Inspection on 23/09/05 for Eothen

This inspection was carried out on 23rd September 2005.

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

The inspector 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 12/10/06

Eothen 29/12/05

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 Unannounced Inspection 23rd September 2005 11.25 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.V253818.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. Eothen DS0000007193.V253818.R01.S.doc Version 5.0 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 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.V253818.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24/01/05 Brief Description of the Service: Eothen is a residential home registered to provide care for 41 older people. The service runs on a low-key Christian ethos and has a non-smoking policy. The home is situated to the south west of Sutton town centre, about half a mile from bus and train services and the main shopping 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, which can be easily accessed by service users. The front (northern side) of the property comprises a threestorey (older) building with accommodation provided on all three floors (served by passenger lift, but still leaving 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 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, though it is projected to increase this number. Meals are prepared on site in a well-provided kitchen by a separately managed catering company. Eothen DS0000007193.V253818.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector arrived for this unannounced visit in the late morning, and stayed on the premises until the evening meal was being served. During this time he was able to meet many service users, speak to the Deputy Manager (who is currently covering the Manager’s post), to have lunch with a group of residents, chat to staff, meet with some relatives, and tour the premises. The inspector was also able to check the outcomes from the requirements and recommendations set at the last inspection visit in January 2005, and also reviewed the current running of the home using the Pre-Inspection Questionnaire which had been prepared by the Assistant General Manager of the Eothen Homes organisation and returned to the Commission in preparation for the inspection. The inspector is grateful for the hospitality and kindness shown to him during his visit. What the service does well: The home continues to provide an excellent personal service to the individuals resident at Eothen. Despite the departure, more recently, of the person who was expecting to take on the Registered Manager post from the previously (registered) ‘Operations Manager’, the home was continuing to run smoothly well overseen by ‘acting-up’ staff who were familiar with the home and, more importantly, known by - and familiar to - the service user group. Service users responded substantially to the Commission’s questionnaire (thirty forms were returned); it was good to see such a high response rate, and such generally positive views expressed. These are expressed more fully in the specific detailed sections that follow. Relatives and visitors also responded well to the Commission questionnaire; twenty-four were returned, with a unanimous opinion of the overall care provision being at least to a ‘satisfaction’ level. Those adding comments, as well as ticking positive responses, were universal in expressions such as: ‘First Class’ / ‘Exceptional’ / ‘Super’ / ‘Highest standard’. The inspector reflects that these responses are exceptional - when compared to most homes, in their positive approbation and good opinion of the home. Leaving the final comment to a relative: ‘It is the most wonderful home I have ever visited. The staff members do an unbelievable job. Thank you so much’ and to a service user: ‘I am very happy to live at Eothen (Sutton).’ Eothen DS0000007193.V253818.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Eothen DS0000007193.V253818.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 Eothen DS0000007193.V253818.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): 1 - 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 and able to meet the needs of the applicant. EVIDENCE: A Statement of Purpose and Service User Guide is provided at the home; the document is comprehensive and covers all areas required by Regulations 4 & 5 and the associated Schedule One. The general introduction at the beginning makes clear the bedroom sizes are all over 10 square metres and states the policy on sharing double bedrooms (the home has 38 rooms, three of which may be shared by partners / relatives). Charges vary (currently ranging from £560 – £660), dependent on bedroom size and facilities provided (17 of the 38 have ensuite facilities). Charges are made additionally for Chiropody, the Hairdresser, and for toiletries and other personal items (newspapers, etc). Eothen DS0000007193.V253818.R01.S.doc Version 5.0 Page 9 The home has now has a revised service user contract, which meets all of the requirements of Standard 2. Service users placed by a local authority will also - alongside the home’s own terms and conditions - have a three-way contract negotiated between themselves, the home and the local authority. Service users admitted to the home through care management arrangements will have a care manager’s comprehensive