Inspection on 06/11/07 for Engelberg

This inspection was carried out on 6th November 2007.

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

Engelberg 04/07/06

Engelberg 10/05/05

Engelberg 17/09/04

Engelberg 28/04/04

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Maple Lodge

Heathlands

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Ravenhurst

Bank House

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

CARE HOMES FOR OLDER PEOPLE Engelberg Engelberg Ash Hill Compton Wolverhampton West Midlands WV3 9DS Lead Inspector Sue Woods Key Unannounced Inspection 10:00 6th November 2007 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Engelberg DS0000030104.V347122.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. Engelberg DS0000030104.V347122.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Engelberg Address Engelberg Ash Hill Compton Wolverhampton West Midlands WV3 9DS 01902 420613 01902 713587 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) home.fxg@mha.org.uk Methodist Homes for the Aged Angela Jeavons Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Engelberg DS0000030104.V347122.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Females 60 years and above, males 65 years and above. Maximum of 2 residents with Mild Dementia. Date of last inspection 4th July 2006 Brief Description of the Service: Engelberg is registered with the Commission for Social Care Inspection to provide accommodation and personal care to a maximum of 32 older people. The registered provider is Methodist Homes for the Aged and the registered manager is Angela Jeavons. The extended building has been adapted to provide for the needs of physically frail older people. 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. There is a large and very well maintained garden that is accessible to all people who live there. Consultation with people who live at the home takes the form of an internal audit that also seeks the views of relatives, representatives and staff. People who use the service and their representatives are able to gain information about this home from the Statement of Purpose and Service User Guide. Inspection reports about this service can be obtained direct from the provider or are available on our website at www.csci.org.uk The weekly fees range from £417 to £484. Engelberg DS0000030104.V347122.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced key inspection of Engelberg took place on 6th November 2007. The inspection started at 10.00 am and lasted seven and a half hours. The inspection reviewed all twenty of the key standards for care homes for older people and information to produce this report was gathered from the findings on the day and also by review of information received by CSCI prior to the inspection date. A quality rating based on each outcome area for service users has been identified. These ratings are described as excellent/good/adequate or poor based on findings of the inspection activity. As part of the inspection the inspector met with a number of people living at the home, a relative and with staff on duty at the time of the visit. Support for the inspection came from the registered manager who was available all day. Two care files were reviewed in detail and extracts were seen from others. Information was also gathered from reviewing staff files and other documents referred to within the report. Prior to the inspection the registered manager completed and returned an Annual Quality Assurance Assessment (AQAA). Information contained within this document was seen to overall reflect the service offered by the home although not all issues identified at the time of the inspection had been noted. What the service does well: People who live at Engelberg told the inspector that they are very happy to live there. People feel that their privacy is respected and have good opportunities to celebrate their religious beliefs. One relative, in a letter to the home, said that the ‘ethos of the home is like no other’. She went on to say that staff ‘treated mom with utmost love and care’. The home works closely with district nurses and provides a dedicated service to people upon death and after they have died. Staff feel that they have good support and training opportunities. Visitors to the home are always made very welcome and the home receives numerous compliments about the quality of the service it provides. Engelberg DS0000030104.V347122.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Engelberg DS0000030104.V347122.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Engelberg DS0000030104.V347122.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Appropriate procedures are in place to successfully accommodate an admission to the home however paperwork is not always available to support that an assessment of needs takes place. People who would like to live at Engelberg may base their decision on incorrect information if the Statement of Purpose does not accurately reflect the service offered at the home. EVIDENCE: The inspector saw three care files. Two contained an initial assessment of need. The inspector could not establish if the third person had received an assessment prior to admission as the assessment form was blank. The manager said that some information had been archieved but as all files are Engelberg DS0000030104.V347122.R01.S.doc Version 5.2 Page 9 being reviewed this information would be made available. The home does not offer intermediate care and this is reflected in the statement of purpose. This document however was seen to require additional information to ensure it accurately reflected the service offered at the home and that contact information was correct. The manager began working to update this document at the time of the inspection. Engelberg DS0000030104.V347122.