Inspection on 26/01/06 for Englewood Care Home

This inspection was carried out on 26th 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Englewood Care Home 25/01/10

Englewood Care Home 06/04/09

Englewood Care Home 30/04/08

Englewood Care Home 24/01/08

Englewood Care Home 14/08/07

Englewood Care Home 21/11/06

Englewood Care Home 25/05/06

Englewood Care Home 04/05/05

Englewood Care Home 20/12/04

Englewood Care Home 18/06/04

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

CARE HOMES FOR OLDER PEOPLE Englewood Englewood Care Home 42-44 Egerton Park Rock Ferry Birkenhead Wirral CH42 4QZ Lead Inspector Leila Mavropoulou Unannounced Inspection 26th January 2006 10:30 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 Englewood DS0000054702.V281428.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. Englewood DS0000054702.V281428.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Englewood Address Englewood Care Home 42-44 Egerton Park Rock Ferry Birkenhead Wirral CH42 4QZ 020 8597559 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) Englewood Care Limited Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Englewood DS0000054702.V281428.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service should at all times employ a suitably qualified and experienced manager who is registered with the National Care Standards Commission. A maximum of 24 adults over the age of 65 years may be accommodated in the category OP 4th May 2005 Date of last inspection Brief Description of the Service: Engelwood is a care home providing personal care and support for 24 older people both male and female over the age of 65. Accommodation is provided on three floors, which are accessible by a passenger lift. The home has two communal areas on the ground floor. There is lounge and a large dining room and conservatory to the rear of the building overlooking the garden. The home has a call system, assisted baths; grab rails etc to assist service users and to promote their independence. Englewood DS0000054702.V281428.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which lasted five hours. During the inspection five service users, four staff and the acting manager were spoken to find out their views about the service provided at Engelwood. In addition, service users, staff records and other records were inspected. A tour of the building was carried out. What the service does well: What has improved since the last inspection? A new lift has been installed to improve service users independence and safety. The car park to the front of the property has been tarmac and plants pots are placed around the car park to improve the appearance of the service. Englewood DS0000054702.V281428.R01.S.doc Version 5.1 Page 6 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. Englewood DS0000054702.V281428.R01.S.doc Version 5.1 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 Englewood DS0000054702.V281428.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 Service users or their representatives would know that their needs would be met through the homes’ admission procedure and the information provided in the Statement of Purpose. EVIDENCE: The Statement of Purpose provides information about Englewood such as: the facilities offered, staffing etc. The information contained in the Statement of Purpose would give prospective service information regarding the suitability of the Englewood in meeting their needs. The Statement of Purpose must be reviewed to ensure it continues to reflect accurate information about the service and that it has all the information required by the Care Homes Regulation 2001. Service users are given a written terms and condition, which show the weekly fees and what services are included in the fee. Letters are sent to service users informing them of fee increases. New service user are assessed by the acting manager before they are admitted to Englewood, to ensure service user needs could be met within the existing resources. Service users files show that information obtained from the preadmission assessment is used to develop an initial service user plan and risk Englewood DS0000054702.V281428.R01.S.doc Version 5.1 Page 9 assessment. Wherever, possible service users are encouraged to visit the home to ensure that they like the “feel” of the home. The home does not provide intermediate care. Englewood DS0000054702.V281428.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 The assessed needs of service users are met. However, the recording of information must be improved to show the current care provided to service users. EVIDENCE: Service users have care plans and risk assessments showing how their identified needs would be met and how they would be minimised. Discussion with the acting manager and service user files seen showed that even though the service users plans are reviewed monthly, the content of some service user plans were no longer applicable. Staff monitors closely the health needs of service users and where necessary referrals are made to the service users GP. Many of the service users are incontinent and advice is sought from the continence adviser. However, discussion with the acting manager indicated that some service user continence needs must be reviewed with the continence adviser to promote their wellbeing. The “draw sheets” currently being used must be replaced as they are worn. The registered person should investigate