Inspection on 12/10/06 for Eothen

This inspection was carried out on 12th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Eothen 29/12/05

Eothen 23/09/05

Eothen 24/01/05

Eothen 10/06/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Eothen 31 Worcester Road Sutton Surrey SM2 6PT Lead Inspector David Pennells Key Unannounced Inspection 12th October 2006 10:30a 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 Eothen DS0000007193.V306565.R01.S.doc Version 5.2 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. Eothen DS0000007193.V306565.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eothen Address 31 Worcester Road Sutton Surrey SM2 6PT 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) 020 8642 2830 020 8643 7961 enquiries@eothenhomes.org.uk www.eothenhomes.org.uk Eothen Homes Limited Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (41) of places Eothen DS0000007193.V306565.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th December 2005 Brief Description of the Service: Eothen is a residential home registered to provide care for 41 older people. The service is underpinned by a low-key, but positively declared, Christian ethos ‘Eothen’ - from the Greek - means ‘The Dawn’ and is referenced into Paul’s Epistle to the Romans (13:12). The home also has a non-smoking policy. There are also a small number of sheltered housing flatlets on site - though there is little link between these independent living environments and the service itself. The home is ideally situated just to the south west of Sutton town centre, no more than half a mile from bus and train services and the main shopping, leisure and entertainments centre of the town. The building forms a quadrangle, with many rooms looking out onto an extremely well kept and attractive central garden (maintained to this standard even in the depths of winter), and which service users can easily access throughout the year. The front (northern side) of the property comprises a three-storey (older) building with accommodation provided on all three floors (served by passenger lift, but still leaving for some rooms some steps to negotiate). Towards the rear of the property is the newer south wing, with accommodation on the ground and first floors. There is ample communal space that includes small quiet lounges, a central lounge, a large (underused) lounge in the south wing, and two dining rooms. The home is very well maintained and, despite its size, maintains a smart - but warm and homely ambience. There are thirty-eight single bedrooms, three of which are large enough to be used as double occupancy for couples, if they so wish. Seventeen of the bedrooms currently have ensuite facilities, and it is projected in future to increase this number. All care and laundry services are provided in-house; meals are prepared on site in a well-provided kitchen, but by a separately managed catering company. Eothen DS0000007193.V306565.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector was met and welcomed by the Assistant Manager / care Coordinator, Ann Gould - who was able to assist the inspector to review the requirements set at the last inspection, and to clarify any points raised. Following the examination of some paper work, the inspector was invited to take lunch with service users in the dining room and then, as ever, was free to roam the house - where he met with a significant number of additional service users. The inspector toured the building, randomly checking the premises for security and safety - and returned to the office to discuss his findings with the Assistant Manager. Due to the need for the inspector to clarify some issues relating to staff recruitment, the inspector returned to the home the following Tuesday evening (17/10/06) - when he met with the newly-appointed manager, Sue Henderson. The inspector is grateful to the service users, staff and management of the home for their welcome, hospitality and positive cooperation throughout this inspection visit. What the service does well: Eothen Sutton continues to provide a very good personal service to individuals resident at the home. Despite the departure more recently of the appointed manager, the home has now settled on the appointment of a familiar face to the home - Sue Henderson - the previous deputy, who is valued and appreciated by staff and service users alike. The home was continuing to run smoothly, this ‘takeover’ being seamless, with staff known by - and familiar to - the service user group. Relatives and visitors have again responded very well to the Commission’s questionnaire; twenty-two (out of a possible maximum total of usually 38) being returned, with a generally highly positive opinion of the overall care provision being to a good level - if not higher. The inspector again reflects that these responses are exceptional - when compared to most homes - in their quantity, positive approbation and good opinion of the home’s service - which has been through a ‘rollercoaster’ of different local managers over this last year-and-a-half. Stability, now hopefully, is established again. Service users again were unanimous in their positive feelings