time scale of 31/10/04 not met) 23 (4) (a) The registered person must ensure that all of the recommendations and requirements in the Fire prevention Officers report dated 15/03/05 are fully implemented. 23 (2) (c ) The registered person ensures that the extractor fan and hood in the kitchen is proffessionally cleaned. !8 The registered person must ensure that all staff receive a copy of the general Social Work Council Code of practice. That the registered provider ensures that a recent photograph and a copy of the Birth Certificate or passport are placed on all staff files. 01/07/05 01/07/05 01/06/05 01/06/05 Engelberg E56 000030104 Engelberg V225046 UI 100505 Stage 4.doc Version 1.30 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Engelberg E56 000030104 Engelberg V225046 UI 100505 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Address 1 Address 2 Address 3 Address 4 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 Engelberg E56 000030104 Engelberg V225046 UI 100505 Stage 4.doc Version 1.30 Page 23 - 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!