assessment of need completed - a copy of which is obtained and kept on file. Senior staff members assess other potential (‘private’) residents and a three-page comprehensive proforma, relevant to the user group is used. The visit to the prospective service user also ensures that questions can be answered, and the potential newcomer is also assessed / considered in the light of compatibility with the other existing service users. The assessor decides whether the home can provide appropriate care to prospective users; the home does not aim to offer care to people with dementia, and to this end undertakes an assessment of users’ cognitive abilities. The 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. Almost all prospective users are invited 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; there is an initial trial period of six weeks, whereafter a Placement Review will be held, involving Care Managers and relatives or ‘significant others’. Whilst offering the possibility of respite (‘holiday’) stays, the home does not offer an intermediate care service - which involves assessment & rehabilitation. This standard (No 6) in not applicable and not, therefore, inspected. Eothen DS0000007193.V253818.R01.S.doc Version 5.0 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 & 10. Service users can be assured that their needs will be clearly set out in a care plan – and this includes identifying specific and general health care needs; all health care requirements are fully met by the home. Service users can expect to be treated with the cordiality and respect expected of a home espousing the Christian religious ethos – and can also be assured that their rights to privacy are upheld. EVIDENCE: Reviews of individual service users were carried out and recorded monthly, and all records seen were up to date. Risk assessments were also seen on file, and included some covering specific issues alongside manual handling. Risk assessments are carried out by senior staff and regularly reviewed. Day-to-day notes are still not kept on a daily basis for some service users; this deficit, it is hoped, will be addressed as care staff are encouraged more to participate in the recording systems at the home. Eothen DS0000007193.V253818.R01.S.doc Version 5.0 Page 11 Both GPs used at the home (from different practices) responded to the Commission’s questionnaire, indicating a positive relationship between the home and the medical practitioners. The principal House GP holds a weekly surgery at the home itself. The Chiropodist visits three-monthly and Opticians and Dentists are regular visits every half-year, as well as service users being encouraged to engage with the local community resources nearby – or to keep their own practitioners if this is possible. The ‘Medication’ Standard - Standard 9, was found to be met at the last inspection visit, and will be fully reviewed at the next visit. At this visit the lunchtime medication practices were obliquely observed and all appeared to be very much in order. Relative’s & Visitor’s responses were clear that the staff do their job of caring well: Staff members were described as ‘kind and considerate’, another stated they were ‘very happy with the care of our relative – the staff are kind and gentle’, further responses stated: ‘my relative is dealt with great kindness and patience’, ‘my relative is very happy and cared for to the highest standard’. ‘We are very pleased with the level of care my relative has at Eothen.’ A newcomer to the home as a service user stated: ‘The staff are very kind.’ Another wrote: ‘I am very happy here and find everyone caring, friendly and very helpful’. One service user spoken to by the inspector said: ‘Although I don’t like this place, we’re very well looked after.’ Clearly the necessity to reside in residential care still ‘hurts’ at times - but this candid statement is an expression of the openness the home has encouraged in its service users. Eothen DS0000007193.V253818.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, & 15. Service users can expect life to the home to be stimulating 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 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. EVIDENCE: ‘The home is super – my relative is much happier and healthier now.’ So wrote one happy relative. ‘ My relative is treated with great respect and affection’ stated another commentator. ‘I like the atmosphere here’ stated a contented service user. Activities within the home include Art classes, Church Services / Bible Study, Mobile Library, Exercise Classes, Quizzes, etc. The general ambience of the home was one of open and positive communication and a good amount of laughter was in evidence - once the atmosphere caused by the arrival of the inspector in the house was resolved. The Physiotherapy Activity worker ran a Eothen DS0000007193.V253818.R01.S.doc Version 5.0 Page 13 session of musical keep fit during the inspection visit – prior to lunch – working up a good appetite for the service users who participated! 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 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 are popular. Activities outside the home include Theatre visits, trips to National Trust and Royal Horticultural Society sites, and Seaside trips in the summer. Sutton Accessible Transport is used to ensure that all – whatever their degree of mobility – can get out. ‘Visitors are always welcome’ reassured one questionnaire writer. A number of visitors were observed, with their loved-ones, in the home during the inspection. Relatives / carers confirm that they were welcomed at the home; they are welcome to call 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. ‘The food is good – lots of vegetables.’ Stated a relative – this latter point being endorsed by a service user in their questionnaire. The home provides a rotating menu of minimally four weeks - which provides a choice of menu over six days of the week. Although there is only a ‘Roast’ declared on a Sunday, alternative meals could be provided if requested. Tea and cake at 3pm is followed by the evening meal – which is again a cooked event (home made 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 before lunch was served; good humour pervaded. In line with the Christian ethos of the home, ‘Grace’ was said by a staff member, and joined in collectively by all present. It being Friday, fish and chips were served with peas, with a meat salad as the alternative. Tomato, Tartar and Mayonnaise sauces were available – as well as wedges of fresh lemon. The inspector then moved to the small side dining room to take lunch with this group of currently six service users - which was thoroughly enjoyed. This dining area is certainly an arena for banter and comment; again humour and light-hearted challenges being a good thing to see in a care home. Sadly, the lemon wedges arrived only in time for the inspector to benefit from this on his main course, to the disappointment of at least one (or more?) service user. Attention will have to be made to ensuring that the full provision is set up and delivered for all in this small extra room - as well as the main dining room. Eothen DS0000007193.V253818.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Service users can be confident that their comments and complaints will be taken seriously and fully investigated and resolved, through the home’s own procedure. 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 – though the Adult Protection guidance provided at the home should be updated, to ensure that staff follow the most up-to-date procedures where required. EVIDENCE: Complaints are taken very seriously by the home, the Area Manager having an overview of all such issues to ensure their proper management and handling. The home’s - and the local authority’s - Complaints Procedure leaflets were openly available in the home. Despite this, five relatives / visitors - and five service users - responded in their Commission questionnaires that they were not aware of the home’s Complaints Procedure / who to speak to if they are unhappy with their care. It may well be worthwhile the home reviewing how this is communicated to services users and their loved-ones. The fact that five complaints had been logged since the last inspection indicates that the home is keeping its ‘ear to the ground’ – and all complaints were fully investigated and resolved. Eothen DS0000007193.V253818.R01.S.doc Version 5.0 Page 15 A requirement set back in mid-2004 concerning the home’s Adult protection procedure – requiring that it must be amended to ensure that the multi-agency local authority Vulnerable Adult Policy’s approach corresponds with that of the home - especially in regard to seeking advice and assistance early on in the process, after a disclosure has been made – has not been responded to; the policy held in the procedure file was dated 11.06.03 – so is clearly not a revision. The requirement is therefore again reiterated. Eothen DS0000007193.V253818.R01.S.doc Version 5.0 Page 16 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 equipped to meet their specific special needs and that their own room will be furnished and decorated according to their taste and to blend in with their own property and personal furnishings. EVIDENCE: The home is well located in a pleasant residential road conveniently close to the shopping centre of Sutton. The physical environment of the home is of an exceptionally high standard, with regard both to decoration and maintenance. Feedback from service users and relatives indicated they appreciated this attention to detail. ‘The home is always being redecorated – it is a beautiful home’ comments one relative. Eothen DS0000007193.V253818.R01.S.doc Version 5.0 Page 17 There are very attractive and well-maintained front flower beds, and the courtyard garden in the centre of the home - which is quite for service user’s use - is a real ‘paradise’ to sit in - with seats and parasols provided; access being straight off the public rooms of the house. ‘Beautiful gardens to look at and walk in’ commented a service user. The home meets the revised Standard requirement regarding bedrooms. All service users who now wish for a key to their personal bedroom have one. Seventeen of the bedrooms (including all three rooms that can be doubly occupied) have ensuite toilet facilities; others have, minimally, a washbasin. In addition, communally, there are nine toilets, six bathrooms and a shower facility. These include mechanically ‘assisted baths’ and a shower that can be used with a seat. ‘Everything is very clean’ commented a relative. Grab rails are available around the building and a (new) passenger lift is provided. Many service users use mobility aids, such as walking frames. There is a new call bell system, universally available, which