the availability of alternative products to “draw sheets” to promote the comfort and health of the service users. Englewood DS0000054702.V281428.R01.S.doc Version 5.1 Page 11 The dentist, optician visits the once a year and the chiropodist visits every six weeks. Service users seen by the chiropodist have to pay for the treatment, as this is not included in the weekly fee paid by service users. The medication records are well maintained. A record is kept of service users medication received, administered and returned to the pharmacist. Some staff have attended training on the Administration of Medication. Currently, staff are provided training on Administration of Medication as part of their induction. However, the registered provider should ensure that staff responsible for the administration of medication receives formal training. Staff were observed respecting service users right to privacy and dignity when they were providing assistance with various aspects of personal care and the manner in which they spoke to service users. Service users have access to a telephone, where they are able to make and receive telephone calls. Discussion with the acting manager indicated that terminally ill or dying service users would be cared for at Englewood with the support of other health professionals. Englewood DS0000054702.V281428.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Improvements could be made to the range of activities provided to service users to maintain their interests. This could be achieved by increasing visits to places of interest locally. EVIDENCE: The activities of daily living at Englewood are flexible to reflect service users preferences. This is evidence by service users choosing to have their meals in their bedroom; able to keep pets in their bedroom e.g. bird etc. The staff organises a range of activities for service users such as: playing scrabble, cards, videos, bingo etc. and a record is kept of service user participation in activities. Discussion with the acting manager indicated that the home’s mini bus is not used frequently to take service users to community facilities, which they would enjoy. The service users do not like going on long trips. Staff spoken to felt that more service users would go out if the trips were organised on the day. There is an unrestricted visiting policy at Englewood and service users are able to choose where to see their visitors. Staff would support the service users to manage their finances. Some monies are left in the office for safekeeping and staff maintains a record of all income and expenditure of service user monies. The acting manager audit service users monies weekly. Englewood DS0000054702.V281428.R01.S.doc Version 5.1 Page 13 Service users are encouraged to bring their own furniture into care home to personalise their bedroom, providing they comply with current fire and electrical regulations. A record is kept of all food provided to service users. Englewood would cater for service users that have specific dietary requirements such as: diabetes, soft diet etc. The staffing level is sufficient to provide the assistance required by service users at mealtimes. The Environmental Officer visited the home and the recommendations and requirements made have been met. Englewood DS0000054702.V281428.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 The home has policies and procedures to protect service users from abuse. However, the registered person must ensure that staff left responsible for the running of the home is aware of the Wirral Adult Protection Policy. EVIDENCE: Engelwood has a complaint procedure, which is displayed in a prominent position. The complaint procedure gives details of how complaints would be investigated, by whom and the timescale for completion of the investigation. There has been no complaint since the last inspection. Staff would support service users to vote if they wish to do so. There are various policies and procedures in place to protect the service users and staff from abuse. Recently, a number of staff attended training on abuse. The registered person must ensure that staff responsible for the home is aware of the Wirral Adult Protection procedure. Staff must know the procedure to be followed if there is an allege incident of abuse. The registered person must ensure that all staff receive training on the managing physical and verbal aggression. Englewood DS0000054702.V281428.R01.S.doc Version 5.1 Page 15 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): 19,20,21,22,23,24,25,26 The furniture in the service users private accommodation meets the needs of the service users. However, the quality of the furniture is worn and should be replaced. EVIDENCE: The garden to the front of the property has been tarmac and plants have been placed at intervals to improve the appearance of the home. The larger garden to the rear of the property was clean and well maintained. Both gardens are easily accessible by wheelchair users. The communal areas at Engelwood are on the ground floor. There is a large lounge, dining room and a conservatory. The conservatory is used as a smoking area. The flooring in the conservatory area is very worn and stained and must be replaced. The dining room is used for activities such as: board games with service users. The tablemats and tablecloths are worn through frequent washing and must be replaced. Most of the service users bedrooms have