Inspection on 29/12/05 for Eothen

This inspection was carried out on 29th December 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 12/10/06

Eothen 23/09/05

Eothen 24/01/05

Eothen 10/06/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Eothen 31 Worcester Road Sutton Surrey SM2 6PT Lead Inspector David Pennells Unannounced Inspection 29th December 2005 13:45 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Eothen DS0000007193.V273435.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.V273435.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 enquiries@eothenhomes.org.uk www.eothenhomes.org.uk Eothen Homes Limited Care Home 41 Category(ies) of Old age, not falling within any other category registration, with number (41) of places Eothen DS0000007193.V273435.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd September 2005 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, leisure and entertainments centre of the town. The building forms a quadrangle, with many rooms looking out onto an extremely well kept and attractive central garden (even in the depths of winter), which can be easily accessed by service users. The front (northern side) of the property comprises a three-storey (older) building with accommodation provided on all three floors (served by passenger lift, but still leaving some steps to negotiate). Towards the rear of the property is the newer south wing, with accommodation on the ground and first floors. There is ample communal space that includes small quiet lounges, a central lounge, a large (underused) lounge in the south wing, and two dining rooms. The home is very well maintained and, despite its size, maintains a smart, but warm and homely ambience. There are thirty-eight single bedrooms, three of which are large enough to be used as double occupancy for couples, if they so wish. Seventeen of the bedrooms currently have ensuite facilities, 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.V273435.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection visit was conducted at the home throughout the afternoon of a mid Christmas-week inspection visit. The inspector was met and welcomed by Sue Henderson the Acting Home Manager - who was just going off duty, and who handed the inspector over to the Deputy Manager, Ann Gungah - who was able to assist the inspector to review the requirements set at the last inspection, and to make contact with the proprietor - who was on duty at their Head Office in Newcastle (for clarification over staff members’ CRB checks). Following examination of paper work, the inspector was free to roam the house an d meet the service users - many of whom he met prior to, or coming to or actually at the supper table. The inspector also toured the building - randomly checking the premises for security and safety. The inspector is grateful to the service users, staff and management of the home for their welcome, hospitality and cooperation during this inspection visit. What the service does well: What has improved since the last inspection? Eothen DS0000007193.V273435.R01.S.doc Version 5.0 Page 6 In many respects, the standard of the service at the home cannot be ‘improved’ – such is the high general standard provided. It can only be said that the home continues to operate a very good level, and the senior management, the management (past and present) - and the staff should be proud of the level of service that they continue to provide. 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.V273435.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.V273435.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): None inspected at this visit. 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. The home does not provide intermediate (rehabilitative) care - and therefore standard 6 does not apply. EVIDENCE: The above judgement statement is brought forward from the previous inspection report - when all the standards (1-5) that were inspected, were found ‘met’. Eothen DS0000007193.V273435.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): 9 only. 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: The above first and last judgement statements cover standards 7, 8 & 10 examined at the last visit - and which the inspector has no doubt continue to be met. The central statement covers the examination, this time, of the home’s medication management and procedures - listed in standard 9 - which was also found ‘met’ (see over the page). “I think they’re marvellous – the people [staff] here.” - stated one service user and another stated: “The girls are lovely here.” Appreciation of the staff member’s caring input was heard on many occasions throughout the visit. Eothen DS0000007193.V273435.R01.S.doc Version 5.0 Page 10 A recommendation (under standard 7) regarding the training of care staff and the implementation of recording about service users by all grades of staff, rather than just the duty manager, to be encouraged was still, apparently not being undertaken - though the proprietors had assured the Commission that training was taking place. The home is losing good first-hand reports through staff having to verbally report, and then the senior scribing any incident that happens in the home. It is now accepted best practice that records should be made by staff who are directly involved with service users – not those who are at the end of the chain of command. The pitfalls of recording ‘reported speech’ are well documented; the ‘direct report writing style’ will guarantee greater accuracy and closer reporting, if properly put in place. A couple of ‘suspect’ weight records were noted in service user records - which the deputy manager was to look into; it is important that all staff take notice of the lateral comparison of such records - significant rises or falls do need exploring, as the scales provided appeared to be accurate and reliable. All staff members involved in administering medication have received accredited training from the supplying / visiting pharmacist, Boots the Chemist (inspection visits - minimally annually - were also found to be satisfactory). Medication records were comprehensively checked during the inspection and all were found to be in a satisfactory order. Medication procedures were checked and found well managed. Storage is concise and accurate. Just one issue of dating eye drop containers immediately when they are opened was to be directly addressed by the deputy manager. Observation of administration showed that recording and administration was undertaken as a ‘single action’ as best practice dictates. Eothen DS0000007193.V273435.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): 14. 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 can expect to be allowed to exercise control and choice over their lives within the context of concerned care at the home. Service users are certain of a nourishing and nutritious diet being provided at the home, served in pleasant surroundings, with all appropriate ‘trimmings’ and a courteous service. EVIDENCE: The above statements are - except the penultimate - brought forward from the previous report - when standards Standard 12, 13 & 15 were found ‘met’. Standard 14 (indicated by the third judgement statement) was therefore audited on this occasion, and also found ‘met’. The situation concerning service users being able to exercise choice and control over their lives was exampled to the inspector through the following facts: some service users continue to Eothen DS0000007193.V273435.R01.S.doc Version 5.0 Page 12 manage their own finances, holding cheque books and statements, etc and may self medicate if assessed as safe to do so; solicitors / relatives / care managers or relatives are involved with each individual resident at the home; information about advocacy services is available in the home; service users bring personal possessions – to a significant degree, often, into the home; the home has a policy and procedure relating to ‘access to personal records’. Eothen DS0000007193.V273435.