is also linked to the front door bell - and staff pagers ensure discrete calling and responses. Manual handling hoists are also available. In the dining room, only two out of every six chairs at the tables have arms. The inspector hopes that a previous recommendation is still at the back of the registered provider’s minds – to increase the number of chairs with arms if and when the need arises for furniture replacement. Whilst acknowledging the existence of a microphone which is used by staff for activities /events, an induction loop system is also still recommended; this would enable those service users with hearing aids to ‘tune in’ to TV / Radio and microphone broadcasts – but avoiding all the surrounding ‘hubbub’ of noise that can so easily obstruct a hearing aid user’s ability to properly hear and to participate. Hot water temperatures in bedrooms and bathrooms are tested regularly, and records show these were within safety limits. The Code of Practice with regard to prevention of Legionella poisoning is observed, with annual checks and tests of the water storage systems. The majority of staff members have in the past year undertaken a certificated Infection Control course. The home has a new laundry, external to the home an excellent safe environment - easily accessed from a home. All the washing and drying / ironing equipment is of good quality and includes an appropriate foul linen / sluicing facility on the washing machine. Eothen DS0000007193.V253818.R01.S.doc Version 5.0 Page 18 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 & 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 are available to provide the service, and by maintaining rigorous employment practices. EVIDENCE: Relatives’ comments included: ‘The staff are wonderful – it is not easy caring for the elderly’. ‘The staff do an unbelievable job.’ ‘I am sure it would be hard to find anywhere with such caring staff.’ Staffing is provided at a level of a minimum of five care staff on throughout the waking day – often more (six or seven in the morning), with seventy hours of cleaning input over seven days (more in the weekdays, lass at weekends), a six or five hour daily laundry staff input and the kitchen is staffed and managed by an independent company. Night staffing is provided at a level of three care staff every night. Twenty-two care staff members (and two deputies) provide the care input, alongside five ancillary staff (again, not including the kitchen). All but one relative / advocate thought there were sufficient staff members provided at them home. Eleven care staff members now have a qualification at NVQ Level 2 or above, so the National Minimum Standard has been achieved within the set timescale. More staff members are undertaking the training, but the lack of Assessors from some colleges has been a hindrance. Eothen DS0000007193.V253818.R01.S.doc Version 5.0 Page 19 Vacancies created by the absence of the Operations Manager / Care Manager and vacancies in the night care team had led to twenty agency shifts being used in the past two months – sadly, using thirteen different (and therefore many unfamiliar) staff. Fortunately most day shifts were quite short (4 & a half or 5 hours only). The home’s recruitment policy expects two written references to be received prior to appointment. All files have a copy of terms and conditions of service and staff confirmed they have received these and also a job description. Every staff member has a completed enhanced CRB check. Staff training in the past year has ensured that all staff have had input on Fire, Health & Safety, Dealing with Abuse, and Skin Integrity. Nine staff members have also undertaken First Aid training. Training planned in the next year includes all the above issues, where appropriate, and will include Medication Training updates for all relevant staff, and also updates on Manual Handling. Eothen DS0000007193.V253818.R01.S.doc Version 5.0 Page 20 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 during a vacancy situation when a manager is not formally in place. Service users can be assured that the home will be run, and assessed against the criteria of their best interests – including taking account of best practice with regard to finances and with regard to the health and safety of both service users and staff. EVIDENCE: ‘The home is run more like a first class hotel and not a residential home. It is run very efficiently and all the clients are well looked after’ - thus states a relative. Another spoke of the home being ‘exceptionally well run’. Eothen DS0000007193.V253818.R01.S.doc Version 5.0 Page 21 The home previously had an operations manager - who was the registered manager and a ‘Home manager (responsible for the care / staff) under her. The former took maternity leave and then did not return, accepting redundancy, and the home manager was then due to take over the ‘registered manager’ reins. Unfortunately, due to sickness / personal circumstances, she has now left – this leaving the home to find a new person to take on the registered role. Recruitment processes for a new manager were underway at the time of the inspection visit. Pending the appointment of a new manager, the Deputy Manager, Sue Henderson, is acting into the management role, supported by the Eothen Senior Management, and the home’s senior care staff group. Sue has nine years of experience working at Eothen, and has helped