Inspection on 20/07/05 for Eresby Hall

This inspection was carried out on 20th July 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 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

Eresby Hall 26/04/07

Eresby Hall 21/11/05

Eresby Hall 04/11/04

Eresby Hall 28/06/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Eresby Hall Ancaster Avenue Spilsby Lincs PE23 5HT Lead Inspector Julie Western Unannounced 20 July 2005 9.30 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 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. Eresby Hall C53 C04 S2354 Eresby Hall V239429 200705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Eresby Hall Address Ancaster Avenue Spilsby Lincolnshire PE23 5HT 01790 752495 01778 394404 manager.eresby@osjct.lincs.co.uk The Order of St John Care Trust Telephone number Fax number Email 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 Ritchie Care Home 45 Category(ies) of Old Age (OP) - 45 registration, with number of places Eresby Hall C53 C04 S2354 Eresby Hall V239429 200705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 04/11/05 Brief Description of the Service: Eresby Hall is one of 16 care homes in Lincolnshire operated by the Order of St John Trust. It is a large two-storey purpose built home, which is registered to accommodate up to forty-five older persons. It is situated in its own wellmaintained grounds in the market town of Spilsby, which has a variety of services and facilities. It is approximately a quarter of a mile from the town centre where public transport is readily available linking Spilsby with the coastal town of Skegness and the market town of Boston. Accommodation is provided on two floors, which are accessible via a lift or stairs. There are thirty-five single and five twin rooms and on the day of the inspection 40 residents were being accommodated. One of the rooms is used for respite care. Lounge and dining areas are on both floors. In addition the home also provides up to six-day care places; these did not form part of the inspection. The homes statement of purpose makes reference to the principles of care such as privacy, dignity, independence and rights of service users. The stated philosophy of care is to provide its service users with a secure, relaxed and homely environment in which service users care, well being and comfort are of prime importance. Eresby Hall C53 C04 S2354 Eresby Hall V239429 200705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over 4 hours. A partial tour of the building took place and care records were inspected. The main method of inspection used was called ‘case-tracking’; this involved selecting three residents and tracking the care they received through the checking of their records, discussions with residents and care staff and observation of practices. Some policies and procedures were examined and records concerning the safety of the home were also seen. Five of the 33 residents, five of the 40 care and ancillary staff and two visitors were spoken with. The Manager was present throughout the inspection. What the service does well: What has improved since the last inspection? Recent refurbishment and redecoration included the kitchen and servery on the first floor. The home has recently purchased four new wheelchairs, a Standaid and a wheelie commode. The home is now fully staffed with a new, young staff group to complement the core of more experienced staff. Eresby Hall C53 C04 S2354 Eresby Hall V239429 200705 Stage 4.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Eresby Hall C53 C04 S2354 Eresby Hall V239429 200705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Eresby Hall C53 C04 S2354 Eresby Hall V239429 200705 Stage 4.doc Version 1.40 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 standard(s) 1-6 The home clearly sets out what it intends to do for its residents and this information is freely available to residents. Prospective residents are encouraged to take time before making the decision to move into the home on a permanent basis. EVIDENCE: The statement of purpose was very comprehensive; it took the form of a folder with inserts. The Manager said a copy was given to all residents on admission, together with a copy of the service user guide, which was called the Residents’ Handbook and a copy of the latest Orders of St. John Care Trust quarterly magazine. The day care resource gave prospective residents a chance to experience life in a residential care home and some residents had also been to the home for respite care or to spend a day and have coffee or meals in the home. Eresby Hall C53 C04 S2354 Eresby Hall V239429 200705 Stage 4.doc Version 1.40 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 standard(s) 7-11 The home’s records give a clear indication of the needs of residents and enable staff to meet their needs with sensitivity and regard for their privacy and dignity. EVIDENCE: The three care plans looked at in depth contained clear and comprehensive assessments, were reviewed regularly and were signed where possible by the service user or relatives/advocates. There was a clear medication policy and the most recent visit from the pharmacist was 5/705, from which there were no requirements. Residents said they felt safe and well looked after; one resident commented ‘they’re good – they do a lot of work but they don’t rush you’. The staff team were observed carrying out their duties with kindness and sensitivity towards the residents, especially when attending to their personal needs. A visiting district nurse said that the standard of care at the home was excellent and the carers were ‘knowledgeable and interested in what we’re doing’. Eresby Hall C53 C04 S2354 Eresby Hall V239429 200705 Stage 4.doc Version 1.40 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 standard(s) 12-15 A wide variety of and activities is available and residents are informed about the programme of events. The residents exercise choice about which activities, if any, they wish to participate in and what meals they want to eat. EVIDENCE: The home employs an activities organiser who works flexibly 20 hours weekly; she is responsible for seeking the views of residents about what they wish to take part in. There is also a very active ‘Friends of Eresby’ volunteer fundraising group, the last event being a trip out with residents for lunch at a local pub. The housekeepers recently won the Trust’s housekeeping competition and with the prize money, some residents had a