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Inspection on 14/06/05 for Englishcombe House

Also see our care home review for Englishcombe House for more information

This inspection was carried out on 14th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home is currently managed well and there is a good relationship between staff and residents. Residents have opportunity to have a varied daily life at the home. They receive good meals, visitors are encouraged and various informal activities are available. Those who were able to inform, did so, in relation to the enjoyment of being in the garden and going on trips with staff members. The staff team show a commitment to residents in their care. Relationships were observed to be courteous and discreet. The standard of care is good, and the home has a pleasant atmosphere.

What has improved since the last inspection?

The front garden has now been completed with additional seating and arbour. This provides a safe area for residents. Residents and visitors were pleased with the effect. Training has been robust in areas relating to providing care and wellbeing of the residents at Englishcombe. This is evident by the overview matrix that has been developed.

What the care home could do better:

The manager has been asked to improve a section in the residents care plans and associated records. This can be undertaken by the recording of consultation in the documentation of service user or their representative involvement in the reviewing process. This would better reflect the residents` views and consultation. Staffing arrangements should be reviewed at times when residents` needs are raised.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Englishcombe House 33 Englishcombe Lane Bath B&NES BA2 2EE Lead Inspector Jill Cornelius Unannounced 14th June 2005 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 and Care Homes for Adults 18 – 65*. 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. Englishcombe House D56_46576_EnglishcombeHse_233693_140605_Stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Englishcombe House Address 33 Englishcombe Lane, Bath, BaNES, BA2 2EE 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) 01225 428369 Cedar Care Homes Limited Mrs Michele Aldrich CRH-PC 20 Category(ies) of DE 20, DE(E) 20 registration, with number of places Englishcombe House D56_46576_EnglishcombeHse_233693_140605_Stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: A. May accommodated people with dementia aged 50 years and over. B. Mrs Aldrich to obtain the Registered Managers Award by December 2005. IF SHE HAS THIS ALREADY THEN THIS CONDITION HAS TO COME OFF; IT WILL NEED TO ANYWAY WHEN MICHELLE LEAVES.. Date of last inspection 30/03/05 Brief Description of the Service: Englishcombe is a home for twenty people aged 50 years and over with dementia.The home is situated in a southwestern suburb of Bath with easy reach to the city centre by car or bus and has panoramic views over the city centre from the front of the building. Englishcombe House D56_46576_EnglishcombeHse_233693_140605_Stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one day. Opportunity was taken to tour the premises, examine records and talk to staff and residents who were able to do so. All the residents were seen during the inspection. Two of the residents had visitors who gave their views to the inspector. What the service does well: What has improved since the last inspection? The front garden has now been completed with additional seating and arbour. This provides a safe area for residents. Residents and visitors were pleased with the effect. Training has been robust in areas relating to providing care and wellbeing of the residents at Englishcombe. This is evident by the overview matrix that has been developed. Englishcombe House D56_46576_EnglishcombeHse_233693_140605_Stage4.doc Version 1.30 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. Englishcombe House D56_46576_EnglishcombeHse_233693_140605_Stage4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Standards Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6-10 and 18–21) (Standards 11–17) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37–43) Englishcombe House D56_46576_EnglishcombeHse_233693_140605_Stage4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. 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. Prospective service users have an opportunity to “test drive” the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3 and 4 The admission process is well managed and residents/representatives are given clear information regarding the service. EVIDENCE: The Statement of Purpose has been reviewed and updated. The pre admission assessments were found to contain sufficient details. One new resident and their representatives said that they received a warm welcome. Relatives said they were informed of their loved one’s day to day progress in settling at the home by the manager. Englishcombe House D56_46576_EnglishcombeHse_233693_140605_Stage4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6-10 and 18 –21 (Adults 18-65) 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. Including their physical and emotional health needs. 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. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. Service users receive personal support in the way they prefer and require. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 7, 9, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 and 10 Residents are looked after well in respect of their health and personal care needs. Residents or their representatives need to be involved in care planning. EVIDENCE: Reviews of care needs are undertaken monthly and each aspect of the person’s care needs are considered. Consultation with residents and/or their representatives during review processes has not been happening. Englishcombe House D56_46576_EnglishcombeHse_233693_140605_Stage4.doc Version 1.30 Page 10 Administration of medication was seen and considered to be safe. Senior staff have undertaken accredited training in the administration and management of medication. Observation during the inspection showed staff having a good awareness of protecting residents’ privacy and dignity. A visitor commented the “access to other health professionals for their relative was undertaken promptly. This gave them a sense of security for their loved one”. Englishcombe House D56_46576_EnglishcombeHse_233693_140605_Stage4.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 11 – 17 (Adults 18-65) are: 12. 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. Including opportunities for personal development. Service users engage in appropriate leisure activities. Service users maintain contact with family/ friends/ representatives and the local community as they wish. And have appropriate personal, family and sexual relationships. 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. 