Inspection on 21/11/05 for Eresby Hall

This inspection was carried out on 21st November 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 20/07/05

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 Inspection 21st November 2005 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 Eresby Hall DS0000002354.V267947.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. Eresby Hall DS0000002354.V267947.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Eresby Hall Address Ancaster Avenue Spilsby Lincs PE23 5HT 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) 01790 752495 The Orders Of St John Care Trust Mrs Carol Yvonne Ritchie Care Home 45 Category(ies) of Old age, not falling within any other category registration, with number (45) of places Eresby Hall DS0000002354.V267947.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th July 2005 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 with the coastal town of Skegness 10 miles and the market town of Boston 17 miles away. 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 30 residents were being accommodated. 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, wellbeing and comfort are of prime importance. Eresby Hall DS0000002354.V267947.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 two inspectors carried out the inspection, which took place over 3 ½ 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. Six of the 30 residents, three of the 40 care and ancillary staff and two visitors were spoken with. What the service does well: What has improved since the last inspection? The rolling maintenance programme has continued with several more bedrooms having been redecorated. All but five of the windows have been replaced with new P.V.C. windows and the home has recently purchased parasols and benches for the garden and specially adapted plates to enable residents to maintain their independence while eating. Eresby Hall DS0000002354.V267947.R01.S.doc Version 5.0 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 DS0000002354.V267947.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 Eresby Hall DS0000002354.V267947.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1-5 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. It was recommended that the service users’ guide was retained in the resident’s room. 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. The home had recently sent packages out to targeted parts of the community advertising Christmas respite care or meals. Eresby Hall DS0000002354.V267947.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): 7-10 The home’s records give a good indication of the needs of residents and enable staff to meet their needs with sensitivity and regard for their privacy and dignity; although care plans are now more concise, there is still some crossreferencing and repetition. EVIDENCE: The three care plans looked at in depth contained comprehensive assessments, were reviewed regularly and were signed where possible by the service user or relatives/advocates. Risk assessments were however, repetitive and on one occasion needed cross-referencing. There was a clear medication policy and the most recent visit from the pharmacist was 5/705; any issues from this have been addressed. Residents said they felt safe and well looked after; one resident commented ‘I’ve no complaints at all’. The staff team were observed carrying out their duties on the whole 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 good and the staff group were knowledgeable about the needs of the residents. Eresby Hall DS0000002354.V267947.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): 12-15 A wide variety of events and activities, including an annual holiday, is available and residents are well 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 and on the day of the inspection was taking a resident out for the morning on a one-to-one basis. 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 pub in Partney. Two residents described how a mini-bus was hired in August to take them to the Trust’s seaside bungalow for a holiday and the Manager said that several other residents went on three days of trips including a mystery tour. Residents and staff confirmed that there was always a great deal of choice regarding the activities and events at the home; the Christmas diary was already displayed around the building. The five-week rota menu was balanced, with a use of fresh vegetables and fruit and residents said they enjoyed the meals very much. The menus on the dining tables included an alternative choice. The kitchen no longer prepares meals on wheels. Eresby Hall DS0000002354.V267947.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): 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 DS0000002354.V267947.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): 19,20,24,26 The residents live in a comfortable and pleasant environment with both private and communal space, which is generally suitable for their needs. EVIDENCE: The rolling maintenance programme has continued with several more bedrooms having been redecorated. All but five of the windows have been replaced with new PVC windows and the home has recently purchased parasols and benches for the garden. Overall, the standard of decoration internally was good and afforded residents a great degree of comfort. The home smelled clean and fresh throughout and a visitor 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. On the day of the inspection the lounge was being decorated and several residents were in their own rooms; doors were wedged open with a variety of items including wooden wedges, a stuffed toy and a footstool. It was recommended that the use of wedges was riskassessed and the Manager arranged for the Fire Officer to visit to give advice. It was also recommended that the wooden safety gate on the first floor was risk-assessed. Sluice doors should be kept locked. Eresby Hall DS0000002354.V267947.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): These standards were not inspected. EVIDENCE: Although the standards were not fully inspected, the staffing rota showed that there were enough staff on paper to care for the needs of the residents. Staff members agreed, especially since there were currently less residents in the home. However, two residents said they did not think there were enough staff to complete their tasks in the given time; this is probably due to the layout of the building, which is on two floors and has several small seating areas, meaning that staff were not always visible. It was recommended that staffing arrangements were continually monitored. Eresby Hall DS0000002354.V267947.R01.S.doc Version 5.0 Page 14 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): 31,32,35,37 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. Residents’ finances are kept safely. EVIDENCE: The Manager has been in post since 14th June 2004. She is a qualified RNMH nurse and has been in the caring profession for 23 years, with one year as a management trainee with OSJCT before her present appointment. She has just completed the NVQ Manager’s Award and is awaiting verification. Residents spoken with said they were constantly asked for their views on matters concerning the running of the home. Accounts of service users’ monies held for service users by the home were examined and two samples were found to balance; the accounts contained receipts for goods purchased on behalf of the service user. The Manager said that monies were audited regularly by herself and also by Trust representatives and records confirmed this. Eresby Hall DS0000002354.V267947.R01.S.doc Version 5.0 Page 15 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 X X X 3 X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X 3 X 3 X Eresby Hall DS0000002354.V267947.R01.S.doc Version 5.0 Page 16 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 OP19 Regulation 13[4] Timescale for action The registered person must carry 16/01/05 out risk assessments on the wooden safety gate on the first floor and on door wedges, using the advice of the Fire Officer. Sluice doors should be kept locked. Requirement 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 OP1 OP13 Good Practice Recommendations It is a recommendation that the service user guide is retained in the resident’s room for the use of the resident and family. It is a recommendation that the home considers the acquisition of some transport as the home is some distance from a town of any size and there are no means of taking residents out on a regular basis. It is a recommendation that staffing arrangements are continually monitored. 3. OP27 Eresby Hall DS0000002354.V267947.R01.S.doc Version 5.0 Page 17 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby 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 DS0000002354.V267947.R01.S.doc Version 5.0 Page 18 - 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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