Inspection on 17/11/05 for Eothen

This inspection was carried out on 17th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Eothen 22/01/09

Eothen 24/01/07

Eothen 11/05/05

Eothen 18/10/04

Eothen 26/04/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Eothen 45 Elmfield Road Gosforth Newcastle Upon Tyne Tyne & Wear NE3 4BB Lead Inspector Elaine Malloy Announced Inspection 17th November 2005 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 DS0000000442.V252778.R01.S.doc Version 5.0 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. DS0000000442.V252778.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Eothen Address 45 Elmfield Road Gosforth Newcastle Upon Tyne Tyne & Wear NE3 4BB 0191 213 0707 0191 2130075 enquiries@eothenhomes.org.uk www.eothenhomes.org.uk Eothen Homes Limited 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) Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places DS0000000442.V252778.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th May 2005 Brief Description of the Service: Eothen is a purpose built care home that is situated in a residential area of Gosforth. It is close to a range of shops and other local amenities. The home provides personal care to 37 older people. It is equipped with a passenger lift. There are 35 single bedrooms and one double bedroom, all with en-suite facilities. Communal lounge and dining areas are provided. There are baths and showers, and separate toilets. The home has car parking space and accessible attractive gardens. DS0000000442.V252778.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and took place over 6 hours. Management, staff, residents and visitors were spoken to. Residents and relatives completed surveys about the service. Areas that the home was asked to improve at the last inspection were checked. The building and a range of records were inspected. What the service does well: What has improved since the last inspection? Residents are provided with a variety of social activities, outings and events. A new Manager has recently been appointed and is due to take up post in the near future. Care staffing levels have been increased. DS0000000442.V252778.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. DS0000000442.V252778.R01.S.doc Version 5.0 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 DS0000000442.V252778.R01.S.doc Version 5.0 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): Standard 3 was assessed at the last inspection, and was met. Standard 6 is not applicable. EVIDENCE: DS0000000442.V252778.R01.S.doc Version 5.0 Page 9 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, 9 and 10. Care plans were not updated to demonstrate changes to resident needs and dependency. Charts for meeting continence needs were not fully completed. Medication records are to be improved by making sure staff always sign or enter codes to show if medication has been given. Residents confirmed that staff treat them with respect, and maintain their privacy and dignity. EVIDENCE: At the last inspection a Requirement was made about updating care plans and improving records for residents continence needs. Care plans had not been updated to reflect residents current needs. This was evident from assessments that showed higher dependency levels, and from care plan evaluations. There was some improvement to the recording of continence management care plans. However continence charts were still not being properly completed and monitored. Staff who administer medication have received training. The home uses a monitored dosage medication system. Some pre-printed directions for DS0000000442.V252778.R01.S.doc Version 5.0 Page 10 medication were unspecific. The home was following this up with the supplying pharmacist. General Practitioners were also being informed where residents regularly refuse medication. Gaps were evident to signatures in the medication records. Staff must ensure they always sign to confirm medication has been given, or record the relevant code to state why it was not given. The Controlled Drugs Register was appropriately recorded. Health and personal care is carried out in the privacy of the resident’s bedroom. Telephones are provided in all bedrooms. There are laundry systems to ensure residents always have their own clothes. Management agreed to purchase ‘lingerie bags’ to enable washing of individual’s tights, stockings, socks etc. Residents told the Inspector that they are treated well by staff. They said staff are respectful towards them, privacy is maintained, and personal care is carried out in a dignified way. DS0000000442.V252778.R01.S.doc Version 5.0 Page 11 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. Residents are provided with a variety of daily social activities and planned outings and events. EVIDENCE: At the last inspection a Requirement was made for residents’ social preferences to be established, and information used to make provision of daily activities. This had been followed by asking residents about the type of activities they would like, and including suggestions into programmes. An annual plan of outings and events was arranged, and this is added to as further events are organised. In forthcoming months there was an