Inspection on 24/01/07 for Eothen

This inspection was carried out on 24th January 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Eothen 22/01/09

Eothen 17/11/05

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 Key Unannounced Inspection 09:30 24 January to 7th February 2007 th 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 DS0000000442.V314244.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 DS0000000442.V314244.R01.S.doc Version 5.2 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) Mrs Sylvia Dixon Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places Eothen DS0000000442.V314244.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th November 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 and support 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. A guide to the home’s services and inspection reports are readily available at the home. The current weekly fee is £426.00 for residents who are either privately funded or funded by the Local Authority. Eothen DS0000000442.V314244.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection. It was carried out by one inspector over two days and took 14 hours. The home manager completed a questionnaire on information about the service. This was returned to the Commission before the inspection. Key standards were inspected through discussion with management, staff and residents, examining the home’s records and touring the building. Surveys were also made available to residents and relatives to get feedback on the service. Areas that needed improvement from the previous inspection were checked. What the service does well: Residents spoke positively about living at the home. Comments included, “I’m quite happy with my care”, “I’d give the home 5 stars”, “Very friendly staff and very nice office staff”, “The food is very nice and they have a lot to choose from”, “The staff are very good but if I ever had a problem I would go to the office”, “The home is always lovely and clean”. New residents have their care needs thoroughly assessed before they move into the home. All residents have care plans that show how they are assisted with their health, personal and social care. Residents’ health care needs are met. A good range of social activities and outings are offered. Residents are supported to keep contact with family, friends and the local community. Residents are encouraged to stay independent and make choices and decisions in daily living. There is a varied menu with choice of meals and residents said they enjoyed the food. Residents understand how to make a complaint and any complaints received are taken seriously. There are procedures for protecting vulnerable adults and staff are trained in prevention of abuse. Residents live in a clean, comfortable building that is maintained to a high standard. The home provides good staffing levels to meet resident needs. Staff are given training relevant to caring for older people and over 50 have completed qualifications in care. Eothen DS0000000442.V314244.R01.S.doc Version 5.2 Page 6 Resident finances are safeguarded. There are systems to ensure residents and staff health and safety. 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. The summary of this inspection report can be made available in other formats on request. Eothen DS0000000442.V314244.R01.S.doc Version 5.2 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 DS0000000442.V314244.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 is not applicable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. New residents have their needs thoroughly assessed before admission to the home is agreed. EVIDENCE: The records of two residents who had moved into the home in recent months were examined. These showed that detailed assessments of care needs were carried out with the person before being admitted. One lady was assessed whilst in hospital and medical staff had provided information. The other lady had previously lived in a care home in another part of the country. Her assessment had been completed by telephone and documentation was provided by the other home. A Social Work assessment is obtained where a Local Authority will be funding the resident’s care. The potential resident and their relatives can visit the home before admission and staff record these visits. Eothen DS0000000442.V314244.R01.S.doc Version 5.2 Page 9 All residents who completed surveys said they received enough information about the home before moving in. Some residents indicated that relatives had helped them when choosing the home. Eothen DS0000000442.V314244.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have generally well recorded plans that show how they are helped to meet their care needs. Residents receive good support from staff and medical professionals in meeting their health care needs. Residents are protected by the home’s medication system. Resident privacy and dignity is respected. EVIDENCE: A sample of resident care records was examined. The home uses a range of assessments to identify residents’ health, personal and social care needs. Care plans are then drawn up which demonstrate how staff will support residents in meeting their needs. The plans were generally well recorded. The inspector Eothen DS0000000442.V314244.R01.S.doc Version 5.2 Page 11 and manager discussed how some interventions could be made more specific. Staff review care plans regularly by recording evaluations, however these were not always completed monthly. At the last inspection there was an outstanding Requirement to update resident care plans where necessary to reflect their current needs. Care plans were seen that had been updated or re-written where needed. Each resident who completed a survey said they always or usually received the medical support they need. One relative commented, “The management of the home have demonstrated a professional