day trip to Woodhall Spa. Residents and staff confirmed that there was a great deal of choice regarding the activities and events at the home. Future events included the hire of a mini-bus in August to take two groups of four residents to the Trust’s seaside bungalow and several other residents on three days of trips including a mystery tour and a trip to the local supermarket. The midday meal was nutritious and residents said how much they enjoyed the meals. There were menus on the dining tables which including an alternative choice. Menus contained a lot of pastry and cakes, particularly at tea-time and it was recommended that they were reviewed in order to maintain a healthy Eresby Hall C53 C04 S2354 Eresby Hall V239429 200705 Stage 4.doc Version 1.40 Page 11 diet. One item past its sell by date was found in the first floor refrigerator and one not dated was found in the kitchen refrigerator. The kitchen staff also prepared up to 12 meals on wheels twice a week. Eresby Hall C53 C04 S2354 Eresby Hall V239429 200705 Stage 4.doc Version 1.40 Page 12 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 standard(s) 16-18 The home’s complaints procedure is clear and gives residents and their relatives the confidence that comments and concerns will be listened to; there is a robust adult protection procedure. EVIDENCE: Residents and visitors to the home all said they did not wish to complain but knew how to make a complaint. The home had received no formal complaints in the last twelve months. There was a clear adult protection procedure, which was linked to the Local Authority procedures. Staff members spoken with had received training on adult protection issues. Eresby Hall C53 C04 S2354 Eresby Hall V239429 200705 Stage 4.doc Version 1.40 Page 13 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 standard(s) 19-24,26 The residents live in a comfortable and pleasant environment with both private and communal space, which is generally suitable for their needs. EVIDENCE: The standard of decoration internally was generally good and afforded residents a good degree of comfort. A visitor who went to several homes in the area compared it favourably and said it was always very clean. The gardens were well tended with flowerbeds, a pond and seating areas for residents to sit out in good weather. The home has a rolling maintenance programme and two bedrooms were being decorated on the day of the inspection. Risk assessments are carried out on the premises to ensure that residents are safe from any potential hazards. The home was in need of some general upgrading and the Manager said that quotes had just been received to install double glazed windows, redecorate the main lounge and dining area and provide new dining chairs, provide new carpets for the main stairs and entrance areas, new kick plates to bedroom doors and a new electric sluice. Eresby Hall C53 C04 S2354 Eresby Hall V239429 200705 Stage 4.doc Version 1.40 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,30 Staff numbers are in sufficient quantity for them to be able to care for the residents. Staff members are suitably trained, qualified and competent; they undergo an induction programme before commencing their duties. EVIDENCE: The residents were very positive about the care they received from the staff and a visitor said ‘they’re always friendly and helpful’. The most recent staff member to be appointed confirmed that she had given two references, which were followed up, a CRB check and undertaken an induction programme before commencing work. Training was undertaken by in house and external trainers. The home had an at-a-glance training plan which showed that staff had received statutory training was completed with future recent specialist training being an update on medication and a course on dementia. Seven staff members had National Vocational Qualification at Level 2 with two having NVQ at Level 3. The staff rota showed that there were enough staff numbers according to the staffing matrix and shifts were staggered to accommodate the needs of residents. Eresby Hall C53 C04 S2354 Eresby Hall V239429 200705 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31-33, 36,38 The home is managed competently and the staff are supported and supervised in carrying out their respective roles. The views of residents are listened to and they are involved in decisions affecting them. EVIDENCE: The registered Manager is progressing towards the NVQ Manager’s award at Level 4. The quality assurance manual demonstrated a positive approach to seeking the views of residents and residents spoken with said they were constantly asked for their views on matters concerning the running of the home. The Manager said that quality surveys went out with invoices each month, for relatives/advocates to complete. There was a record of meals with satisfaction, complaints and concerns logged. The home has the International Standards Organisation 9000 award and the Investors in People award. In addition, the home is regularly audited by headquarters. Eresby Hall C53 C04 S2354 Eresby Hall V239429 200705 Stage 4.doc Version 1.40 Page 16 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 2 COMPLAINTS AND PROTECTION 2 3 3 3 x 3 x 3 STAFFING Standard No Score 27 3 28 3 29 x 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 4 x x 3 x 3 Eresby Hall C53 C04 S2354 Eresby Hall V239429 200705 Stage 4.doc Version 1.40 Page 17 None Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP15 Regulation 12[1][a] Requirement The registered person must ensure that refrigerators are regularly checked for out of date items of food and that items are dated on being opened. The registered person must forward dates for the commencement of the refurbishments identified in Standards 19-26. Timescale for action 15th September 2005 15th September 2005 2. OP19 23[2][b] 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 OP15 Good Practice Recommendations It is a recommendation that menus are reviewed to provide a diet less rich in pastry and cakes, particularly at tea-time. Eresby Hall C53 C04 S2354 Eresby Hall V239429 200705 Stage 4.doc Version 1.40 Page 18 Commission for Social Care Inspection Unity House, The Point Weaver Road Lincoln LN6 3QN 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 Eresby Hall C53 C04 S2354 Eresby Hall V239429 200705 Stage 4.doc Version 1.40 Page 19 - 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. 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