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9, 10 and 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at Engelberg are protected by effective systems for the administration and monitoring of medication and people receive excellent care during and after death however when care needs change they are not always recorded in the care plan meaning that staff do not know how to offer effective support. EVIDENCE: Before the inspector saw the care plans the manager stated that they are all in the process of being reviewed and updated. Three files were then reviewed. Two files contained updated information in relation to how care and support needs are to be met. Support needs had been identified in the plans however it was difficult to establish how the needs are met on a daily basis due to a complex cross-referencing system. Some information was based more on medical rather than social needs. Engelberg DS0000030104.V347122.R01.S.doc Version 5.2 Page 11 The third file had not been updated and the information contained in the plan did not reflect the person’s current needs or provide staff with guidance as to how to keep the person safe or protect others and themselves from identified behaviours. Medication storage, administration and recording systems were reviewed and found to be satisfactory. A recent internal audit had picked up some issues in relation to recording and the manager was able to demonstrate how she has taken action to address these issues. A second audit is scheduled to take place three days after the inspection. Two people are supported to manage their own medication and assessments support this arrangement. The home works closely with district nurses and records of health care appointments are recorded in care files. The home excels in its support for people who are near the end of life. The home can organise funerals and staff have received training to support all aspects of death and dying. The manager promotes discussions in relation to end of life support with people who live at the home and relatives. At the time of the inspection the manager and the staff team received a letter from a relative thanking them for the care they had shown. The letter demonstrated how people value the approach to death and dying within the home. People told the inspector that their privacy is respected. One person said she is able to lock her room and that staff always knock before entering. One relative, in a letter to the home said that the ‘ethos of the home is like no other’. She went on to say that staff ‘treated mom with utmost love and care’. Engelberg DS0000030104.V347122.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who live at Engelberg are able to choose their life style, social activity and keep in contact with family and friends and this should improve further when the activity coordinator starts work at the home. People enjoy a varied diet according to their assessed needs and individual choice. EVIDENCE: People who live at Engelberg told the inspector that they are very happy to live there. They gave examples of some activities that have taken place and are looking forward to the start of an activities coordinator. At the time of the inspection no structured activities were taking place. A number of people were sleeping in the lounge. Some people prefer to spend time in their room and staff support this. Hobbies, likes and dislikes are recorded in care plans. The manager fully acknowledged in the AQAA that she plans to develop activities within the home over the next twelve months. Engelberg DS0000030104.V347122.R01.S.doc Version 5.2 Page 13 People living at Engelberg have regular opportunities to celebrate their religious beliefs although others prefer not to take part in the regular worship sessions. Visitors to the home told the inspector that they are always made very welcome. Letters from relatives reflect that they feel involved and communication records demonstrate regular contact takes place. People living at Engelberg told the inspector they liked the meals. One person confirmed that her identified dietary needs are met and choices are available. Menus were not reviewed on this occasion. The kitchen assistant identified that there is always a cooked meal at lunchtime and a choice of hot or cold snacks at teatime. Engelberg DS0000030104.V347122.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. People who use the service and their representatives have access to a complaints procedure, which enables their views to be listened to. The home has not followed safeguarding procedures placing some people at risk of physical harm from the behaviours of others. EVIDENCE: Everyone who spoke with the inspector felt that they would be listened to if they had a complaint. The manager gave examples of situations where she has responded to comments to improve services and recognised that some challenges are ongoing. Relatives commented on the ‘open ethos’ of the home and communication between the home and relatives, friends and health care professionals is good. At the time of the inspection situations were identified where the home had not followed its own policies and procedures to keep people safe and this was discussed at length with the manager. Correspondence with the home and an individual within the organisation prior to the inspection reflects that adult protection is an area where further training is required. Engelberg DS0000030104.V347122.R01.S.doc Version 5.2 Page 15 Following the inspection the manager contacted outside agencies to discuss possible safeguarding ‘issues’ and has identified an external training course to ensure that both the management and the staff team have the necessary skills and understanding to ensure people living at the home are not at risk. The manager stated that staff have had either no training or no recent training in managing challenging behaviours and as a result are themselves currently at risk of harm. Engelberg DS0000030104.V347122.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Engelberg is clean and well maintained providing the people who live there with a comfortable place to live. EVIDENCE: During a tour of the home all areas were seen to be clean. Bedrooms were personalised and no hazards were identified. Staff with responsibility for the maintenance and cleaning of the home were knowledgeable of their roles and were seen to be wearing appropriate personal protective clothing. Staff were aware of the need for data sheets and risk assessments to support the use of chemicals and these documents were available for review near to where the products are stored. Engelberg DS0000030104.V347122.R01.S.doc Version 5.2 Page 17 The maintenance worker said the home had a budget for repair and maintenance and the office had just been painted and decorated and a new fire panel installed. The home is in the process of having patio doors from the music room to a new patio area overlooking the garden. Engelberg DS0000030104.V347122.