approach when responding to my mother’s deteriorating health”. Residents use eight local doctor practices. The District Nursing Service provides services to individuals when required. A District Nurse had recently reviewed resident continence assessments and products. There are arrangements for residents to receive home visits from an optician, dentist and podiatrists. Residents with deteriorating mental health are referred for reassessment, and where necessary have had input from a specialist Challenging Behaviour Team. All contact with health professionals is recorded. The home organises staff to escort residents to hospital appointments or relatives can accompany. The inspector observed a carer giving reassurance to a lady resident who was waiting to go to a hospital appointment and was anxious. Individual’s health needs are assessed and care planned. All residents have their moving and handling needs assessed. Good examples were seen of moving and handling care plans. These detailed encouraging mobility, how staff support with transfers, aids used and preventing pressure areas. Resident nutritional needs are assessed and weights are monitored. Sitting weighing scales are provided. The home encourages residents who are able, to continue to administer their own prescribed medication. One resident currently orders, collects and administers her medication. A risk assessment is completed and the lady has a lockable facility for storage. This is a good example of maintaining independence. Medication practices are in the process of being reviewed. Medication is administered by staff who have completed relevant training and competency assessments are being introduced. Medication records were examined. Each resident has a photograph for identification purposes. At the last inspection a Requirement was made that there must be no gaps to signatures/codes in medication administration records. This had been followed up and no gaps were evident. The Controlled Drugs register was appropriately recorded. Eothen DS0000000442.V314244.R01.S.doc Version 5.2 Page 12 Privacy and dignity issues are built into the home’s policies and procedures on personal care delivery. Care practices are discussed at staff meetings. An example was seen of a risk assessment and care plan for a resident who wishes to bathe independently and have her privacy respected. All bedrooms have en-suite facilities that enable residents to wash and toilet in private. Personal care and any medical examination/treatment are carried out in the privacy of the resident’s bedroom. Two sisters, who chose to share, occupy a double bedroom. Residents are asked the name they wish to be addressed by and this is recorded on their pre-admission assessment. Residents are informed that the home currently employs an all female care team. Each bedroom is equipped with a telephone so that residents can make and receive calls in private. Mail is given unopened to residents and staff or relatives give support in dealing with correspondence, where needed. Individuals clothing is labelled/marked to make sure it can be identified and each person has his or her own laundry basket. The home employs specific laundry staff. One relative gave comments in a survey about the laundry. They said they recognised it is a difficult area to organise, but felt improvements could be made in making sure clothing is returned to the correct owner. Eothen DS0000000442.V314244.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with a good range of social activities, entertainment and outings. Residents are supported to maintain contact with relatives, friends and the local community. Residents are encouraged to make choices and decisions and take control of their lives. Residents are consulted about the food provided and are offered a good, varied diet with choice of meals. EVIDENCE: Residents social needs are assessed and care planned. Where necessary relatives are asked to provide information on the person’s background, lifestyle and interests. A number of residents told the inspector they were aware of the activities available. One lady said she checks the notice board where details of Eothen DS0000000442.V314244.R01.S.doc Version 5.2 Page 14 activities are displayed. Other residents said they were happy to keep themselves occupied with their own interests or were selective about participating in group activities. The majority of survey responses about social activities were positive. Residents said that there was always, usually, or sometimes activities arranged by the home that they could take part in. Additional comments included, “I prefer to make my own decisions and be independent and go out every day. I therefore feel that I do not need to take part in organised activities within the home”, “It would be nice to play bingo sometimes. More games if possible”. A relative commented, “A few more group activities e.g. bingo would be welcome”. Residents are consulted about social activities at Resident Meetings. Records are kept of daily activities provided and those residents who have participated. These showed a good variety of activities. Regular activities include an art class, armchair exercises, and games and quizzes. Some residents had recently taken part in gardening sessions, planting spring bulbs. A relative of a former resident visits weekly and reads novels to residents. A Lay Preacher is starting to provide weekly services and Bible Study sessions. The home has a volunteer who does one-to-one and group social sessions with residents, and another volunteer is due to start in the near future. Information is kept on entertainers, transport and venues. Seasonal events, outings and visiting entertainment are forward planned and recorded on an annual plan. These had included Christmas, Easter and Garden Parties with entertainers, a fireworks display, and trips to the Discovery