about the home and the service provided; the absence, and comings and goings, of appointed managers not disrupting the home’s good standards, thanks especially to the senior staff support and also to other staff’s ongoing quality input. Eothen DS0000007193.V306565.R01.S.doc Version 5.2 Page 6 Once the new manager has been registered with the Commission, has settled into her new role, and staffing has settled down within the new management regime, the inspector expects to return at the next key inspection and rate the home at the highest level. What has improved since the last inspection? What they could do better: Only two requirements are set from this key inspection: that the [revised] Regulation 19 process be employed when recruiting staff, especially when using staff under a PoVAFirst process; and that fire drill frequency must be stepped up to ensure that all staff are fully appraised of the actions to take in such an eventuality. Four recommendations revolve around: the need to review the provision of activities and trips for those especially who do not engage with the ‘in-house’ programme; the provision of an induction ‘loop’ to assist those who are hearing aid users to more fully engage in communal activities; an identified need for an additional fire exit pointer sign at the south wing exit; and the recommended focus on fully checking out the authenticity of references. Eothen DS0000007193.V306565.R01.S.doc Version 5.2 Page 7 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. Eothen DS0000007193.V306565.R01.S.doc Version 5.2 Page 8 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 Eothen DS0000007193.V306565.R01.S.doc Version 5.2 Page 9 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. Service users can be confident that they will be furnished with adequate information – and opportunities to visit - to make an informed choice about moving into the home, this being accompanied by the home conducting an assessment to ensure that the home is suitable for them and able to meet the needs of the applicant. The home does not provide intermediate (rehabilitative) care - and therefore standard 6 does not apply. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Eothen DS0000007193.V306565.R01.S.doc Version 5.2 Page 10 EVIDENCE: A new brochure is available for the home, alongside the Statement of Purpose and Service User Guide, which is provided at the home; these documents are comprehensive and cover all areas required by Regulations 4 & 5 and the associated Schedule. The general introduction states clearly the bedroom sizes and states the policy on sharing double bedrooms (the home has 38 rooms, three of which may be shared by partners / relatives). Service users admitted to the home through local authority care management arrangements will have a care manager’s comprehensive assessment of need completed - a copy of which is obtained, kept on file and used to construct the care plan. Senior staff members assess other potential (‘self-funding’) residents and a three-page comprehensive proforma, relevant to the older person user group, is used. The home’s visit to the prospective service user also ensures that questions can be answered, and the potential newcomer is also considered in the light of compatibility with the existing service users. The assessor decides whether the home is able to provide appropriate care to prospective users; the home does not aim to offer care to people with dementia, and to this end undertakes a modest assessment of users’ cognitive abilities. This visit also assesses whether a potential service users’ level of dependency might indicate a need more for nursing care – in which case a placement at Eothen would be inappropriate. Most prospective users are invited minimally to the home to have a meal, meet their potential fellow service users and the staff, and to view the facilities including the room on offer for their occupation. If the offer of a place is accepted, they are admitted on a trial period (an initial six week block), whereafter a Placement Review will be held, involving Care Managers and relatives and/or ‘significant others’. Whilst offering the possibility of respite (‘holiday’) stays, the home does not offer an intermediate care service - which involves assessment & rehabilitation. Standard (No 6) in not applicable and has not, therefore, been inspected. Eothen DS0000007193.V306565.R01.S.doc Version 5.2 Page 11 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 - 10. Service users can be assured that their needs will be clearly set out in a care plan – this includes identifying specific and general health care needs; the use of medication where appropriate, and all other health & care requirements. Service users can expect to be treated with the cordiality and respect expected of a home espousing the Christian religious ethos, to also receive elements of ‘pastoral care’ – and can be assured that their rights to privacy and dignity are upheld. