CARE HOMES FOR OLDER PEOPLE
Epworth Care Home Front Street Tanfield Lea Stanley Durham DH9 9LX Lead Inspector
Gavin Purdon Unannounced Inspection 17th January 2006 09:30 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 Epworth Care Home DS0000063213.V267590.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. Epworth Care Home DS0000063213.V267590.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Epworth Care Home Address Front Street Tanfield Lea Stanley Durham DH9 9LX 01207 236 379 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) X9 Services Ltd Mrs P Hardy Care Home 31 Category(ies) of Dementia - over 65 years of age (31), Old age, registration, with number not falling within any other category (31) of places Epworth Care Home DS0000063213.V267590.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 18th July 2005 Brief Description of the Service: Epworth Residential Care Home is owned by a private company,X9 Health Care Epworth Ltd. It looks after the personal care of up to 31 older people who are physically or mentally frail, but does not provide nursing care. Epworth Residential Care home is in the village of Tanfield Lea, not far from Stanley town centre. There are local shops and village amenities close by. The home is on two floors connected by stairs and a passenger lift. Bedrooms are a generous size, and most have en suite toilets. Outdoor space is limited but the rear of the home looks out onto a local park and woodland area. Epworth Care Home DS0000063213.V267590.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and lasted 3 and a half hours. It looked at the safety and maintenance of the building and how pleasant and convenient a place it is to live and work in. It looked at staffing arrangements, at how many staff, and how reliable, organized, and trained they are, to look after the residents at the home safely and well. The inspection also looked at what management checks are made, and recorded, to show that the home is run safely for the benefit of residents and to the satisfaction of residents. The building was looked at, staff and residents were spoken with in private, and management records seen. On the whole, the findings were good to excellent. Residents were comfortable and happy and staff thought they were in a position to do a good job for their residents. People thought that changes and developments to ways of work and management of care were making the home even better. What the service does well: What has improved since the last inspection? Epworth Care Home DS0000063213.V267590.R01.S.doc Version 5.0 Page 6 Staff and management thought that the home’s very good standard of training, with the NVQ 2 qualification now held by all care staff, had made a difference to the standard of care provided, and was a big benefit to the home. Staff and management thought the good staffing levels, the new staff rota system and the appointment of an activities coordinator were important changes. Staff said, “These improvements are working well. The atmosphere’s different. Residents are more lively. Staff are more motivated. There’s more to do and more to talk about.” 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. Epworth Care Home DS0000063213.V267590.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 Epworth Care Home DS0000063213.V267590.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): Not assessed on this occasion. EVIDENCE: Epworth Care Home DS0000063213.V267590.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): Not assessed on this occasion. EVIDENCE: Epworth Care Home DS0000063213.V267590.R01.S.doc Version 5.0 Page 10 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): Not assessed on this occasion. EVIDENCE: Epworth Care Home DS0000063213.V267590.R01.S.doc Version 5.0 Page 11 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): Not assessed on this occasion. EVIDENCE: Epworth Care Home DS0000063213.V267590.R01.S.doc Version 5.0 Page 12 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. Residents have the benefit of living in safe and well-kept surroundings. Residents are comfortable and are protected by good standards of hygiene and cleanliness in the home. EVIDENCE: Records and schedules were seen for the general upkeep of the home and for maintenance of essential services and equipment. These showed that there is an organized and thorough approach to keeping the home safe and pleasant for residents to live in. Staff and residents thought the home was a nice place to live and work in. The manager explained how everyday practices, equipment, and training made sure that the home was clean and hygienic. On the day of the unannounced inspection the home looked well cared for and was odour free.
Epworth Care Home DS0000063213.V267590.R01.S.doc Version 5.0 Page 13 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, 29, & 30. Residents benefit from the particularly good staffing levels in the home and from the attention of skilled staff. Residents benefit from a care workforce that is 100 qualified to NVQ Level 2 in care practice. Residents are protected by the home’s thorough recruitment practices. Residents benefit from an able and well trained staff group looking after them. EVIDENCE: On the Tuesday morning of the unannounced inspection there were 19 residents at Epworth. There was a Manager, Deputy Manager, Senior Carer, Carer, Activities Coordinator, plus kitchen and cleaning staff, on duty. This was in line with the staff rota seen. These staffing levels are above the expected standard. They do allow a very good level of support and attention to be given to residents. Staff and residents said they were happy with the standard of care given and received.
Epworth Care Home DS0000063213.V267590.R01.S.doc Version 5.0 Page 14 All 11 care staff hold the NVQ 2 qualification in care. This is an outstanding achievement. Staff thought that their training had given them more ideas about giving residents better care. The care staff personnel records seen showed that the home is thorough in the vetting of its staff. It takes all the required steps to make sure that its residents are protected from job applicants not really suitable to care for vulnerable people. Discussions with management and staff showed that people are very interested in training at Epworth, and want to be good and better carers, for their own satisfaction and for the benefit of residents. Epworth Care Home DS0000063213.V267590.R01.S.doc Version 5.0 Page 15 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. Residents benefit from the home having stable and capable management interested in developing management skills and practices for the good of residents and staff. Residents benefit from the home’s interest in checking that good standards of care are provided and that residents are happy with their care. The home could draw the findings of these checks together and let residents and relatives know the overall results of these surveys. The home has financial procedures to ensure that money kept for residents and spent on their behalf is well recorded and accounted for. Residents are protected by the home’s many safe working practices, but the recording of fire safety training and practice needs to be improved. EVIDENCE:
Epworth Care Home DS0000063213.V267590.R01.S.doc Version 5.0 Page 16 The home’s manager has the NVQ 3 qualification and has arranged to start the Registered Manager’s Award this year. The manager is experienced, and well thought of by staff and residents. The manager has the benefit of management support and development arrangements provided by the company that owns the home. The manager explained how management methods were operated in the home, and how these were developing. The manager thinks that these improvements are for the good of the home, its staff and its residents. Surveys of residents’ and relatives’ views were seen. These were gathered by the home’s activities coordinator. They give an important message that residents have a right to say what they think about their care ,and to expect their view will be taken notice of. The home’s use of resident surveys is an area of good practice that could be developed further by collecting, analysing and publishing the overall results based on individual comments. Records of money kept and spent on behalf of residents were looked at. These records were up to date, accurate and complete. This provides a good standard of protection for service users. Health and safety records seen, and discussions of training and practice with management and staff, showed that the home is safety conscious and aware of the need to protect its staff and residents. 2 staff interviewed gave a good verbal account of what to do and what not to in the event of a fire, but the conduct and recording of fire safety training and practice must be improved. Epworth Care Home DS0000063213.V267590.R01.S.doc Version 5.0 Page 17 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 X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 4 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Epworth Care Home DS0000063213.V267590.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP38 Regulation 23(4) Requirement The conduct and recording of fire safety training and practice must be improved. Timescale for action 17/04/06 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 OP31 OP33 Good Practice Recommendations The home’s manager should commence the Registered Manager’s Award in 2006 as planned. The home’s use of resident surveys is an area of good practice that should be developed further by collecting, analysing and publishing the overall results based on individual comments. Epworth Care Home DS0000063213.V267590.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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