Museum, Tynemouth, Whitley Bay and Jesmond Dene. The home has an open visiting policy and residents choose who they wish to see. Visits take place in the resident’s bedroom or lounge/dining areas. One relative commented in a survey that they visit frequently and usually have to wait five minutes for anyone to answer the door. They said on one occasion they waited for 17 minutes. Contact with family, friends and the community is supported. Use is made of local amenities such as shops and a café on Gosforth High Street and a local park. Staff accompany individuals or small groups of residents to go into Newcastle City Centre. Links have been made with George Stephenson School and pupils and residents have worked together on a reminiscence project about leaving school and employment. Relatives/visitors who completed surveys said the home helps their relative/friend to keep in touch with them. They said they are always or usually kept up to date with important issues affecting their relative/friend. Eothen DS0000000442.V314244.R01.S.doc Version 5.2 Page 15 Comments included, “Pass messages on my behalf”, “Kept informed regarding doctor’s appointments etc”. The home’s management does not have Appointeeship responsibility for any resident’s financial affairs. Some residents continue to manage their finances, whilst other are supported by relatives and solicitors. Cash for personal spending can be held in the home’s safe. Information on advocacy services is available, and these would be accessed if needed. Before admission potential residents and their relatives are told what is provided in bedrooms and agree with the manager those items they will bring into the home. Inventories of belongings are recorded. Residents choose the décor and how they wish to personalise their bedrooms. An example was given of a resident who has chosen to change her bedroom carpet and pay for this. The home has policies and procedures on record keeping, including confidentiality and access to personal records. In practice residents are involved throughout assessment, care planning and reviews, and where possible sign their care plans. Relatives who completed surveys said that the service always or usually supports people to live the life they choose. Residents have choice of meals and choose whether to eat in the dining room or their own bedroom. Nutritional needs are assessed and records are made of individual’s food likes/dislikes. Catering staff have regular contact with residents and the chefs attend Resident Meetings. Kitchen staff meetings are held. The latest meeting showed discussion on food, equipment and providing greater choice for residents with diabetes. Beverages are served regularly throughout the day and kitchen assistants replenish juice/water jugs. Seasonal events and special occasions are catered for. There is a 4-week cycle of menus that is currently being reviewed. Breakfast is a choice of cereals, porridge, fruit, yoghurt, juices, toast and cooked breakfast daily. There is a choice of main meal at lunch and tea, followed by dessert. Different snacks are provided for supper. Independent eating is encouraged, with use of feeding aids if necessary. One resident uses a plate guard. Staff assist residents at mealtimes by prompting, cutting up food and feeding anyone who is poorly or unable to feed themselves. The inspector dined with residents at lunch. Some residents take it in turns to say Grace before meals. The dining tables were attractively set with tablecloths, napkins and condiments. Hot and cold drinks were provided. The meal was served efficiently and staff were observed assisting residents where necessary. The manager agreed to check with residents if those who are able Eothen DS0000000442.V314244.R01.S.doc Version 5.2 Page 16 wish to serve themselves from vegetable tureens. All residents spoken with said they enjoyed the food and there is always choice/alternatives available. The majority of residents who completed a survey said they always liked the meals. Others said they usually or sometimes liked the meals. Comments included, “The meals are nice, I enjoy them”, “The food is very nice and they have a lot to choose from”, “I always have a choice but if I do not like the food they would make me something else”, “Most times I like plain food”, “Some meals I don’t like on the menu but I ask for something different”, “Too much pepper/salt”, “Sometimes waiting to go for lunch takes too long”. A relative commented in a survey, “My mum does not like the food very much but she is a fussy eater”. Eothen DS0000000442.V314244.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and relatives are confident of any concerns being listened to, and any complaints received are properly investigated. The home aims to protect residents from any form of abuse. EVIDENCE: The home’s complaints procedure is displayed and a copy is provided in the Service User Guide that is given to each resident. Four complaints were received and investigated in the past year. Records are kept in the complaints file. The inspector reminded that each complaint should have an outcome recorded. The Commission had not received any details of concerns or complaints about the home since the last inspection. Residents spoken with knew how to make a complaint. A visiting relative said he would have no hesitation in speaking to the manager. All except one resident who completed surveys said they would know whom to speak to if they are not happy and know how to make a complaint. Comments included, “The staff are very good but if I ever had a problem I would go to the office”, “They are very good at sorting out things”, “Ring the bell and complain to whoever answers”. All relatives who completed surveys said they know how to make a complaint and had always or usually received an appropriate response Eothen DS0000000442.V314244.R01.S.doc Version 5.2 Page 18 if they had raised concerns. Comments included, “Manager very approachable”, “Any concerns have received a quick and professional response”, “I have been informed of the procedure by the head of the home”. There are policies and procedures in place on prevention of abuse, protecting vulnerable adults (POVA), and ‘whistle blowing’ (informing on bad practice). The local POVA procedure was discussed with the manager. Mrs Dixon understands her responsibility to report and notify any allegations of abuse to the relevant authorities. All staff receive training on protecting residents from abuse. Eothen DS0000000442.V314244.