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Care plans are well established for each service user, setting out the clear individual needs and goals of each service user. At the time of the inspection visit, there had been three admissions to the home within two days, and staff members were hard-pressed to ensure that all documentation was fully completed to ensure the fullest service at the very start of the placement. An emergency admission had precipitated this ‘crisis’ - pointing up the need to ensure that placements are as well planned beforehand as possible. Eothen DS0000007193.V306565.R01.S.doc Version 5.2 Page 12 The expressed health needs of a service user are heeded by staff and handed onto the senior staff, who refer to the GP. The relationship the home has with the District Nursing service was evidently - from engagements observed by the inspector during his visit - was positive. The principal GP used at the home responded positively to the Commission’s questionnaire, indicating a positive relationship between the home and the medical practitioners at the practice. The principal House GP holds a weekly ‘surgery’ at the home itself. The Chiropodist visits three-monthly and Opticians and Dentists are regular visitors every half-year, as well as service users being encouraged to engage with the local community resources nearby in the town, or to keep their own practitioners if this is possible. All staff members involved in administering medication have received accredited training from the supplying / visiting pharmacist, Boots the Chemist (inspection visits - minimally annually - were also found to be satisfactory). Medication records were checked during the inspection and all were found to be in a satisfactory order. Medication procedures were previously checked and found well managed. Storage is concise and accurate. Observation of a staff member administering medication showed that both recording and administration was undertaken as a ‘single action’ - as best practice dictates. The general culture of the home was noted to be respectful and dignified though at the same time being relaxed and friendly. A staff member who has recently retired from Eothen’s employment had the responsibility for the ‘pastoral (spiritual) care’ of the service users at the home. She now is now returned, through ‘volunteering’ at the home, and continuing this very important element of care for the service users. The inspector hopes that the element of ‘spiritual care’ will also continue to be the focus of a paid staff member at the home (possibly to co-work with the volunteer); the special religious focus of the home providing an element that most homes ‘leave out’. Eothen DS0000007193.V306565.R01.S.doc Version 5.2 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 - 15. Service users can expect life to the home to be pleasant and enjoyable; the home can provide opportunities for them to engage with activities both inside and outside the home – to ensure that activity and social links are maintained. Families and friends of service users can expect to be welcomed at the home at any time. Service users can expect to be allowed to exercise control and choice over their lives within the context of concerned care at the home. Service users are certain of a nourishing and nutritious diet being provided at the home, served in pleasant surroundings, with all appropriate ‘trimmings’ and a courteous service. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Activities provided within the home include Art classes, Church Services / Bible Study, visits from the Mobile Library, Exercise Classes, Quizzes, etc. Eothen DS0000007193.V306565.R01.S.doc Version 5.2 Page 14 The general ambience of the home is one of open and positive communication and a good amount of laughter was in evidence - once the identity of the inspector was established. Regular Service Users’ Meetings are held every 2/3 months and minutes are displayed and circulated to all service users in big print format. Service users are consulted about issues such as outings, the menu and activities. Service user’s reviews include a consideration of users’ involvement with the external community; a small number of service users get to the local shops independently; local churches are accessed by individual preference. Local women’s clubs and theatre trips for some are popular. Activities outside the home include theatre visits, trips to National Trust & Royal Horticultural Society sites, and occasional seaside trips in the summer. “We have visited at 8.20am and at the end of the working day, and we were welcomed into this happy environment; drinks were offered without being asked.” wrote one questionnaire respondent. A number of visitors were observed and met with their loved-ones during the inspection. They confirmed that they were welcome at the home at any reasonable time. The staging of ‘Open Days’ further evidences contact with the outside world, and a wish to minimise the sense of isolation to the home. Surveys received from service users and their relatives brought out some comments regarding a perceived lack of activities: “It would be beneficial for residents if there could be more visits / excursions to places outside the home.” “Even visits to have coffee in the local town could help break the boredom of sitting around the lounge.” “Could