Inspection on 24/05/06 for Ennis House

This inspection was carried out on 24th May 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Ennis House 23/11/09

Ennis House 13/08/07

Ennis House 01/12/05

Ennis House 18/04/05

Ennis House 05/11/04

Ennis House 14/04/04

Ennis House 28/05/03

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

1 Marten Road

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Ennis House 59-61 Enys Road Eastbourne East Sussex BN21 2DN Lead Inspector Lucy Green Key Unannounced Inspection 24th May 2006 10:45 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 Ennis House DS0000021096.V291056.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. Ennis House DS0000021096.V291056.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ennis House Address 59-61 Enys Road Eastbourne East Sussex BN21 2DN 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) 01323 720719 Mr Michael Baldry Mr Michael Baldry Care Home 40 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (40), Old age, not falling within any of places other category (40) Ennis House DS0000021096.V291056.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The maximum number of service users to be accommodated is forty (40). Service users must be older people aged sixty-five (65) years and over on admission. A maximum of twenty service users at any one time may be aged between fifty (50) and sixty-four (64) years. This includes one named service user aged forty-nine (49) years on admission. Service users with a primary diagnosis of past or present mental illness only to be accommodated. 1st December 2005 Date of last inspection Brief Description of the Service: Ennis House is registered to provide long-term residential care for up to forty older people with either a past or present mental disorder. This service does not provide intermediate care. The home is a large property, which has been created by adapting and linking three terraced houses. The home is situated in a residential area of Eastbourne, close to the town centre. Resident accommodation is provided in single rooms, many of which have ensuite facilities. Communal space is provided by a number of lounges and a dining room - which offer both smoking and non-smoking facilities. The home has sufficient toilets and bathrooms. A passenger lift provides partial access to the upstairs of the home. Two spacious gardens are situated to the rear of the property Information provided by the Provider on 03 May 2006 details that the current cost of placement at Ennis House is £366.06. Additional charges are payable for hairdressing, chiropody and newspapers. More detailed information about the services provided at Ennis House can be found in the home’s Statement of Purpose and Service User Guide – copies of these documents can be obtained directly from the Provider. Latest CSCI inspection reports are on available on request at the home. Ennis House DS0000021096.V291056.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulations 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at Ennis House are referred to as ‘residents’. This report reflects a key inspection based on the collation of information received since the last inspection, feedback from representatives and visiting professionals, an unannounced site visit which lasted seven hours on Wednesday 24 May 2006 between the hours of 10:45am and 5:45pm and a follow-up announced visit between 9:30am and 11am on Wednesday 14 June 2006. The site visit included a tour of the premises and an examination of medication, care and staffing records. The Inspector joined residents in the dining room for their lunchtime meal and observed the afternoon activity. Throughout the inspection process, the Inspector spoke with sixteen of the thirty-seven residents individually and observed the way other residents were supported in communal areas. In addition feedback questionnaires were received from six residents. Telephone conversations were held with one visiting healthcare professional and written feedback was received from five Doctors. Comment cards were given to the home to pass onto relatives and visitors, but none had been returned at the time of writing this report. The Inspector spoke with the Registered Manager and seven staff members, including the Care Manager, Activities Co-ordinator, three Senior Carers and one Carer, both individually and collectively throughout the inspection process. What the service does well: Ennis House provides a high quality service to the people it accommodates. The home has a relaxed and friendly environment where people are supported to live their lives as they choose. The home has an experienced team of staff who enjoy their work and have a good understanding of the needs of the people living at the home. Residents spoke highly of the support received by staff and positive relationships between staff and residents were observed. Choice is given paramount importance at Ennis House and staff consult with residents about all aspects of their daily lives as a matter of routine. The provision of meals enables residents to have food and drink at times which suit Ennis House DS0000021096.V291056.R01.S.doc Version 5.1 Page 6 them. As such, breakfast is served across a period of several hours to enable accommodate the differing times that people get up. The home has to manage a lot of resident medication and there are robust systems in place to ensure that this is managed 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. Ennis House DS0000021096.V291056.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 Ennis House DS0000021096.V291056.