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with a clean, comfortable and well-maintained environment. EVIDENCE: Senior managers continue to audit the building on a monthly basis. Records are kept of maintenance and repairs. All parts of the building seen were clean and suitably decorated, furnished and equipped. Bedrooms are redecorated as needed, and residents can choose the décor. All bedrooms have en-suite facilities. The majority of residents have televisions in their rooms and all have telephones. Residents spoken with were happy with the comfort of bedrooms and had personalised their rooms with furnishings and belongings. In recent months corridors and staircases have been redecorated and had new carpets Eothen DS0000000442.V314244.R01.S.doc Version 5.2 Page 20 fitted. Consideration is being given to creating a separate prayer/quiet room in the communal lounge. There are procedures on control of infection and staff receive relevant training. Supplies of disposable gloves and aprons are provided for staff use. Suitable hand-washing facilities are provided. There are arrangements to dispose of clinical waste. The laundry and sluice are located away from kitchen and dining areas. A designated staff member attends meetings at the local Communicable Diseases Unit. All residents who completed surveys said the home is always or usually fresh and clean. Comments included, “The cleaning lady is very good”, “The home is always lovely and clean”. Relatives said, “The cleanliness of the home is up to scratch – best home we have visited”, “Rooms kept clean and tidy”, “The house is well maintained”, “Maintain good levels of cleanliness”. Eothen DS0000000442.V314244.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good staffing levels are provided to meet the needs of the number of residents. The home is committed to residents being cared for by qualified workers. Residents are protected by the home’s recruitment process. Staff are provided with training relevant to the needs of the people they care for. EVIDENCE: All care staff are aged over 18 and staff left in charge of the home are over 21 years of age. At the time of the inspection there was 35 residents. Good care staffing levels are provided. Rotas indicated five carers on duty across the waking day and two carers at night. An additional carer is also provided from 7am to 8am and the person in charge of the evening shift now stays until 10pm. Two relief carers are employed to cover for holidays, sickness, and escort duties and there has been some use of agency staff. The home provides a good level of domestic, laundry and catering staff hours. Eothen DS0000000442.V314244.R01.S.doc Version 5.2 Page 22 Residents who completed surveys said that they always or usually received the care and support they needed. They said staff listen and act on what they say, and are always or usually available when they need them. Comments included, “When I buzz the buzzer the staff come to my room”, “More often have to wait a long time for staff to get back to you”, “They do their best”, “The staff are always helpful”, “I’m quite happy with my care”, “Very friendly staff and very nice office staff”. A resident told the inspector that she was very happy and supported by staff and said “I’d give the home 5 stars”. Relatives who completed surveys said the home always or usually meets the needs of their relative/friend, gives the support/care they expected and that staff have the right skills and experience. Comments included, “My mother is extremely happy in the home”, “Very caring, my mother likes the staff and it would appear they like her”, “(Have) qualified care workers”. Over 50 of care staff have achieved National Vocational Qualifications (NVQ) in care. NVQ qualifications have been achieved at Levels 2 and 3 in Care, and further staff are studying. Two staff are NVQ Assessors and one has completed NVQ Level 4 in Management. The home’s two care co-ordinators are due to start an NVQ accredited course on Team Building/Leading. At the time of the inspection there was no staff vacancies. A sample of newer staff recruitment files was examined. These contained appropriate details including photograph and proof of identification, application form, references from suitable sources, interview records and health questionnaires. All staff are recruited subject to Criminal Records Bureau (CRB) checks being carried out. CRB checks were also examined. Records of all staff training courses and certificates are maintained. In the past year staff have received training in the following areas: induction training for new staff, National Vocational Qualifications, safe working practices (fire safety, moving and handling, first aid and food hygiene), 10 week care assistant course, eye care, social activities, adult protection, health and safety, medication, catheter care, and skin integrity. Training was planned on continence promotion, caring for confused residents, and refresher courses in safe working practices. Eothen DS0000000442.V314244.