Inspection on 25/01/06 for Engleburn

This inspection was carried out on 25th 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

Engleburn 09/12/08

Engleburn 12/03/07

Engleburn 01/09/05

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 Ms Sue Kinch Unannounced Inspection 25th January 2006 09:30 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 Engleburn DS0000012069.V280608.R01.S.doc Version 5.1 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. Engleburn DS0000012069.V280608.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Engleburn Address Milford Road Barton-on-Sea Hampshire BH25 5PN 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) Mrs Maureen Grey Mrs Tracey Dawn Holland Care Home 26 Category(ies) of Dementia - over 65 years of age (26), Old age, registration, with number not falling within any other category (26) of places Engleburn DS0000012069.V280608.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st September 2005 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 DS0000012069.V280608.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second, unannounced inspection for the year 2005-2006. The inspection was carried out on 25 January 2006 from 09:30-14.30. The inspector spent five hours talking with individual residents and groups of residents, staff and the manager, examining records and viewing parts of the home. Findings at this inspection need to be considered with those noted in the previous report. What the service does well: 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. Engleburn DS0000012069.V280608.R01.S.doc Version 5.1 Page 6 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 Engleburn DS0000012069.V280608.R01.S.doc Version 5.1 Page 7 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): Not Assessed . Standard 6 does not apply. The key standard was assessed at the inspection on 1/9/05. EVIDENCE: Engleburn DS0000012069.V280608.R01.S.doc Version 5.1 Page 8 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): 7,9,10 Residents benefit from care plans that set out the support needed from staff. These take risk into account. Records being held securely promote residents confidentiality. Medication is well organised in the home but clear guidance on administration of ‘as required’ medication would benefit service users and protect staff. EVIDENCE: A sample of care plans was viewed and was satisfactory. How needs will be met was documented. There was evidence that care plans are started when residents arrive at the home and are developed as new issues arise. The range of issues covered in care plans include, a physical plan, a night plan, a nutritional assessment, medical needs, likes and dislikes, recreational needs, a moving and handling assessment and risk assessments. The manager is introducing a new format for moving and handling assessments to extend the details of support needed. This will give staff more detailed guidance. Since the last inspection the manager has made progress in ensuring that the rationale for a locked front door is documented in risk assessments for relevant residents. Some examples were seen during the inspection. Some others Engleburn DS0000012069.V280608.R01.S.doc Version 5.1 Page 9 needed to be found and placed in files. The manager reported that these were being reviewed with relevant others as reviews take place. Medication is well organised in the home. A staff member confirmed that medication training is received before carrying out the tasks. Staff were able to demonstrate knowledge of elements of the medication policy. Records of administration are held securely. Medication is pre dispensed before administration but is administered by the same person. The manager said that this was the most effective system for the home. This should be risk assessed. Medication was administered during the inspection in a respectful way. Medication is signed for when administered. Discussions were held about ‘as required’ medication with staff and the manager. In the two instances checked clear guidance for giving such medication was not available. Resident’s records are held securely. After the last inspection the manager provided a secure cabinet for them. Staff confirmed that records are held securely. Engleburn DS0000012069.V280608.R01.S.doc Version 5.1 Page 10 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): Not Assessed The key standards were assessed at the inspection on 1/9/05. EVIDENCE: Engleburn DS0000012069.V280608.R01.S.doc Version 5.1 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 Residents are confident that any issue or concern raised will be addressed promptly. EVIDENCE: Residents spoken with were asked how responsive they found the staff and management. Residents gave very positive comments about the staff saying that they were ‘pleasant’,‘ would deal with problems’ and ‘if you raise an issue it is sorted’. Confidence in the manager to deal with things was also expressed. Some relatives spoken with were also confident that matters would be, and had been acted upon adequately. The manager reported that no complaints had been received recently but that a complaints book was available. The procedure is in the service users guide that is given to new residents. It was advised that a copy of the complaints procedure is made available for easy access. The manager agreed to do this. Engleburn DS0000012069.V280608.R01.S.doc Version 5.1 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 Living in a clean, well-maintained, pleasantly decorated and homely environment enhances resident’s lives. EVIDENCE: The lounges, dining room, hall, corridors and five bedrooms observed were pleasantly decorated and clean. The ground floor corridor was being redecorated and lots of pictures were ready to be hung. The home has a fulltime maintenance worker and a book was available for staff to record tasks to be completed. Four residents were asked about the environment and said that they found it comfortable, warm and clean. Two residents were asked if they could think of any improvements needed. Neither had any suggestions. Two others felt that if things went wrong they were fixed straight away. Four residents were asked about their bedrooms and all were happy with them. Engleburn DS0000012069.V280608.R01.S.doc Version 5.1 Page 13 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28 Residents benefit by receiving care from a stable and committed staff group, which is regularly receiving training and new guidance. EVIDENCE: Adequate numbers of staff are provided in the home. At the start of the inspection four staff were on duty. All had been in post for 1-6 years. Four staff work until after lunch. Then three staff work on duty for the rest of the day. Staff confirmed these numbers and stated that two waking night staff work at night. A cook works from 8 until 2pm each day. Staff are encouraged to do training. This was assessed at the last inspection. However, the number of staff members assessed or being assessed to National Vocational Qualification (NVQ) level 2 or above was considered. The standard of 50 of staff at level 2 is exceeded. Most of the other staff are working towards level 2 and those who have achieved it are working on level 3 or above. Engleburn DS0000012069.V280608.R01.S.doc Version 5.1 Page 14 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): 31,35,38 Residents benefit from the home being run by an experienced and trained manager. They also benefit from health and safety being addressed but further action is needed to demonstrate that they are not at risk from hot surfaces. EVIDENCE: The manager has completed NVQ level 4 in care and has nearly finished the Registered Manager’s Award. She also ensures that she has regular training in a range of care issues. The standard will be fully complied with when this is achieved. Some of the residents choose to manage their own money. Money is held for some residents at the home after consultation with residents or those responsible for their finances. Records and receipts for transactions are held to demonstrate how individual monies are spent. Engleburn DS0000012069.V280608.R01.S.doc Version 5.1 Page 15 Evidence of health and safety being addressed at the home was noted but further work is needed to ensure that all necessary action has been taken on two issues. Following the last inspection it was required that risks associated with balconies were assessed and plans in place where necessary. The manager and member of staff confirmed that these had been completed. Evidence of this was viewed in the records. Most of the radiators in the home are covered. However some in the corridor and one in the bathroom on the first floor are not. They were very hot to touch. The manager was aware and reported to be addressing this by providing new radiators. A risk assessment however is needed to demonstrate that risks in the interim have been assessed and any significant risk acted upon. The inspector noted that windows on the first floor did not have restricted openings. The manager was advised to consult with the environmental health officer in respect of this and undertake risk assessments. Engleburn DS0000012069.V280608.R01.S.doc Version 5.1 Page 16 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X X X X X X STAFFING Standard No Score 27 3 28 4 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x x x 3 x x 2 Engleburn DS0000012069.V280608.R01.S.doc Version 5.1 Page 17 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 OP9 Regulation 13(2) Requirement The registered manager must ensure that guidance from the doctor for ‘as required’‘ medication is clearly documented. The registered manager must ensure that hot surfaces have been risk assessed and action taken to reduce identified risks. Timescale for action 25/02/06 2. OP38 13 (4) (a) 25/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Engleburn DS0000012069.V280608.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Engleburn DS0000012069.V280608.R01.S.doc Version 5.1 Page 19 - 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. 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