cover management vacancies beforehand; she has just completed her NVQ at Level 3 and is seeking to complete her Level 4. The inspector sat with a group of staff at their lunchtime break, and they reported that things were running smoothly despite the changes in personnel / management. There is an annual development plan available in the home including the ongoing schedule of proposed refurbishment / redecoration. Senior managers visit 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. The Commission now requires – as is demanded by regulation – that monthly visit reports be submitted to the Commission for information. User feed back is encouraged through Service user’s Meetings. Regular surveys of other professionals who know the home (GP, optician, chiropodist, dentist) and of service users and their relatives/carers were undertaken; the inspector was given a full copy of the past survey at a previous inspection. There is a safe within the home to which only designated senior staff members in the home have access rights. 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. The home does not act as Appointee for any service user at the home. Four service users continue to maintain their own benefit books, and seven are in control of their own financial affairs. Families / advocates are principally in charge of monies held for service users who do not manage their own financial affairs. Health and safety matters were generally found to be in good order; all maintenance and monitoring records were available and (excepting the issues identified below) up to date and comprehensive. Eothen DS0000007193.V253818.R01.S.doc Version 5.0 Page 22 Checking on a requirement set at the last inspection visit, it was found that the fire alarm checking book evidenced a lack of regular testing for a three-month period from the beginning of May to the end of July 2005. Following on from then, the record was just ‘ticked’ rather than counter-signed by the person conducting the test; this needs rectification, as any test should the signed - to enable reference back to the person who undertook the test. This requirement is, therefore, reiterated. Another record kept by the home – again the subject of a requirement from the last inspection – was the clearer recording of what/which appliance(s) is checked when ‘Fire fighting equipment’ was examined. A tick in a box under a “satisfactory: yes / no” heading is not really sufficient. The requirement is also, therefore, reiterated. ‘I think all homes should be run as a charity and not profit-making for the owner.’ Thus stated a relative who is clear in their own mind that the service provided at Eothen is ‘second to none’ - and feels that the removal of a profit motive – allowing the ‘ploughing back’ of monies into the service, is of benefit to service users. It has to be admitted, bearing in mind the all-round quality of service provided at this home – that this perception is quite possible correct. Eothen DS0000007193.V253818.R01.S.doc Version 5.0 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 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 4 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Eothen DS0000007193.V253818.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? YES 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 OP18 Regulation 13(6) Requirement The home’s policy and procedure on Adult Protection must be amended to ensure that the agreed local authority vulnerable adult policy’s approach corresponds with that of the home. Previous timescales of 30.08.04 & 30.05.05 not met. Timescale for action 30/11/05 2 OP33 26(1) (2) Copies of the monthly visit 30/11/05 reports – undertaken in response to Regulation 26 - and submitted to the registered provider, must in future be sent to the CSCI office in Croydon. Fire alarm testing must be conducted consistently, week on week, whatever the situation / time of year. Timescale of 01.02.05 not met. The monthly visual checks of fire extinguishers should be more specifically recorded - to identify which was actually checked. Timescale of 01.02.05 not met. 30/11/05 3 OP38 23(4)(c)(v) 4 OP38 23(4)(c)(v) 30/11/05 Eothen DS0000007193.V253818.R01.S.doc Version 5.0 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 OP7 Good Practice Recommendations That training for staff members in report writing would enhance the quality of entries in care notes and also would encourage direct reporting, rather than indirect records being made. Efforts should also continue to ensure that a (minimally) daily entry is made in each service user’s care notes to reflect their daily lives at the home. Brought forward from previous report. That the small dining room users should not be ‘forgotten’ – in regard to condiments / sauces being provided when they are freshly served with the meals provided. That the home review its communication of the Complaints procedure to both service users and relatives / visitors – to ensure that all know who to approach if they are dissatisfied with the service at the home. 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 life of the home. Brought forward from previous report. 2 OP15 3 OP16 4 OP22 Eothen DS0000007193.V253818.R01.S.doc Version 5.0 Page 26 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.V253818.R01.S.doc Version 5.0 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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