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, 3 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective and current residents benefit from the provision of comprehensive information about the services provided at Ennis House. The improved assessment systems ensure that the home can meet the needs of the people it accommodates. There is no provision for intermediate care at Ennis House. EVIDENCE: The home has an up to date Statement of Purpose and Service User Guide which provide comprehensive information about the services offered at Ennis House. Both staff and residents spoken with were clear about the purpose of Ennis House and the level and type of care provided. A new assessment pro forma has been produced and this was examined in respect of the two most recent admissions. There was documentary evidence in respect of both individuals that the home had conducted a thorough and detailed assessment prior to admission. The home had also obtained copies of Ennis House DS0000021096.V291056.R01.S.doc Version 5.1 Page 9 the latest Care Management Assessment and Integrated Care Programme Approach for these individuals. Prospective residents are encouraged to visit the home prior to admission to assess the suitability of the placement. There was evidence in care plans and from speaking with the individuals, that both people recently admitted to Ennis House had visited the home prior to moving in. In both cases the home had confirmed in writing to the individual and their Care Manager when the trial period had expired and that the home could meet the individual’s needs for a permanent stay. There is no provision for intermediate care at Ennis House and therefore Standard 6 is not applicable. Ennis House DS0000021096.V291056.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health and personal care needs are fully met in a respectful and private way. Residents are further protected by the way medication is managed. EVIDENCE: Staff practices observed throughout the inspection again demonstrated a good understanding of the residents and their needs. Discussion with staff produced evidence that they have an excellent knowledge about the people they support. It was clear from observation, talking to residents and staff and from the written material in place, that care and support is provided in a sensitive, dignified and respectful way. One resident informed the Inspector that she has a key for her bedroom door and that staff always respect her privacy and knock before entering her room. Another resident confirmed that staff support them with their personal routines in an appropriate way. Residents are Ennis House DS0000021096.V291056.R01.S.doc Version 5.1 Page 11 encouraged to be as independent as possible and it was entirely obvious that staff provide support in the way preferred by each individual. A sample of five care plans were viewed and it was pleasing to note that significant improvements have been made in this area. There was evidence that each resident has a plan of care that provides detailed information about their health and welfare needs. Care plans are compiled with a multidisciplinary approach and are now well maintained and easy to use. Care plans are reviewed on a monthly basis and any changes made are recorded. It was evident that residents and other relevant parties are now included in compiling and reviewing care plans. Care plans contain risk assessments for a range of areas and in line with a requirement from the last inspection these have been reviewed and additional information included. It is now possible to track the level of risk and the controls in place to minimise the risk. Residents are fully supported with their health care needs and care plans contain a record of any visits or contact with professionals external to the home. There was evidence of current involvement from General Practitioners, District Nurses, Dentists, Chiropodists, Optician and the Community Mental Health Team. Following the inspection, the Inspector wrote to nine General Practitioners to gain feedback on their experiences of the way Ennis House manages residents’ healthcare. At the time of this report, five comment cards and been returned, all of which were positive of the way healthcare is provided. One Doctor wrote: “there are some residents who would not be able to live in any other home in Eastbourne. The staff are understanding, patient and caring”. Records demonstrated that residents are regularly weighed and dietician input is sought where necessary. One resident currently has very high healthcare needs and the care plan reflected the necessary steps being taken in respect of pressure care and maintaining nutrition. The home has a good system in place for managing the large amount of medication that has to be administered each day. Records were clear and it was possible to track changes of medication. The home has introduced new guidelines for the correct handling of prn medication (prescribed as necessary). Several staff have undertaken relevant medication training and a further three staff are booked on a course for February 2006. A Senior Carer reported that only senior staff who have been appropriately trained and supervised handle medication. It was identified that four residents administer some of their own medication. It was evident from discussions with staff that appropriate discussions and Ennis House DS0000021096.V291056.R01.S.doc Version 5.1 Page 12 assessments had taken place to ensure that these individuals were competent to manage their medication, however, these assessments were not recorded in the care plan. It is therefore required that these are included and regularly reviewed. Ennis House DS0000021096.V291056.R01.S.doc Version 5.1 Page 13 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to lead their lives how they choose. Residents benefit from a sociable and inclusive environment where there are lots of opportunities to participate in fulfilling activities. Choice and flexibility are given paramount importance at mealtimes. EVIDENCE: The programme of activities at Ennis House has continued to flourish and now the established routine of daily activities exceeds the National Minimum Standards. One individual has taken responsibility for the co-ordination of activities in the home and has produced a social profile for each resident which provides a synopsis of information about the social likes and dislikes of each resident. The activity timetable provides a raft of meaningful activities including skittles, cricket, bingo, arts and crafts and card games. Evaluation sheets are in place for each day and therefore it was possible to track the activities that had taken place, who had participated and how successful each event was. On the day of inspection, the Inspector observed six residents playing cards with the activities co-ordinator and two other residents were happily watching the game Ennis House DS0000021096.V291056.R01.S.doc Version 5.1 Page 14 and listening to the music that had also been put on. Individual conversation with five residents about the activities highlighted that they valued the opportunities to participate in planned social events each day. The day