Inspection on 01/09/05 for Engleburn

This inspection was carried out on 1st September 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 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

Engleburn 09/12/08

Engleburn 12/03/07

Engleburn 25/01/06

Engleburn 22/12/04

Engleburn 11/08/04

Engleburn 26/01/04

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 Engleburn Milford Road Barton-on-Sea Hampshire BH25 5PN Lead Inspector Sue Kinch Unannounced 1 September 2005, 9:30 st 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. Engleburn H54 S12069 Engleburn V247425 010905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Engleburn Address Milford Road, Barton-on-Sea, Hampshire BH25 5PN 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) Mrs Maureen Grey Mrs Tracey Dawn Holland Care Home 26 Category(ies) of Dementia - over 65 years of age (26) registration, with number Old age, not falling within any other category of places (26) Engleburn H54 S12069 Engleburn V247425 010905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22/12/04 Brief Description of the Service: Engleburn is a large detached property set in its own grounds about a quarter of a mile from the centre of New Milton. The home has a large lounge adjacent to the dining room. Seating is also available in the hallway and in corridors. There are twenty single and three double rooms provided on the ground and first floors. Some rooms have balconies above the garden and some others on the ground floor have french windows to the garden. A fenced garden is available for free access by residents. Engleburn H54 S12069 Engleburn V247425 010905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first statutory, unannounced inspection for the year 2005-2006. The inspection was carried out between on 1/9/05 from 9.30-2.30 and on 2/9/05 from 12.30-15.50. The inspector had a range of short and longer conversations with approximately 9 residents and two relatives. Discussion with four staff and the manager also took place. A sample of records was viewed and some documents were observed. What the service does well: What has improved since the last inspection? What they could do better: The home does carry out risk assessments but some more specific ones are needed. Some residents are not able to go out alone due to risks to their safety. Such restrictions must follow an individual risk assessment having consulted the resident, where possible, and other professionals. Risk assessments should be followed with individual support plans. They are also needed for residents with balconies. The third area for improvement is the security of residents’ personal information to ensure files are locked securely when not being used. Engleburn H54 S12069 Engleburn V247425 010905 Stage 4.doc Version 1.40 Page 6 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. Engleburn H54 S12069 Engleburn V247425 010905 Stage 4.doc Version 1.40 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 Engleburn H54 S12069 Engleburn V247425 010905 Stage 4.doc Version 1.40 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) 3. Standard 6 is not relevant to this home. A system is in place to ensure that residents’ needs are assessed so that their needs can be met before they are admitted to the home EVIDENCE: During the inspection it was confirmed by the manager that no one is admitted to the home for intermediate care. It was also reported that the home rarely admitted anyone for respite care, as the home was generally full. The residents asked were not able to remember if they had been assessed before coming into the home, but one relative was asked and was aware. A sample of records required to be completed before admission to the home were viewed and had been adequately completed. One senior member of staff confirmed that prospective residents are visited to make an assessment. Residents asked, mainly felt that their needs were met at the home. Examples of staff working sensitively with residents’ emotional issues were noted. Engleburn H54 S12069 Engleburn V247425 010905 Stage 4.doc Version 1.40 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) 7,8,10 Residents’ health and welfare is monitored regularly and needs are addressed in an environment where privacy and dignity is promoted. Residents would benefit from restrictions in movement being fully risk assessed and more detailed support documented in some elements of care plans. Security of files would enhance the promotion of confidentiality. EVIDENCE: Care plans were available for the four residents case tracked during the inspection. These were in the process of being reviewed. One member of staff said that she would take the care plan to the resident for this if they understood. Staff spoken to were able to be specific about the care needs of residents discussed. Residents asked were not aware of their care plans. In discussion with the manager and staff it was agreed that this was complicated and levels of dementia would influence involvement. However, possible ways were discussed and the manager agreed to review this. Engleburn H54 S12069 Engleburn V247425 010905 Stage 4.doc Version 1.40 Page 10 A door pad has been provided on the front door and those able to go out independently were reported by the manager to have been given the code. This needed to be documented in their care plans. Risk assessments were not in place for those unable to go out independently and this was also discussed with the