Inspection on 17/01/06 for Englishcombe House

This inspection was carried out on 17th January 2006.

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.

Other inspections for this house

Englishcombe House 23/08/06

Englishcombe House 14/06/05

Englishcombe House 17/03/05

Englishcombe House 25/11/04

Englishcombe House 09/12/03

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Englishcombe House 33 Englishcombe Lane Bath Bath & N E Somerset BA2 2EE Lead Inspector Jill Cornelius Unannounced Inspection 17th January 2006 10:00 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 Englishcombe House DS0000046576.V282491.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. Englishcombe House DS0000046576.V282491.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Englishcombe House Address 33 Englishcombe Lane Bath Bath & N E Somerset BA2 2EE 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) 01225 428369 Cedar Care Homes Limited To be appointed Care Home 20 Category(ies) of Dementia (20), Dementia - over 65 years of age registration, with number (20) of places Englishcombe House DS0000046576.V282491.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate people with dementia aged 50 years and over Date of last inspection 14th June 2005 Brief Description of the Service: Englishcombe House is a home registered for twenty people aged 50 years and over with dementia. The home is situated in a southwestern suburb of Bath with easy access to the city centre by car or bus and panoramic views over the city from the front of the building. The home is a converted older property, providing mostly single bedroom accommodation. There is one double bedroom and one en-suite room. Resident’s accommodation is on 3 floors with communal space on the ground and first floors. There is a passenger lift providing access to all areas. The home has a front garden with patio area and a terraced rear garden offering a safe wandering environment for residents. Ms. Michele Aldrich has relinquished her post as the manager at Englishcombe House. The acting manager is Ms. Jane Mcube and has been in post since December 05. Englishcombe House DS0000046576.V282491.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report following the unannounced inspection of Englishcombe House, which was conducted on the 6th February 06. During the inspection the inspector spent time in discussions with the acting manager, examined a number of records, including six care plans, and records relating to the day-to– day running and management of the home. The inspector spent time observing the residents’ in the home throughout the course of the visit and spoke with four at length and three visitors’. Members of staff were observed on duty and two were consulted individually. The impression given by all these sources was positive and no complaints or concerns were noted. Englishcombe House was found to be clean and tidy. The management team has undergone a change since the last inspection and the acting manager Ms. Jane Mcube is in the process of registration with the Commission for Social Care Inspection. Neither the home nor the Commission for Social Care Inspection has received any complaints about the home since the last inspection. The home’s senior staff team have, however, received a number of thank you letters from relatives praising the quality of care provided and the dedication of the staff team. Two of these highlighted ‘the staff are very caring, the food is plentiful and good’, ‘our loved one is very happy here and he/his health and well being has improved considerably’. An immediate requirement was made in relation to this inspection. See standard 7. What the service does well: Residents’ receive good meals, visitors are encouraged, various informal activities made available and they said that they enjoy days out with staff. Staff were observed as being respectful, warm in manner and sensitive towards the residents. Englishcombe House DS0000046576.V282491.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Englishcombe House DS0000046576.V282491.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 Englishcombe House DS0000046576.V282491.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 and 3 The home provides clear and detailed documentation to enable prospective residents or their representatives to make an informed choice about living at Englishcombe House. Staff are aware of admission procedure with appropriate information in order that residents may make an informed decision on whether the home is able to met their needs. Prospective residents needs are assessed prior to admission to determine the suitability of placement. EVIDENCE: The inspector saw that the home has a well-written statement of purpose. This document contains all of the required information as outlined in Schedule 1. The Inspector looked at four pre – admission assessments, which were completed fully and were informative. The prospective resident, family and carers are involved in the pre – assessment and all information is used to determine the suitability of the placement. The manager had also obtained Englishcombe House DS0000046576.V282491.R01.S.doc Version 5.1 Page 9 comprehensive assessments and care plans from other professionals involved, for example, social workers and hospital staff. One new resident and their representatives said that they “received a warm welcome”. One relative consulted during the inspection confirmed that “they were informed of their loved one’s day to day progress in settling at the home by the manager”. Englishcombe House DS0000046576.V282491.