an en-suite facility. Discussion with the staff indicated that the service users are unable to use the bath in the enEnglewood DS0000054702.V281428.R01.S.doc Version 5.1 Page 16 suite, as they are unable to get in and out of the bath. The staff felt that that if small bath aids were purchase for each service user to meet their particular need, the quality of care provided would improve. Various aids are provided to promote service users independence such as: passenger lift, grab rails, assisted baths etc. There is a hoist in the care home, which has not been serviced. This must be removed unless it is service to confirm it is safe to use. There is also a loop system in the sitting room for those service users with a hearing impairment. Englewood is centrally heated throughout and service users are able to control the heating in their bedroom. The bedrooms are bright and well ventilated, with window restrictors on windows. The fire logbook showed that the emergency lighting has not tested in accordance with the local fire authority recommendation, since August 2005. The hot water temperature has not been tested since September 2005. The registered person must ensure that the hot water is stored at 60 degrees centigrade and distributed at 50 degrees centigrade to prevent the risk of Legionella. The laundry facility is sited away from the food preparation area. New washing machines have been installed with sluicing facility to prevent the spread of infection. Englewood DS0000054702.V281428.R01.S.doc Version 5.1 Page 17 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): 27,28,29,30 Englewood staff meet service users needs and have a good rapport with them. However, the quality of care could be improve through staff supervision and leadership. EVIDENCE: The staffing levels at the care home meet the needs of the service users. A high percentage of the staff group have been working at the care home for many years. Thus, providing continuity of care to service users. The staff have developed their skills and knowledge in working with older people as well as gaining NVQ care qualification. Many of the staff have completed their NVQ level 2 & 3 in care. The home is clean and well maintained. Domestic staff are employed in addition to care staff to maintain the cleanliness of the building. The staffing records have improved. However, the registered provider must ensure that Englewood carries out a Criminal Record Bureau check for all staff employ at the care home. Staff are given a written terms and conditions of employment after their probationary period. Staff files showed that staff are inducted into their role. However, the registered person must review Englewood’s staff induction to ensure it satisfies the TOPPS training specification. It is recommended that the staff training records are review to show clearly the number of paid training days provided each year to staff. Englewood DS0000054702.V281428.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,34,35,36,37,38 The appointment of an experience and qualified manager must be made provide leadership and direction to the staff group to improve the quality of the service provided at Englewood. EVIDENCE: The manager’s post at Englewood has been vacant for approximately ten months. An acting manager has been appointed who is maintaining the dayto-day running of the home. However, there are areas in her knowledge/skills as a manager, which must be address by the registered provider to enable her to carry out her role and responsibility effectively. Discussion with the acting manager and staff indicated that the level of decision making, is very limited in the day-to-day management of the home. This has contributed to essential checks not being undertaken for several months such as: fire and hot water tests. In addition, the lack of formal monthly visit by the registered provider as Englewood DS0000054702.V281428.R01.S.doc Version 5.1 Page 19 required by regulation 26 and formal one to one supervision of the acting manager has contributed to these oversights The service users and staff records are kept in a secure place and are well maintained. The registered person must ensure that service users records are up to date and complies with the requirements of the Care Homes Regulation 2001. A secure place is provided for the storage of service users valuables and the staff maintain records of all service users financial transactions. Records of factors, which would use in reviewing the quality of care provided at Englewood has been maintained. However, these must be evaluated periodically to identify where improvements could be made in the service delivery and a copy of the report must be forward to the Commission. Englewood DS0000054702.V281428.R01.S.doc Version 5.1 Page 20 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 2 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 2 3 3 3 3 X 2 2 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 3 3 1 2 2 Englewood DS0000054702.V281428.