before the inspection, twelve residents had participated in a game of skittles and people were chatting about who had won. A conversation with one resident identified that she does some paid work in the home and with the money she earns she is able to buys newspapers and play the lottery. Some residents are able to go out independently, for others support is required. Staff confirmed that they did everything they could to facilitate people’s wishes. One staff member, commented that one resident would love to go out all day, every day with staff and whilst it is not always possible to make this happen, staff said that she regularly gets to go to the pub, out for walks and is included on regular shopping trips into town. In addition to the in-house activities, the home also has monthly visits from the Music In Care Homes group. Three residents go to church every week, two of which go independently in a taxi and the third is taken and collected by the Manager. It was reported that the Manager has also now licensed a vehicle and has started taking groups of residents on trips outside the home. Throughout the inspection it was evident that residents at Ennis House have a lot of choice and control over their lives. Staff were observed offering choice about drink and meals. It was noted that mail is given unopened to residents and privacy is respected at all times. Conversations with staff highlighted that choice is something they do automatically. When interviewed about choice, one staff member said “residents get any choices they want”. Another staff member re-iterated: “residents have choice about everything; when to get up, what to do, what they want to eat”. Residents were observed during the inspection spending time doing the things they chose, at the time they chose. Bedrooms are decorated and furnished to reflect the individual. In line with a requirement at the last inspection, the home has now improved its systems for evidencing choice. A statement in one care plan said; “[the resident] is given the freedom of choice throughout her daily life at Ennis House”. Throughout each section of the care plan, were examples of how guidelines reflect individual choices and preferences. Ennis House promotes an open door policy for visitors during the day. Residents spoke of visitors they had received and the home maintains a record of the contact each resident has with his or her relatives and friends. Ennis House DS0000021096.V291056.R01.S.doc Version 5.1 Page 15 The provision of meals continues to be of high quality. Meals are prepared according to a four-week rotating menu, with all parties confirming that an alternative is always available. The Manager confirmed that the kitchen is open all day and residents can have snacks and drinks at any time. This was indeed found to be the case on the day of inspection. Breakfast is served over several hours to accommodate the different times people choose to get up. There is always the option of a cooked breakfast and on the day of inspection one resident informed the Inspector that the cooked option that morning was Kippers which she had thoroughly enjoyed. The lunchtime meal was observed, with the main meal being chicken pie, served with vegetables and potatoes. Dessert was peaches and cream. One resident informed the Inspector that they were allergic to poultry and therefore had chosen an omelette and vegetables as an alternative. The food was appetising and nicely presented and all residents spoken with spoke highly of the food provided at Ennis House. Residents are able to choose where to take their meals, but for many this is seen as a social time. The dining room is arranged into small groups and lots of positive interaction was noticed at this time. One resident is on a specialist diet due to currently high healthcare needs, it was noted in the care plan that it was necessary for staff to provide full support at mealtimes and record all food and fluid intakes. These records were found to be current and appropriately completed. Ennis House DS0000021096.V291056.R01.S.doc Version 5.1 Page 16 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 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from an open culture where they are able to express their views and feel valued and protected from harm. EVIDENCE: Ennis House has a complaints policy which is accessible to both residents and visitors to the home. The home has received two complaints in the last twelve months, which were appropriately handled by the Provider. The CSCI has not received any complaints about the provision of service at Ennis House in the last twelve months. The residents spoken with all confirmed that they knew how to complain and stated that if they had any concerns they would go straight to either the Provider or the Head of Care. The staff interviewed were knowledgeable about the vulnerability of residents and the systems in place to protect them. The adult protection policy has recently been updated to include information discussed at the last inspection. The Head of Care and a Senior Carer are booked to attend a training course on abuse, which they will then cascade to the rest of the team. Ennis House DS0000021096.V291056.R01.S.doc Version 5.1 Page 17 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 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from an environment which provides choice of space and privacy, however, a number of maintenance issues impact on both safety and homeliness. EVIDENCE: Ennis House is a large property, which in addition to single bedroom accommodation, offers a range of communal areas. The home is divided into two areas; one of which provides level access by way of a passenger lift. The other part of the building is accessed by stairs and therefore the residents accommodated in this part of the house must be fully ambulant. During a tour of the building, the Inspector again highlighted a number of maintenance issues which require attention. For example, the carpet in a number of areas is frayed, which not only looks worn, but also poses a trip Ennis House DS0000021096.V291056.R01.S.doc Version 5.1 Page 18 hazard. Some parts of the home are used as a general storage areas and for reasons of health and safety and general homeliness, should be cleared. A number of bedrooms were found to be malodorous and some in need of general re-decoration. A maintenance programme is in place