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): 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: The above statements are taken from the last report - as things have not substantively changed; the home’s approach to dealing with complaints is generally good - and the adult protection policy still requires amendment. 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 – had still not been responded to; the policy held in the procedure file was outdated – and clearly not a revision. The requirement is therefore again reiterated - in the hope that the inspector will not be compelled to issue an Immediate Requirement Notice at his next visit to [virtually] force this policy amendment into place. Eothen DS0000007193.V273435.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): None inspected this time. 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 above judgements reflect the previous inspection outcome that found all the environment standards were ‘met’. The inspector did independently tour the building - and found all to be clean, tidy and in good repair. A recommendation that an induction loop be installed in at least one lounge to advantage those who use hearing aids is repeated herein again – as the number of hearing impaired service users is significant – and such a facility would encourage the use of such aids in a positive way. Eothen DS0000007193.V273435.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): 29. 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. Service users can be confident that their safety and security is maintained through the home conducting a rigorous recruitment process, with appropriate records kept. EVIDENCE: The first judgement statement above is quoted from the previous report which examined all standards but No 29 - all being ‘met’. The second paragraph evidences that the remaining standard is found ‘met’. The home’s recruitment policy expects two written references to be received prior to appointment. All files sampled during the course of the inspection had a copy of terms and conditions of service and staff confirmed they had received this and a job description. All staff had now been in receipt of completed CRB checks for care staff - the proprietor confirmed this and management files had previously been brought down from Head Office in Newcastle for the inspector to see. All staff members have received a copy of the GSCC ‘Codes of Conduct’; evidence was noted on staff personal files; each staff member having individually signed for this. Eothen DS0000007193.V273435.R01.S.doc Version 5.0 Page 16 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 & 38. Service users and their advocates can be assured that the home will be managed and supervised in the best possible way, even though a vacancy situation with a manager not formally in place continues. 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, though attention to the ‘basics’ - such as fire alarm testing must not be neglected. EVIDENCE: The home has now been without a manager since early in the year, when the home’s Care Manager left the home’s employ. Prior to this, a situation with a Operations Manager and a Care Manager was in place - and the Operations Manager had been away on maternity leave for some time and eventually did not return to her post. Eothen DS0000007193.V273435.R01.S.doc Version 5.0 Page 17 It is concerning to the Commission that not too long a period is allowed to elapse pending the appointment of the new manager. Seniors acting up at present seem to be coping very well, generally, but this temporary circumstance can become difficult if left too long. The proprietors are required to expedite the recruitment process and to find a new incumbent for the post. Regulation 27 audit visits conducted by the proprietors are thoroughly carried out; the format is excellently concise. There are at least three styles of audit assessments: Resident-focused / medication-focused and premises focused. The Commission had received a report for the inspection visit of 9/11/05 and the inspector awaits further copy reports (the requirement to provide the Commission – under regulation 26(5) - with copies of the visit reports was set in the last inspection report). Hopes – following the previous inspection visit report – that fire alarm testing would be undertaken consistently from thereon were thwarted, when the inspector found that the fire alarm call point tests had not been completed since the 29/11/05 - evidencing a neglect of four weeks and two days (and quite probably longer if the inspector had not pointed this out). It is imperative that such checks are carried out systematically on a weekly basis; the inspector fails to perceive the problem in achieving this. The inspector required of the duty manager that the checks neglected over the past four weeks be undertaken – and documentary evidence faxed to the Commission within 24 hours of this visit. The inspector is able to report that this action was taken promptly the following morning at the home.) The visual checks of the fire extinguishers within the home was also not recorded adequately; the inspector had previously asked that a format be implemented to evidence which specific extinguishers had been checked – an ‘all checked’ expression - when there are 21 appliances dotted around the building, is clearly not satisfactory. The inspector also recommends that the frequency of fire drills be reviewed; this due to the fact that only eight staff took part in what is described as the 6monthly drill – suggesting that a relatively small percentage of the entire staff team experience specific involvement in a drill. Three-monthly Fire training is also given for day staff – but the experience of an actual drill has the most powerful effect on staff’s attitudes and future behaviour. Eothen DS0000007193.V273435.R01.S.doc Version 5.0 Page 18 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 X 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X X X X 2 Eothen DS0000007193.V273435.R01.S.doc Version 5.0 Page 19 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 & 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 & 30/11/05 not met. The proprietors must urgently recruit - and propose to the Commission for registration - a full-time manager for the home. Fire alarm testing must be conducted consistently, week on week, whatever the situation / time of year. Timescales of 01/02/05 & 30/11/05 not met. The monthly visual checks of fire extinguishers should be more specifically recorded – to identify which was actually checked. Timescales of 01.02.05 & 30/11/05 not met. Timescale for action 28/02/06 2. OP31 8(1) (2) 28/02/06 2. OP38 23 (4)(c)(v) 30/12/05 3. OP38 23 (4)(c)(v) 31/01/06 Eothen DS0000007193.V273435.R01.S.doc Version 5.0 Page 20 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. The proprietors report ‘ongoing training’ in this regard. 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. The proprietors are understood to be considering this suggestion. That the frequency of fire drills be reviewed – with a view to more staff experiencing a direct involvement in an actual fire drill practice. A new recommendation. 2. OP22 3. OP38 Eothen DS0000007193.V273435.R01.S.doc Version 5.0 Page 21 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.V273435.R01.S.doc Version 5.0 Page 22 - 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!