external Tea Dance, Christmas Lunch at a hotel, an in-house Christmas Party with entertainment, a visiting singer/entertainer, visit by the Salvation Army, a Fashion/Clothes Party, and Easter festivities. A 3 week programme of daily social activities was in place. This included a good variety of activities, for example art class, remininiscence, quizzes, singalong, Bible Study, knitting, dominoes, armchair exercises to music, poetry reading, films, manicure and hand massage, and various games. Sessions of ‘residents choice’ were incorporated. Local outings with staff accompanying residents are provided. DS0000000442.V252778.R01.S.doc Version 5.0 Page 12 Most residents told the Inspector that they were aware of the range of activities available. The senior care worker who takes responsibility for organising activities agreed to circulate information to all residents. DS0000000442.V252778.R01.S.doc Version 5.0 Page 13 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. All complaints received are thoroughly investigated. There are systems in place to protect residents from abuse, including staff training. EVIDENCE: Resident and staff meetings are held to obtain feedback about the service. Minutes are recorded and demonstrated good attendance and a variety of topics being debated. 8 complaints were recorded in the period since the last inspection. Each was appropriately investigated and responded to within 28 days. Where applicable staff statements and response letters are maintained. Action that has been taken as a result of any complaint was documented. The home has policies and procedures for the protection of vulnerable adults, including prevention of abuse and whistle blowing (informing on bad practice). Staff are provided with relevant training. There have been no allegations of abuse. DS0000000442.V252778.R01.S.doc Version 5.0 Page 14 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 and 26. The home continues to be maintained to a high standard, and kept very clean. EVIDENCE: All areas of the home seen were clean, and nicely decorated and furnished. Resident bedrooms were personalised with their belongings. Regular checks of the environment are carried out, including health and safety issues. In the period since the last inspection there had been the following improvements: Storage space created for wheelchairs; sluice refurbished; new fridge/freezer purchased; and an air-conditioning unit installed in the food store. There are plans for a mains-fed water system to be introduced. This will be done on a phased basis to alleviate any disruption in the building. DS0000000442.V252778.R01.S.doc Version 5.0 Page 15 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, 29 and 30. Good staffing levels are provided to meet the needs of the number of residents. The home follows a robust recruitment procedure. Staff are provided with a good range of training relevant to their work with older people. EVIDENCE: At the time of the inspection there was 37 residents. Staffing levels have been increased in the evenings by having an extra carer on duty. There is also an extra carer on duty from 7 - 8a.m each morning. The staff rota showed 5 carers on duty across the waking day and 2 carers at night. Agency staff have been used to cover for absence due to sickness, holidays and vacant positions. The home provides good weekly domestic, catering, and laundry staff hours. A new Manager was recently appointed and will be taking up post in the near future. A sample of personnel files for staff that had been recruited in recent months was examined. These contained suitable information including identification, application form, references, health questionnaire, interview record, and Criminal Records Bureau checks. Files had recently been audited and management was following up on a previous employer reference for one staff member. DS0000000442.V252778.R01.S.doc Version 5.0 Page 16 New staff complete induction and foundation training to required standards. Training files were well organised with sections for different topics, associated questionnaires, and the home’s own policies and procedures. In the past year training courses have been provided on fire safety, moving and handling, first aid, food hygiene, prevention of abuse, dementia, continence, and sensory impairment. Further staff have also achieved NVQ qualifications in care. DS0000000442.V252778.R01.S.doc Version 5.0 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): 33, 35 and 38. An annual quality assurance plan needs to be developed. Management should follow up on negative feedback from CSCI surveys. Residents’ personal finances are safeguarded. Thorough checks are carried out to make sure the home meets health and safety requirements. EVIDENCE: The home has methods for monitoring the quality of the service provided. An annual quality assurance plan needs to be developed that incorporates these measures. DS0000000442.V252778.R01.S.doc Version 5.0 Page 18 CSCI comment cards were made available to residents and their relatives/visitors to obtain their views on the quality of the service. 