manager. These need to demonstrate that residents would be otherwise at risk and needed to include consultation with relevant professionals. A more specific risk issue was discussed with the manager in respect of one resident and a review of risk was advised. Records are held of regular health monitoring. Residents asked and able to discuss needs, felt that their health needs were taken care of. Privacy and dignity is promoted in the home. This was discussed with five residents and a relative. Examples given of how this is done were: by staff knocking on the door, staff shutting the door when providing personal care and by their general approach to residents. One resident said she had ‘no grumbles about privacy’. Security of records was discussed with the manager. Personal files of residents were not held securely. The manager agreed to deal with this. Engleburn H54 S12069 Engleburn V247425 010905 Stage 4.doc Version 1.40 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) 12,13,14,15 The home promotes independence and provides support for activities, contact with relatives and use of the community. Residents benefit from relaxed meals in pleasant surroundings and a choice of food. EVIDENCE: Independence in leisure pursuits is encouraged. The home has a plan of activities for residents each afternoon. A plan is available each week. The plan for the week of the inspection included some external activities, which happen in addition to the in house activities. A staff member was planning to go out on each afternoon of the inspection. A scrabble session took place on the second afternoon of the inspection. Records are held of those who become involved in activities. This is needed as the groups going out or involved in in-house activities are small and staff need to monitor the support people get. Contacts with relatives and friends are supported. Visits were made to the home during the inspection and residents were also going out with friends and relatives. Residents confirmed that they could have visitors and could see them privately. Friendly approaches to visitors from staff were seen. Consideration is given to residents’ choice and control over their lives. Routines and preferences of residents are documented in care plans. In individual conversation with three residents they said that there was some choice in Engleburn H54 S12069 Engleburn V247425 010905 Stage 4.doc Version 1.40 Page 12 routines at the home. Some visual aids are used to help residents remember details such as the day, date, and times of meals. A notice board contained this information. Residents were asked about food. Positive comments were received about the quantity, quality and temperature of it. One person said she was ‘happy with the food’. Another said she had ‘no complaints about the food’ A mixture of views were held about how much choice there was although residents thought that something else would be offered if the food provided was not wanted. At lunchtime however a choice was available. The cook confirmed that she had knowledge of the residents’ likes and dislikes. A choice of food was on the menu and evidence of variation was recorded in the food records. Staff confirmed that choices are available for lunch and tea. Likes and dislikes are recorded in care plans. Food was provided in a pleasantly decorated dining room and residents were provided with tablecloths and napkins. The lunch looked attractive and was a leisurely part of the day. Most residents said that breakfast was served in bedrooms between 7 and 8am. This suited those asked. Morning drinks were served with biscuits and residents confirmed that this also happened in the evening after tea. ` Engleburn H54 S12069 Engleburn V247425 010905 Stage 4.doc Version 1.40 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 standard(s) 18 Effective systems are in place in the home to promote the protection of service users. EVIDENCE: An adult protection policy is in the home for staff to read. Staff confirmed this. Discussions were held with two staff about adult protection. One member of staff spoken to had not received training in it and this is advised. However both were able to describe the types of abuse that can occur in a residential setting for the elderly and both were aware of whistle blowing. Both showed a general concern for the rights of residents to be protected and for their needs to be met. One member of staff was presented with a fictitious scenario and in response demonstrated an understanding of taking immediate protective action and also reporting. Advice was given to review the policy about dealing with aggression taking national guidance into consideration. It referred to situations in which restraint could be used but in insufficient depth to give staff clear guidance. Engleburn H54 S12069 Engleburn V247425 010905 Stage 4.doc Version 1.40 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 standard(s) 26 Effective systems are in place to promote infection control in the home and to keep the home clean, offering a pleasant and clean home for residents. EVIDENCE: On both days the areas of the home seen included a sample of rooms and the shared areas. These were clean and free from offensive odours. Domestic staff are employed to clean the home. Comments from residents and a relative included ‘ room lovely, clean home’, and ‘ always clean, no smells’. The manager showed evidence of staff having been trained in infection control. The home has a