always do with a few more activities.” “They (activities) feel rather forced to amuse - which does not suit me very well.” A recommendation is therefore made to review the situation concerning possibly providing a wider variety of activities / outings to stimulate service users and to provide a broader spectrum of opportunities - especially perhaps focusing on those who otherwise do not take part in the ‘communal’ activities. The situation concerning service users being able to exercise choice and control over their lives is apparent through the following facts: some service users continue to manage their own finances, holding cheque books and statements, etc and may self-medicate if assessed as safe to do so. Solicitors / care managers / friends or relatives are involved with each individual resident at the home. Information about advocacy services is available in the home. Eothen DS0000007193.V306565.R01.S.doc Version 5.2 Page 15 Service users bring personal possessions – to a significant degree, often, into the home. The home has a policy and procedure relating to ‘Access to personal records’. Meal times are significant to many at the home, which provides a rotating menu of four weeks - providing a choice of menu over six days of the week. Sunday’s lunch is always a roast - but an alternative can be provided. The main meal is served at lunchtime. Alternative dishes can be provided if requested. Tea and homemade cake at 3pm is followed by the evening meal – which is again a cooked event (homemade soup and a hot dish), with a sweet. Drinks and snacks are available to anyone on request at any time. The inspector was able to talk to service users in the main dining room over lunch; good humour - as ever - pervaded. In line with the Christian ethos of the home, ‘Grace’ was said by a staff member, and joined in collectively by all present. One service user felt that the vegetables served (“mainly root vegetables”) were overcooked. Other than this comment all the reactions received about the food provided were very positive and appreciative. Eothen DS0000007193.V306565.R01.S.doc Version 5.2 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. Service users can be confident that their comments and complaints will be taken seriously and fully investigated and resolved, through using the home’s own procedure and guidelines. The home ensures that service users are protected from physical, mental and financial abuse, through the adoption of clear procedures and by adherence to best practice in this area – the Adult Protection guidance provided at the home ensuring that staff follow the most up-to-date procedures if / when required. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The inspector has had the opportunity to closely observe and examine the home’s management’s response to an issue of a complaint that was eventually, due to follow-on circumstances, handled within the context of an adult protection procedure. The outcome of the entire process was satisfactory - in so much as the home was found to have undertaken all possible steps promptly, transparently and appropriately, once the issues came to light. A previous requirement that the home amend its adult abuse / protection procedure to reflect the local authority’s actual process has now been completed. The proprietors actively sought advice from the Commission regarding the actual policy wording and the new policy document is now in place. Eothen DS0000007193.V306565.R01.S.doc Version 5.2 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. Service users can expect to reside in a home that is kept clean and odour-free, that is well maintained, and provides well-furnished and well-decorated communal and private rooms. Service users can expect that the home will be generally equipped to meet their specific needs and that their own bedroom will be furnished / decorated according to their taste, and to accommodate their own personal property. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The above judgements reflect previous inspection outcomes that found all the environment standards were ‘met’. The inspector independently toured the building - and found all to be clean, tidy and in good repair. A recommendation that an induction loop be installed in at least one lounge to advantage those who use hearing aids is repeated herein again – as the Eothen DS0000007193.V306565.R01.S.doc Version 5.2 Page 18 number of hearing impaired service users is reasonably significant – and such a facility would encourage the use of such aids in a positive way. Maintenance records confirmed that all ongoing attention is taken to ensure the safety and comfort of service users. Staffing rotas indicated a focus on cleaning throughout both the week and weekend - ensuring the highest possible standards of ongoing cleanliness. An additional fire exit sign is recommended for the south wing exit towards the laundry area. The South wing corridor bedrooms and en-suites have been decorated. In three rooms, the wash hand basin has been moved into the ensuite facilities, thus integrating this function within the rooms, and providing for greater privacy. The laundry