and many of the issues raised by the Inspector are included on this schedule. A general requirement has therefore been made that the Manager review the priority of work being done to ensure all areas of the home are maintained to a safe standard. Ennis House DS0000021096.V291056.R01.S.doc Version 5.1 Page 19 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from being supported by an experienced and committed team of staff EVIDENCE: On the day of inspection, there were sufficient staff to support the needs of residents as detailed in the care plans. Rotas indicated that staffing levels provide a minimum of eight care staff between 8am and 2pm and five care staff between 2pm and 8pm. At night, the home is staffed by two waking carers. In addition to care staff the home employs adequate numbers of cooking and domestic staff. Staff spoken with all confirmed that staffing levels were adequate at this time. The residents who spoke with the Inspector again commented how nice staff were. One resident expressed: “the staff are a good crowd and really look after you” and another told the Inspector: “I like living here very much, everyone is very nice and people go to so much trouble for you”. The interaction between residents and staff was again observed to be extremely positive. Staff training is ongoing, four staff (20 ) have now completed and four staff are working towards National Vocational Qualifications (NVQ). Fifteen staff have either completed or are undertaking an induction in line with the National Ennis House DS0000021096.V291056.R01.S.doc Version 5.1 Page 20 Training Organisation through an outside training body. Once the induction training has been completed, it is reported that these people will then move on to NVQ’s. The home has a training matrix in place and planned updates include manual handling, first aid, medication and fire training. It was a requirement of the last inspection that specific training in supporting people with mental health needs and managing challenging behaviour be provided for staff. The Head of Care reported that they have been unable to find a provider of this training. After the inspection, the Inspector provided the home with some contact points to assist them and this requirement is re-affirmed. The home has not employed any new staff since the last inspection and therefore the staff files for two previously recruited staff were inspected. It was pleasing to note that the required information was in place for both individuals, including satisfactory checks with the Criminal Records Bureau, two written references, completed application form and full employment history. The Inspector reminded the home to fully check the status of any oversees staff in respect of working permissions. Ennis House DS0000021096.V291056.R01.S.doc Version 5.1 Page 21 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, 35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a home that is well managed and run for their best interests. The home will need to develop formal systems for quality assurance in order to continuously improve service delivery. EVIDENCE: The management team at Ennis House, ensure that the home is run in the best interests of the people who live at the home. The Registered Owner/Manager has been in post for eighteen years and has a wealth of experience in this field. That being said, he does not have either the care or management qualifications required by the National Minimum Standards. The Head of Care is working towards NVQ 4 in Care and Management and a Senior Carer holds the Registered Managers’ Award and NVQ level 4. The management team therefore collectively have the required skills and qualifications. It is therefore Ennis House DS0000021096.V291056.R01.S.doc Version 5.1 Page 22 judged that at this time, that the outcome for the people living at Ennis House is that they are living in a well managed home. Ennis House is an open and inclusive environment where people feel valued and listened to. That being said, there are however, no formal systems in place for monitoring quality assurance. It was discussed with the management team that the home needs to develop its own formal systems of self-audit and gaining feedback, in order that the home can continuously improve. As part of this process, regular recorded supervision sessions should be happening on a one-to-one basis for staff and regular staff meetings should also occur. Residents’ finances are safeguarded by a system that ensures all transactions are logged and receipts maintained. The home undertakes a series of health and safety audits, which include weekly fire drills for staff. The Inspector was impressed with the measures that have been put in place in response to issues which were identified during fire drills. For example, an additional bell was put in place in the laundry as it was discovered that if two washing machines were on spin cycle at the same time, the fire alarm could not be heard in the laundry. Staff fire training is currently occurring on an annual basis and it has therefore been required that this is increased to six-monthly. Ennis House DS0000021096.V291056.R01.S.doc Version 5.1 Page 23 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Ennis House DS0000021096.V291056.R01.S.doc Version 5.1 Page 24 YES 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 OP19 Regulation 23(1)(a) Requirement The process of redecoration and refurbishment must continue giving priority to areas of health and safety. Staff receive training in managing challenging behaviour and supporting people with mental health needs. (Previous timescale of 01/05/06 not met) A formal system of monitoring quality assurance to be put in place. (Previous timescale of 01/03/06 not met) This should include regular staff supervision and staff meetings. Staff to receive fire training at least once every six months. Timescale for action 01/08/06 2. OP30 18(1)(c) (i) 01/09/06 3. OP33 24 01/09/06 4. OP38 23(4)(d) 01/08/06 Ennis House DS0000021096.V291056.R01.S.doc Version 5.1 Page 25 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 OP9 Good Practice Recommendations Risk assessments are in place for those service users who self administer their own medication. Ennis House DS0000021096.V291056.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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. 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