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? YES 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 OP1 Regulation 4 Requirement Timescale for action 30/03/06 2 OP7 15(2) 3 OP8 13 (1)(b) 4 OP9 13(2) The registered person shall ensure that the information contained in the homes Statement of Purpose is current. This should be reviewed in particular to staffing, qualifications and recreational activities. Out-standing from previous inspection. The registered person shall keep the service users plan under 30/03/06 review to ensure it continues to reflect the assessed needs of the service user and demonstrate how those needs would be met. Outstanding from previous inspection. The registered person shall make 30/03/06 arrangement for service users to receive where necessary, treatment, advice and other services from any health care professional such as: continence adviser. The registered person must 30/03/06 ensure that staff responsible for the administration of medication receives appropriate training to carry out their roles and DS0000054702.V281428.R01.S.doc Version 5.1 Page 22 Englewood 5 OP18 18 6 OP20 23 7 OP22 13 8 9 OP23 OP24 16 16 10 OP25 13 11 OP29 17 The registered person shall ensure that staff left responsible for the day-to-day management of the home understands the Wirral Protection of Vulnerable Adult Procedures. The registered person must replace the carpet in conservatory area as it is badly stained and worn. The registered person shall ensure that all electric light bulbs in the stairwell are in working order to promote the health and safety of service users. The tablecloths and place mats in the dining room are worn and must be replaced. The registered person must provide to the Commission a plan for the refurbishment of service user bedroom furniture as some are very worn and in need of replacement. The registered person shall ensure that unnecessary risks to the health or safety of service users are identified and so far as possible eliminated by carrying out regular tests and to maintain a record of the hot water temperature. The registered person is required to ensure that hot water is stored at 60degrees centigrade, distributed at 50 degrees centigrade and provided locally at 43 degrees centigrade. The registered person must ensure that the emergency lighting is tested in accordance with the requirements/recommendation of the local fire authority. The registered person shall not employ a person to work in the care home until they have obtained the information and documentation listed in Schedule DS0000054702.V281428.R01.S.doc 30/03/06 30/03/06 10/03/06 30/03/06 30/03/06 30/03/06 30/03/06 Englewood Version 5.1 Page 23 12 OP31 9 13 OP31 8 2 of the Care Homes Regulation 2001. All staff must have a Criminal Record Check from Englewood or a POVA first check before commencing employment at the care home. The registered person must 30/03/06 ensure that the person managing (Acting Manager) the care home has the necessary skills and experience necessary for managing the home e.g. training on giving staff supervision and appraisal. The registered person must 30/03/06 appoint an individual to manage the care home where they are not in full time day to day charge of the care home. The registered person must write to the Commission outlining the actions taken to fill this position, as it has been vacant for ten months. The registered person shall develop a system or reviewing the quality of care provided at the care home at regular intervals. This is outstanding from the previous inspection. The registered person shall visit the home in accordance with regulation 26 of the Care Homes Regulation 2001. Outstanding from previous inspection. The registered person must ensure that staff is appropriately supervised, by suitably qualified staff. Outstanding from previous inspection. The registered person must ensure that all records require to be kept in the care home are up to date. Outstanding from the previous inspection. DS0000054702.V281428.R01.S.doc 14 OP33 24 30/03/06 15 OP33 26 30/03/06 16 OP36 18 30/03/06 17 OP37 17 30/03/06 Englewood Version 5.1 Page 24 18 OP38 13 &23 The registered person must ensure that the service complies with the recommendations and requirements of the fire officer. 30/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 Refer to Standard OP8 OP12 Good Practice Recommendations The registered person should investigate alternative products which could be used instead of “draw sheets” to promote the comfort and health of service users. The registered person should review the times when the activities co-ordinator employed to ensure that she is available at times when service users are more likely to engage in social activities. The registered person should ensure that information activities in the community is made available and accessible to service users. The registered person should encourage and make available the resources to enable staff to organise residents’ outings to local community facilities at short notice. The registered person should check staff understanding of the homes policy on abuse, whistle-blowing etc after their induction and review their knowledge and understanding in supervision. The registered person should review their staff induction to meet the TOPPS training specification. The registered person should review the format of the staff training records to evidence that staff receive three paid training days a year. 3 OP18 4 OP30 Englewood DS0000054702.V281428.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Liverpool Local Office 3rd Floor Campbell Sqaure 10 Duke Street Liverpool L1 5AS 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 Englewood DS0000054702.V281428.R01.S.doc Version 5.1 Page 26 - 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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