stands alone from the home in the back garden is also staffed seven days a week - ensuring that the designated laundry person can ‘keep on top’ of the throughput, and maintain the laundry environment at its very high standard of order and hygiene. Eothen DS0000007193.V306565.R01.S.doc Version 5.2 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 - 30. Service users, their families and friends can be confident that the home will provide a safe, caring environment at Eothen, through ensuring adequate numbers of competent and trained staff being available to provide the service, and by maintaining strict employment practices. Service users can be confident that their safety and security is maintained through the home conducting a rigorous recruitment process, with appropriate records kept. Quality in this outcome area is generally good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The home continues to maintain suitable staffing levels of 5 or 4 care staff and a senior on duty during the day and 3 on duty at nights. There is capacity to increase these levels if needed. An independent catering company provides catering separately. Cleaning and laundry staffing levels ensure sufficient input across the working week - including weekends. A number of new staff (four) had been appointed since the last inspection visit. Personnel files were examined and showed all necessary checks were generally in place in good time prior to the worker starting their induction period. A number of Criminal Records Bureau checks were inspected and crossreferenced to supporting employment documents. Eothen DS0000007193.V306565.R01.S.doc Version 5.2 Page 20 In regard to one staff member who started under the aegis of a PoVAFirst check (as permitted by amended Care Homes Regulation 19(9)-(11)), the home is reminded that such use of staff with only a ‘preliminary’ CRB check should only be undertaken in exceptional circumstances, that all conditions (Reg 19(10&11) must be satisfied. Examination of the documentation showed full induction and recruitment checks had been completed in this regard. Advice was also given to ensure that referees were contacted at previous employment addresses (as opposed to their home address) - and guidance was also provided on how to verify the authenticity of referees giving references from ‘care home’ addresses. Staff training included a focus on report-writing (including night working staff) and the following has featured in the past 12 months: Health & Safety / Moving & Handling / Medication / Protection of Vulnerable Adults / Infection Control / Skin Integrity / First Aid. Courses on Diabetes and Continence Care are also planned in the near future. At present, eleven of the twenty-two care staff have an NVQ qualification to at least Level 2, thus meeting the commissions standard target of 50 . NVQ in Care training continues. Fourteen staff members currently have a First Aid qualification. All management, senior staff and most night staff have been trained in the home’s medication policy and procedures. Eothen DS0000007193.V306565.R01.S.doc Version 5.2 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. Service users and their advocates can be assured that the home will be managed and supervised in the best possible way, even though the manager is not yet formally registered with the Commission. Service users can be assured that the home will be run, and assessed, against the criteria of their best interests. Best practice with regard to finances can be expected, through the home operating concise and accurate financial procedures. The health and safety of both service users and staff can broadly be relied on, though attention to staging more fire drills must be increased. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Eothen DS0000007193.V306565.R01.S.doc Version 5.2 Page 22 EVIDENCE: Sue Henderson, previously the Deputy Manager and previously Acting Manager during the manager vacancy periods at the home has now been appointed Home’s Manager for Eothen Sutton. She brings with her significant experience of working in a care home, having worked her way up the promotion ladder. Service users have expressed their pleasure at having a manager - who knows the home and them - being appointed. She is now to be put forward by the proprietors for registration by the Commission. Having conducted inspections with her in the past, the inspector has no doubts as to Mrs Henderson’s capacity to undertake the role - especially with the positive support from ‘Head Office’ and the General Manager’s input, in particular. The home employs a variety of audits to measure the quality of the service provided and user satisfaction. Among the spectrum is included management audits / surveys / meetings / associated staff supervision, training and appraisal. Feedback from service users and their relatives (including detailed questionnaires) revealed a generally content picture: “The staff are extremely helpful and my (relative) is very happy there” “They listen to ad act on what my (relative) says” “Excellent home!” “Staff are delightful, caring, and helpful - you have a home to be proud of.” “We are made to