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A responsible manager, supported by a good management team, manages the home. The home has good systems in place to monitor the quality of the service. Residents have their personal finances safeguarded. The home aims to comply with health and safety requirements. EVIDENCE: Eothen DS0000000442.V314244.R01.S.doc Version 5.2 Page 24 Mrs Sylvia Dixon has managed the home for the past year and was recently approved as the Registered Manager. She is a Registered General Nurse and is making arrangements to undertake the Registered Manager Award qualification course. There has been some restructure to the management team. This now consists of the Manager, Assistant Manager and two Care Co-ordinators. They have regular management meetings. The inspector observed good rapport between residents and relatives and members of the management team, including offering information and reassurance. The home’s Statement of Purpose is being updated to add in the Registered Manager’s details. At the last inspection a Recommendation was made to develop an annual quality assurance plan. This had been introduced in the form of a policy that specifies the methods by which the quality of the service is measured. These include the home’s business plan; six monthly ‘Council of Management’ meetings; annual surveys; internal audits; monthly ‘conduct of home’ visits/reports; staff training, meetings, supervision and appraisal; resident meetings and reviews; the complaints process; and review of the home’s policies and procedures. The organisation’s senior managers provide frequent support to the home. They also carry out detailed monthly ‘conduct of home’ visits, and additional audits such as checking staff files and resident care records. The manager said that the results of resident surveys were being collated and she was following up on issues raised. The CSCI questionnaire that the manager completed indicated that a number of the home’s policies and procedures had not been reviewed for some time. Relatives who completed surveys were asked what they feel the home does well. Many commented on the cleanliness of the building. One relative indicated staff are patient in looking after their mother who can be difficult. Other comments included: “Friendly, helpful and conscientious staff”. “Eothen excels at everything. The staff really care about every resident and treat them all as individuals”. “Enables all residents to be alone or mix with other residents without question”. “Communication, meals, and washing clothes”. “Caring nature, clean and protective”. “Compassionate approach recognising the need to retain the dignity of the elderly”. Relatives were also asked how they think the home can improve. The following comments were made: “At the present time I have no complaints whatsoever”. Eothen DS0000000442.V314244.R01.S.doc Version 5.2 Page 25 “It would be nice if the home had more than one residents lounge. The lounge is large, light and comfortable. However if a resident wants to avoid or limit time with another resident it is difficult to do so”. “That the manager ensures that the staff are carrying out the duties they are assigned to do”. “Have someone to help with hearing aids e.g. cleaning to prevent clogging of tube which puts it out of action. Cleaning shoes e.g. food dropped on them leaves marks”. “Keep up the high standards that already exist”. “Possibly by having more activities to stimulate and interest the residents”. “Staffing levels are generally insufficient, particularly in the evenings and early morning. This causes often long response times to residents call system”. The same relative gave comments about a matter concerning their mother’s care that they found unacceptable. These were relayed to the manager who instructed staff on the particular care practice issue at a staff meeting. Additional comments from relatives included: “Overall, by general standards, seems to be a very good home, albeit expensive”. “A little more television watching time would be appreciated by my mother”. “I am very grateful that my sister and I found Eothen for my mum. Mum is very happy in Eothen and we don’t have to worry about her”. “This is a good home in my opinion – well ran and well staffed”. Resident personal finances were checked. Transactions were appropriately recorded and cross-referenced to numbered receipts where applicable. Two staff carry out weekly checks of balances and cash. The home has a health and safety policy and range of associated procedures. Staff are provided with health and safety training. There is also an internal Health and Safety Committee that meets to discuss issues. Risk assessments are completed for the environment and safe working practices. Servicing and maintenance agreements are in place for facilities and equipment. All fire safety checks, tests and instructions to staff were up to date and recorded. Advice was given to test fire alarms in rotation. Accident reporting was suitably recorded. Analysis of accidents is carried out and will in future include times and locations to help identify any patterns. Eothen DS0000000442.V314244.R01.S.doc Version 5.2 Page 26 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 2 8 3 9 3 10 3 11 X 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 4 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 2 X 3 X X 3 Eothen DS0000000442.V314244.R01.S.doc Version 5.2 Page 27 NO 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. Standard Regulation Requirement Timescale for action 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. 2. Refer to Standard OP7 OP33 Good Practice Recommendations Care plans should be evaluated at least monthly. (a) A review of older policies and procedures should be carried out. (b) Management should address, where possible, negative responses/comments from CSCI surveys. Eothen DS0000000442.V314244.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000000442.V314244.R01.S.doc Version 5.2 Page 29 - 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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