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 and 10 Residents are at risk of not having their health and personal care needs meet. Further attention needs to be given to the completion of new residents care plans within the 24 hrs time scale. The standard of personal care provided to residents is overall good but attention to final grooming is varied. EVIDENCE: It was evidenced that the care plans for four new residents had not had a care plan generated from assessment details. The outcome for residents is that there health care needs be not be fully met or that they may not receive the appropriate treatment. An immediate Requirement was made to action the completion of those identified. Other care plan documentation viewed was comprehensive and overall completion to a good standard. Care plans are reviewed approximately monthly or if a resident needs change. There was recorded evidence of relative involvement of one of the care documents viewed. Discussion with the acting manager took place in relation to this. Englishcombe House DS0000046576.V282491.R01.S.doc Version 5.1 Page 11 Arrangements are made for residents to remain with their own GP if they wish and if the GP consents to visit them at Englishcombe. The GPs visit the home upon request from the home or resident. The consultant psycho geriatrician also visits residents at Englishcombe. There was evidence of multidisciplinary working taking place on a regular basis. Equipment was observed to be in place to prevent pressure sores in residents who were at risk. Arrangements are made on request for residents to attend their own or local dentist / optician. Domiciliary optical services are provided annually and dental on request to the home for residents who are unable to access the community facilities. Residents can meet visitors or visiting professionals in their own rooms. Throughout the inspection it was observed how the management and staff team treat all residents with respect and dignity and how independence is encouraged. Three relatives seen at the time of the inspection confirmed this. One relative said that sometimes her/his father has not had a shave when s/he visits, but this is often because he does not want one. S/he said that he was able to shave himself and she has told staff to continue to encourage him to do this activity himself during the recent review. Another relative commented that the “access to other health professionals for their relative was undertaken promptly. This gave them a sense of security for their loved one”. A care worker was asked to give examples of how individuals are able to make choices and to have some control over their lives, she was able to tell the inspector about individuals decisions, some of these where cross referenced with information seen in individuals care documents and also what had been observed during the inspection. Individuals were seen to be relaxed and at ease in the presence of others. Englishcombe House DS0000046576.V282491.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 and 15 The flexibility of the home’s routines, the provision of activities and opportunities for residents to make visits outside the home need to be maintained. Visitors are made to feel welcome and meals are well managed and provide daily variation, nutrition and social contact for people. EVIDENCE: 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. Residents are able to have visitors at any time and make visits outside the home as they wish. This pattern is welcomed and encouraged by the home and the organisation. The residents in this home have a deteriorating and variable condition of dementia. They will for the greater part rely on the advocacy role of their carers (whether the home’s staff or their relatives) to interpret the majority of their care needs. The residents in this home have a deteriorating and variable condition of dementia. They will for the greater part rely on the advocacy role of their carers (whether the home’s staff or their relatives) to interpret the majority of their care needs. Effective advocacy relies heavily on the observational skills of the staff, especially for residents who are unable to Englishcombe House DS0000046576.V282491.R01.S.doc Version 5.1 Page 13 express themselves. From observation of interactions, there was evidence that staff have the skills and confidence to observe and interpret the needs of residents and advocate effectively on their behalf when necessary. Visitors on the day of inspection commented on the enjoyment of activities. However it was noted by the inspector that there had been a reduced effort in providing/assisting in this area. A record of activities was viewed which showed the following A religious service is held fortnightly. During this unannounced visit the inspector did not receive any complaints. Comments from residents included “I am happy here. There are lots of people to talk to,” “I like it here”, “staff are very nice.” The inspector had opportunity to see several relatives whose comments included: “I am happy with the care provided for my relative and all staff are very caring and supportive”. “The manager and other staff are always willing to talk about how she/he has been and whether he/she is anxious or unsettled”. Relatives meetings have been held during the past 6 months. Discussion with the acting manager took place regarding the importance of this, in relation to offering support to relatives, as well as the opportunity to improving communication. Opportunity was taken in joining the residents at lunch in the lounge / dinning room. The meal was well presented and residents, who were able, commented that it was tasty. The catering staff are able to offer alternative choices right up to and during meal times. Staff members served, supervised and assisted residents’ discreetly in the dining room; the meal was unhurried. A four-week menu plan is provided and this is on display in the home for the residents to see. A copy is also displayed in the entrance hall. A month’s record of meals served is kept and showed a varied and balanced diet. There was also fruit and finger food available for residents throughout the day. The kitchen was not inspected on this occasion. Englishcombe House DS0000046576.V282491.