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15, 16 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13 and 15 Social activities and meals are both well managed. EVIDENCE: During the inspection residents were observed having a lunchtime meal. This was served in a discreet and unhurried manner. Staff were observed to be attentive to residents needs. A number of people commented positively on the food and said that there was always a choice available. This was evidence by a last minute change for one resident. Menus were inspected and found to be balanced and interesting. The availability of snacks throughout the day such as fruit/sandwiches/chocolate helps to keep a high calorific intake as recommended for this client group. Two staff members take responsibility for arranging activities and visits to a number of places. One resident reported the recent trip to Cheddar Gorge and of their delight in eating a Strawberry Cream Tea. Another reported that their preferred choice was to visit a local pub with a staff member. Englishcombe House D56_46576_EnglishcombeHse_233693_140605_Stage4.doc Version 1.30 Page 12 Englishcombe House has an open policy with regard to visitors and this is clear in its statement of purpose and a notice in the home welcoming visitors. Visitors on the day of inspection commented on the enjoyment of activities and food provided at the home. A religious service is held fortnightly. Englishcombe House D56_46576_EnglishcombeHse_233693_140605_Stage4.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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. Including neglect and selfharm. The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Arrangements for protecting residents and responding to concerns are satisfactory. EVIDENCE: Residents’ visitors and staff comments showed that people feel comfortable discussing any concerns with the registered manager. No complaints have been forwarded to the Commission for Social Care Inspection since the last inspection. The home’s adult protection procedure is in line with using Bath and North East Somerset “No Secrets” policy. Englishcombe House D56_46576_EnglishcombeHse_233693_140605_Stage4.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) 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. Shared spaces complement and supplement service users’ individual rooms. Service users have sufficient and suitable lavatories and washing facilities. Provide sufficient privacy and meet their individual needs. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. And lifestyles. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 23, 24, 25, 26 A comfortable and safe standard of accommodation is provided for the residents. EVIDENCE: In general, the environment is well maintained and suited to the needs of the residents. The home is decorated and furnished to a high standard that creates a comfortable and homely ambience. Bathrooms and toilets were found to be of good standard. These are fitted with appropriate aids to help maintain independence for residents. Englishcombe House D56_46576_EnglishcombeHse_233693_140605_Stage4.doc Version 1.30 Page 15 The residents’ rooms seen were homely. Residents had been able to bring small pieces of their own furniture and possessions with them. All areas of the home smelled pleasant and were cleaned to a high standard. The laundry is equipped with suitable machinery ensuring all risks to cross infection reduced. Two residents informed the inspector “how nice their clothing was”. This was also supported by the appearance of all residents on this unannounced inspection. The garden to the front and side offer a secluded safe area for residents and visitors. Improvements to the rear garden are scheduled to start later this year. Englishcombe House D56_46576_EnglishcombeHse_233693_140605_Stage4.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 36 (Adults 18-65) are: 27. 28. 29. 30. • • • Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. 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. Service users benefit from clarity of staff roles and responsibilities. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers standards 27, 29 and 30 (Older People) and Standards 34 and 35 (Adults 18-65) the key standards to be inspected at leat once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28 and 30 Staff at the home are trained, supported and employed in sufficient numbers to meet the needs of the residents. Management of times when residents’ needs are heightened will need further thought by the manager. EVIDENCE: Staffing levels met the minimum standard and residents appeared to be well looked after. One resident informed the inspector that they “liked all the staff”. Discussion took place in relation to times when residents’ needs are heightened. Discussion took place in management of these times was suggested by the inspector. The manager was keen to action this proposal. Six of the care staff hold NVQ2 or above. A training matrix was viewed and evidenced training is well planned. This will support the staff in providing for the varied needs of the residents. The three staff files looked at during the inspection showed that the overall standard of required information they contain is good. Englishcombe House D56_46576_EnglishcombeHse_233693_140605_Stage4.doc Version 1.30 Page 17 Englishcombe House D56_46576_EnglishcombeHse_233693_140605_Stage4.doc Version 1.30 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 37 – 43 (Adults 18-65) are: 31. 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 a well run home and from competent and accountable management of the service. 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. Service users are confident their views underpin all self-monitoring, review and development by the home. 32. 33. 34. 35. 36. 37. 38. • The Commission considers standards 33, 35 and 38 (Older People) and Standards 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 36, 38 There is a positive management approach by the registered manager. The leadership, guidance and the direction of staff all result in consistent quality care. This promotes the health, safety and welfare of the people using the service. EVIDENCE: Residents, their visitors, visiting professionals and staff made positive comments about the management of the home and gave examples of the ways they have been involved and consulted. Englishcombe House D56_46576_EnglishcombeHse_233693_140605_Stage4.doc Version 1.30 Page 19 Senior staff meetings minutes for April and May were viewed and evidenced a route for discussions and learning opportunities. These are undertaken at present on a weekly basis. Other care staff have a meeting on alternate months. An overview matrix of staff supervision has been established and records evidenced this being sustained. Performance issues were observed as being properly followed up and concluded. The records of tests to the fire safety equipment were in good order and health and safety issues were well managed. Englishcombe House D56_46576_EnglishcombeHse_233693_140605_Stage4.doc Version 1.30 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 3 2 x 3 3 4 3 5 x 6 x HEALTH AND PERSONAL CARE ENVIRONMENT Standard No 19 20 21 22 23 24 25 26 STAFFING Score 3 3 3 x 3 3 3 3 Score Standard No 7 8 9 10 11 Score 2 x 3 3 x Standard No 27 28 29 30 3 x 3 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No 16 17 18 Score 3 x 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 3 33 x 34 x 35 x 36 3 37 x 38 3 Englishcombe House D56_46576_EnglishcombeHse_233693_140605_Stage4.doc Version 1.30 Page 21 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, Sch. 3 (1) (6) Requirement care plan to reflect the involvement of the service user whenever capable and or their representative. Timescale for action From 22/07/05 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 30 Good Practice Recommendations Review the staffing arrangements for times when residents needs are hightened as discusssed in standard. Englishcombe House D56_46576_EnglishcombeHse_233693_140605_Stage4.doc Version 1.30 Page 22 Commission for Social Care Inspection 300 Aztec West Almondsbury South Gloucestershire BS32 4RG 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 Englishcombe House D56_46576_EnglishcombeHse_233693_140605_Stage4.doc Version 1.30 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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