completed infection control risk assessment. Staff are provided with disposable gloves and aprons. The laundry facilities were discussed with a member of staff who showed adequate understanding of the tasks involved in dealing with soiled items and knowledge of disposing waste. A clinical waste contract is available at the home. Engleburn H54 S12069 Engleburn V247425 010905 Stage 4.doc Version 1.40 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) 29,30 The manager promotes a culture of learning to expand the staff knowledge base and skills to meet the needs of residents. The recruitment process is sufficiently implemented to safeguard service users. EVIDENCE: There has been little need for recruitment since the last inspection and the residents benefit from a well established staff team. There had been no use of agency staff since the last inspection as where necessary staff cover extra hours. The recruitment records were sampled for two staff as issues had been raised at the last inspection. This process and documentation had been completed satisfactorily. Written evidence was seen in the two files sampled. The manager reported that the Job Description for care staff has been revised in relation to National Vocational Training (NVQ )training. New staff have a week shadowing staff and an initial induction. A record for a new staff member was seen for this. Working through a workbook based on national guidance follows this. This is worked through with a senior and then reviewed by the manager. The new member of staff had been given medication training and was doing training in infection control. Then staff move on to NVQ. There are fifteen care staff and 9 were reported to be working towards their NVQ level 2. 4 Staff have completed it and are working on level 3.2 are working on level 4. Staff are also encouraged to take courses to help them achieve their NVQs and five staff had been trained for half days in communication, equal opportunities, key skills, induction and prevention of abuse in the last year. Records of Engleburn H54 S12069 Engleburn V247425 010905 Stage 4.doc Version 1.40 Page 16 training are held. It was advised to ensure that the length of training was recorded and to include in-house training. Staff confirmed that the training was taking place. Records of supervision are held. Staff confirmed that supervision takes place. Staff appraisals are being introduced to the home and this includes developmental needs. The manager reported to have planned training for staff in infection control, activities, funeral awareness and elder abuse. Residents spoke positively about staff who were said to be ‘ready and willing to listen’, ’approachable’ and ‘smile’. Staff spoke positively about working at the home and were observe to be polite and helpful towards residents. Engleburn H54 S12069 Engleburn V247425 010905 Stage 4.doc Version 1.40 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) 33,38 The manager and staff organise the service to meet residents’ needs. Risk assessments in respect of the balconies would offer greater promotion of safety in the home. EVIDENCE: Service users needs are considered at the home. One resident needed emotional support during the inspection and this was provided. Staff explained the specific needs and the issues informing their decision-making. As agreed at the last inspection a survey has taken place and the home has received feedback, mainly from relatives. The manager said that improvements had consequently been made to the garden but she was planning to provide written feedback. One relative confirmed that he had been given a form and had completed it. Engleburn H54 S12069 Engleburn V247425 010905 Stage 4.doc Version 1.40 Page 18 The second floor of the newer wing offers some residents access to a balcony. The doors four of these were open on the second afternoon of the inspection. Risk assessments and action to safeguard service users was not documented. This must be done to ensure that potential risks to residents have been assessed and acted on where necessary. Engleburn H54 S12069 Engleburn V247425 010905 Stage 4.doc Version 1.40 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 x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION x x x x x x x 3 STAFFING Standard No Score 27 x 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 x x 3 x x x x 2 Engleburn H54 S12069 Engleburn V247425 010905 Stage 4.doc Version 1.40 Page 20 no 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 7 Regulation 15 Requirement Timescale for action 14/10/05 2. 3. 10 38 17(1)(b) 13(4)(a) The Registered Person must ensure that risk assessments are completed in consultation with relevant others,and support plans devised, before any restrictions are placed on residents. The Registered Person must 14/10/05 ensure that residents records are held securely. The Registered Person must 14/10/05 ensure that risk associated with balconies are assessed and support plans devised. 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 7 Good Practice Recommendations It is advised to ensure that care plans are in adequate detail. Engleburn H54 S12069 Engleburn V247425 010905 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Hampshire Area 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 Engleburn H54 S12069 Engleburn V247425 010905 Stage 4.doc Version 1.40 Page 22 - 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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