feel very welcome - a very happy welcoming environment.” “Very happy with the staff encountered - they are all very genuinely caring of the residents.” “I’m continually impressed with the level of care and cleanliness in Eothen.” “I am extremely happy that my (relative) is a resident at Eothen Sutton.” “The staff are wonderfully caring and look after (my relative) beautifully.” “(My relative) is very happy there - 10/10.” “It is the most delightful place and I couldn’t be happier with the TLC my (relative) has received. In fact I can think of no nicer place to end one’s days.” One care manager spoke of the “excellent care” and stated: “I have never had any cause for concern.” The local GP - who provides a visiting service to the home - indicated that he has never received a complaint about the home - and that the assistance / service he receives as the GP is well provided. The only area indicated as variable by a few respondents was the ‘activities’ / ‘outings’ area (see the ‘Daily Life’ section above). Eothen DS0000007193.V306565.R01.S.doc Version 5.2 Page 23 Regulation 26 audit visits conducted by the proprietors are thoroughly carried out; the format is excellently concise. There are at least three styles of audit assessments: Resident-focused / medication-focused and premises-focused. There is an annual development plan available in the home including the ongoing schedule of proposed refurbishment / redecoration. Senior managers visited the home for two days a week during the ‘interregnum’ - from Head Office in Newcastle - and undertake audits of the quality of care, the premises, record keeping and meals and service user satisfaction. Residents’ finances held in safekeeping are well recorded / maintained with a clear audit trail available for all monies handled by the home. There is a safe within the home to which only designated senior staff members in the home have access. A limited amount of money is kept on site in safe keeping for individual users if they so wish, and transactions have to be signed by two people. Care staff members were aware of the need to be accountable for any money they handled for users’ day-to-day needs. Generally the house is exemplary in ensuring the safest possible environment for both service users and staff. All maintenance and safety checks are confirmed by the home to be up-to-date and any remedial work is immediately undertaken when indicated. The inspector, this inspection, only requires that the frequency of fire drills be reviewed; this being due to the fact that only eighteen staff took part in what is described as the ‘6-monthly drills’ most recently in August 2005 and February 2006. The August 2006 drill appeared to have been missed. The entire staff team at Eothen numbers over 30 people, and all should be given the experience of specific involvement in a drill. Regular fire training is given for day staff – but the experience of an actual drill has the most powerful and memorable effect on staff’s attitudes and future behaviour. Drills must also be staged to learn from the reaction of the entire house at different times of the day / evening. Eothen DS0000007193.V306565.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Eothen DS0000007193.V306565.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP29 Regulation 19 Requirement The home is reminded that deployment of staff with only a ‘PoVAFirst’ check should only be undertaken in exceptional circumstances, that all conditions of Reg 19(10) & (11) must be satisfied. Timescale for action 31/12/06 2. OP38 23(4)(e) 31/12/06 The frequency of fire drills must be reviewed - with a view to more staff experiencing direct involvement in an actual fire drill practice. All staff must undertake a drill at least once in the year, and drills must be staged at different times of the waking day. (A recommendation in the previous report.) Eothen DS0000007193.V306565.R01.S.doc Version 5.2 Page 26 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 OP12 Good Practice Recommendations That a wider variety of activity / outings be provided to stimulate service users and to provide a broader spectrum of fulfilling opportunities. That an induction loop system be introduced to one or both of the main lounge areas to enable service users that have hearing aids to ‘tune in’ to items (TV, radio / music centre / microphone) thus enabling them to participate more fully in the social life of the home. (A strong recommendation carried forward from the last report.) That an additional fire exit sign should be provided to more clearly signpost evacuees out of the double doors in the south wing leading to the laundry area. That the home should ensure that referees are contacted at previous employment addresses (as opposed to their own home address) - and that the home should verify the authenticity of applicants referees giving references from ‘care home’ addresses. 2. OP22 3. OP25 4. OP29 Eothen DS0000007193.V306565.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Eothen DS0000007193.V306565.R01.S.doc Version 5.2 Page 28 - 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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