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 and 18 The systems in place help to protect residents from abuse and ensure complaints are responded to promptly. EVIDENCE: Evidence gathered during the inspection confirmed that any concerns raised by residents / advocates are acknowledged and actions taken where possible to resolve issues. Englishcombe has a policy on the protection of service users and follows the inter-agency procedure for the protection of vulnerable adults in Bath and North East Somerset. Staff are trained in ‘Alerter’s awareness of abuse’ and senior staff are trained in the ‘Investigation level’. Discussion with Ms. Jane Mcube, the acting manager promoted the need for staff to have a heightened awareness of their adult protection responsibilities, due to the vulnerability of the residents living at Englishcombe. Englishcombe House DS0000046576.V282491.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, 24 and 26 A comfortable, clean, safe standard of accommodation is provided. EVIDENCE: The home is well maintained both inside and out creates a comfortable homely atmosphere. In consultation with Dementia Voice, the landscaping of the rear garden has been completed and now provides a safe wondering area for residents at Englishcombe. Residents’ bedrooms looked homely and were personalised with residents’ personal possessions and small items of furniture. It was noted that that the home was very clean. Only one bedroom had an offensive odour. This was discussed with the acting manager who was aware of the problem. She stated that the carpet had been cleaned regularly but the smell had persisted. It was planned to be replaced as soon as possible. Englishcombe House DS0000046576.V282491.R01.S.doc Version 5.1 Page 16 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 and 30 Staffing levels are adhering to the previously agreed levels for care and ancillary staff, with the manager being supernumerary to the care hours. EVIDENCE: The duty rotas for a two week period was viewed these showed that the staff complete the same specific hours each week, and staff spoken to verified this. The manager uses it’s own staff group to cover any staff absences. Statutory training undertaken include, manual handling, basic food hygiene, fire safety, first aid and protection of vulnerable adults. Discussion with Ms. Jane Mcube relating for the importance of specialist training such as dementia care and mental health training to ensure that all staff have the appropriate experience to work in this care home is maintained. NVQ training for both domestics and care staff are ongoing. Englishcombe House DS0000046576.V282491.R01.S.doc Version 5.1 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 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, 36 ,37 and 38 Since the last inspection there has been a change in management. The Commission for Social Care Inspection are awaiting the application for registration. Staff are appropriately supervised. Resident’s rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Quality and Assurance monitoring system is in place. The records for each resident are kept securely in the office, along with staff files. EVIDENCE: Since the last inspection there has been a change in management. Englishcombe House DS0000046576.V282491.R01.S.doc Version 5.1 Page 18 Ms. Jane Mcube, previous deputy manager, has undertaken the role of acting manager and her application for registration is awaited. This will be inspected in full during the next inspection. Regular supervision has occurred and the manager needs to maintain supervision sessions for care staff at least 6 times per year and maintain records of these in the staff files. Evidence was obtained by viewing 4 staff records. This was verbally confirmed as being undertaken by 2 staff members asked. Supervision and appraisal overview is used to assist with planning. Senior meetings are in place and held on a monthly basis for the organisation with care meetings every other month. This aims to measure the success in meeting the aims, objectives and the statement of purpose of the home. Records are stored safety and are able to be locked. The organisation has a clear confidentiality policy, a staff member referred to this when asking for identity verification from the inspector upon arrival to the home. Recent Regulation 37 notifications discussed and information needed clarified with acting manager. All visitors to the home are asked to sign in and out. The current insurance certificate was displayed. All appropriate service contracts are in place. Englishcombe House DS0000046576.V282491.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 x x x 3 x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 3 x x 3 3 3 Englishcombe House DS0000046576.V282491.R01.S.doc Version 5.1 Page 20 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 2 Standard OP7 OP37 Regulation 15(1) 26 Requirement Timescale for action 17/01/06 3 OP30 18(1)(c) (i) Ensure all residents have a fully completed up to date written plan of holistic care. Ensure monthly visits are carried 17/01/06 out as per this regulation. Send a copy of the record of these visits monthly to the Commission for Social Care Inspection. Ensure all new staff to undertake training in caring for residents 06/07/06 with Dementia. 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 13 Good Practice Recommendations Review the amount of outside activities on offer to residents at Englishcombe House. Englishcombe House DS0000046576.V282491.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos 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 DS0000046576.V282491.R01.S.doc Version 5.1 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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