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People who use the service are supported by a committed staff team however the homes poor recruitment procedures potentially place them at risk of harm or abuse. EVIDENCE: All staff who spoke with the inspector enjoyed working at the home. They felt they had good support and training opportunities. Staff gave examples of ongoing training courses and certificates were displayed on the wall to reflect achievements. Records seen did not contain evidence of induction however discussions with the manager and staff suggested that this might be due to a filing issue that is currently being addressed. Staff said that they had good support from managers although again records to identify supervision had taken place were not available on all occasions. The home could not demonstrate that appropriate monitoring had taken place in one instance when it had been identified as a need. Engelberg DS0000030104.V347122.R01.S.doc Version 5.2 Page 19 Three staff files were reviewed and all were found to be missing a number of key documents. References had been accepted ‘to whom it may concern’ and there was no evidence that latest employers had been approached. One file contained proof of identity but not the others. No files seen contained a declaration that the person was fit for employment. An issue was identified in relation to CRB disclosures in that the manager had not formally risk assessed information received. Staff files did not contain evidence of formal investigations into practice or document outcomes. When asking people who lived at the home and staff on duty what could be improved at Engelberg all felt that maybe more staff would benefit the home. One person said ‘staff are busy but they seem to cope.’ Others reflected on the difference when the volunteer worker is available for support. The increased support needs of one person living at the home indicates that the manager needs to review staffing levels to ensure she receives support without distracting from meeting the needs of others. Engelberg DS0000030104.V347122.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Recent interim management arrangements have not protected people living at the home and the lack of appropriate paperwork has made it difficult for the home to demonstrate otherwise. The overall health and safety and welfare of people living at the home and the staff team is promoted but recent events where procedures have not been followed have put people at risk. EVIDENCE: The manager of the home is currently working towards the Registered managers Award and will then start the NVQ Level 4 in Care. The manager has Engelberg DS0000030104.V347122.R01.S.doc Version 5.2 Page 21 been absent from the home for a three month period and has only recently returned. Identified incidents during this time have demonstrated that support and monitoring could have been improved to ensure that processes were followed and thus people were kept safe. (See requirements for standard 18 and 29). NOTE: The registered manager demonstrated her commitment to making improvements by emailing an action plan to CSCI following the inspection that showed how issues are being addressed. The home has a system of quality assurance that is comprehensive and takes into account the views of people who live at the home, relatives and representatives and the staff team. A health and safety audit forms part of this process. Health and safety is promoted by the staff team and routine safety checks are carried out with records kept. Although financial records were not reviewed as part of this inspection the manager said that family members support people who live at the home to manage their money. This was supported in a conversation held with a relative. The AQAA states that the home has a detailed finance manual and ‘accompanying training, monitoring etc set out high standards and best practice and procedures’. Engelberg DS0000030104.V347122.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 2 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 3 Engelberg DS0000030104.V347122.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14 (1) & (2) Requirement Timescale for action 31/12/07 2 OP7 15 (1) 7 (2) (B) 3 OP18 13 (6) 4 OP18 13 (6) The home must be able to demonstrate that they have received a full needs assessment from an outside agency or have made their own assessment prior to admission in order to be sure that they can meet the persons care needs when they move in. Care plans must accurately 31/12/07 reflect care needs and be updated as and when those needs change. This is to ensure people receive the care they pay for in order to live a safe and fulfilled life. Managers and staff working at all 23/01/08 levels must receive training in adult protection issues and follow their policies and procedures at all times. This is to ensure that any abuse is noticed and referred to the appropriate agency for investigation. It is also to protect the people living in the care home from harm. Staff must receive training to 23/01/08 manage behaviour that challenges the service and puts people at risk of harm. This is to DS0000030104.V347122.R01.S.doc Version 5.2 Engelberg Page 24 5 OP36 18 (1) & (2) 6 OP29 19(4, 5) Schedule 2 keep both themselves and people living at the home as safe as possible using appropriate techniques that promote the wellbeing of the person challenging the service. Staff must receive regular and recorded supervision to review performance and identify strengths and needs. This is particularly important when issues have been addressed with performance and monitoring is required to identify improvement. Recruitment procedures must ensure that all pre employment screening has been carried out or service users may be at risk of harm or abuse. 30/11/07 12/12/07 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 OP1 Good Practice Recommendations Minor amendments should be made the Statement of Purpose and Service User Guide to ensure both documents are an accurate reflection of the service provided and meets the requirements of the Care Homes Regulations 2001, as amended. This will ensure anyone interested in moving in to the home will have accurate information to base his or her decision upon. It is recommended that the care plan system is made simpler to understand and follow. This is to assist new staff to identify what a persons care needs are and to make it more user friendly for the person it belongs to. It is recommended that staffing levels be reviewed to demonstrate that the home can meet the needs of everyone living at the home. This is because at least one DS0000030104.V347122.R01.S.doc Version 5.2 Page 25 1 OP7 2 OP27 Engelberg 3 OP30 person’s support needs have recently increased significantly. It is recommended that a record be kept on each staff members file to demonstrate that hey have received a structured and relevant induction prior to working at the home. This will also demonstrate that the home is meeting its obligations towards training staff as well ensuring that all staff know how they are expected to work within the home and how to work safely. Engelberg DS0000030104.V347122.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Shrewsbury Local Office Commission for Social Care Inspection 1st Floor, Chapter House Abbey Lawn Abbey Foregate Shrewsbury SY2 5DE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000030104.V347122.R01.S.doc Version 5.2 Page 27 - 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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