14 residents completed and returned CSCI comment cards: 10 said they liked living here and 4 said sometimes; 13 said they feel well cared for and 1 said sometimes; 13 said staff treat them well and 1 said sometimes; 13 said their privacy is respected and 1 did not answer; 1 said they wished to be more involved in decision making within the home and 1 said sometimes; 11 said the home provides suitable activities and 3 said sometimes; 10 said they like the food, 3 said sometimes and 1 said they do not; all said they feel safe here; 13 said if they were unhappy with their care they would know who to speak to and 1 said they did not. Additional comments were made as follows: “This home lacks satisfactory management”. One relative added comments that they wished to remain confidential. 17 relatives/visitors completed and returned CSCI comment cards: Each responded positively about being welcomed into the home and being able to visit in private. 15 said they are kept informed about important matters affecting their relative/friend and 2 said they were not; 15 said if their relative was unable to make decisions that they are consulted about their care and 2 said they were not; 11 said in their opinion there was always sufficient numbers of staff on duty and 6 said there was not; 12 were aware of the home’s complaints procedure; 5 said they had ever had to make a complaint. 9 said they were made aware of forthcoming inspections and 8 were not; 13 were aware of access to inspection reports and 4 were not. Each said they were satisfied with the overall care provided. Additional comments were made as follows: “There are times when the room call button is pressed and a significant period of time passes before someone answers. This could be due to staff holidays etc but I am not sure”. “I think more recreational facilities would stop the residents becoming bored and stimulate their mental capacities. These facilities seem to have become less in the last year”. “The Eothen home is wonderful. Staff, food and personal attention are excellent. I don’t have to worry about my Mum and she is very happy”. “It’s a great place – I hope I finish up somewhere like that!” “They sometimes seem very busy. Perhaps if there was more staff more time could be spent providing daily activities for the residents”. One lady indicated that as a relative she wished to be kept informed and consulted about her sister’s care. The Inspector gave feedback from surveys at the inspection. Action should be taken by management, where possible, to address negative responses and comments. Residents spoken with during the inspection gave positive feedback on living in the home. Each said they were very well looked after and were happy. One DS0000000442.V252778.R01.S.doc Version 5.0 Page 19 lady described staff as kind and helpful. She knew which staff member is her Key worker. She was not aware of the programme of social activities. She particularly liked her bedroom. Another lady said her relative had chosen the home for her, that it was the best one and has a good reputation. She said staff were good and maintained her privacy and dignity. She was not always happy with the food but said she is provided with alternative meals. A resident told the Inspector she was very well treated and believed all the residents are content. She said she eats very well. Another lady said staff are gentle, kind, respectful, happy and friendly. She commented on receiving good assistance and being checked on during the night. She said there are good levels of cleanliness and staff observe hygiene by wearing aprons when serving food. She felt the meals were ‘nutritionally sound’. She was aware of activities and said she planned to join the weekly art class. Resident personal finance records were properly recorded with two signatures for each transaction. Receipts for items bought are kept. Management agreed to make sure that entries specify purchases where the receipt does not identify. A lot of personal spending was evident. Weekly checks of balances and cash are carried out, and additional audits are conducted. Staff are provided with training in safe working practices. The home has a Health and Safety Consultant and Committee. Regular checks of health and safety in the building, and associated records take place. DS0000000442.V252778.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X X STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X X 3 DS0000000442.V252778.R01.S.doc Version 5.0 Page 21 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 OP7 Regulation 15 Requirement (Outstanding Requirement) (a) Resident care plans must be updated where necessary to reflect current needs. (b) Continence charts must be properly completed and monitored. There must be no gaps to signatures/codes in medication administration records. Timescale for action 17/02/05 2. OP9 13(2) 17/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP33 Good Practice Recommendations (a) (b) An annual quality assurance plan should be developed Management should address, where possible, negative responses/comments from CSCI surveys to residents, and relatives/visitors. DS0000000442.V252778.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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 DS0000000442.V252778.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!