Inspection on 26/04/07 for Eresby Hall

This inspection was carried out on 26th April 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

Eresby Hall 21/11/05

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 Richard Ramsden Key Unannounced Inspection 26 April 2007 10:00 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.V327110.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. Eresby Hall DS0000002354.V327110.R01.S.doc Version 5.2 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 www.osjct.co.uk The Orders Of St John Care Trust Mr Stephen James Massey Care Home 45 Category(ies) of Old age, not falling within any other category registration, with number (45) of places Eresby Hall DS0000002354.V327110.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Eresby Hall is registered to provide personal care for service users of both sexes whose primary needs fall within the following category:Old age, not falling within any other category (OP) - 45 The maximum number of service users to be accommodated at Eresby Hall is 45. 21st November 2005 Date of last inspection Brief Description of the Service: Eresby Hall is one of 16 care homes in Lincolnshire operated by The Orders of St John Care 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 well-maintained 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 bedded rooms. 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. The weekly accommodation charges are between £364 and £470. A copy of the last inspection report is available in the home. Eresby Hall DS0000002354.V327110.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector completed this unannounced visit over one day, it took approximately 7 1/2 hours. It included the inspection of care and other records, a discussion with the registered manager, two members of care staff, the administrator and the cook. The inspector spoke with four residents. A partial tour of the building was also completed. Three residents were case tracked, which means that their care plans were examined against the actual care they receive. Prior to completing this visit the inspector assessed the home service history and the last two inspection reports. A Pre-inspection questionnaire completed by the registered manager was also used to plan this inspection. What the service does well: The residents who were spoken with said that staff are always friendly and respectful and ensure that their privacy and dignity is maintained at all times. The observed interaction between residents and staff was of a very good standard. Four residents said that they are very satisfied with their bedrooms and confirmed that they been encouraged to personalise them with small items of furniture, photographs etc. They confirmed that the home is always kept “spotlessly” clean. Residents are encouraged and supported to make choices about their individual lifestyles within the home. The regime within the home is flexible and efforts are made to meet the individual residents needs and aspirations. The home provides an extensive range of activities and entertainment to provide stimulation for the residents. The residents stated that they are very happy with the food provided, they confirmed that there is always a choice of food and that alternatives will be provided if they do not want the meal suggested on the menu. The meals are freshly prepared on the premises and where possible fresh produce is always used. Eresby Hall DS0000002354.V327110.R01.S.doc Version 5.2 Page 6 The residents and the staff spoken with during the inspection said that the manager is very approachable and that he seeks their views about the way in which the home is run. The staff group are well trained and enthusiastic, which helps to ensure that staff are able to offer the support and assistance that each resident requires. The home has a comprehensive and rigorous quality assurance system, which helps them to monitor, plan and develop the services provided. There were aspects of good practice highlighted in the main body of this report. What has improved since the last inspection? What they could do better: All complaints should be recorded in a central book or file to provide an overview of the nature and frequency of complaints received. A lock should be fitted to the laundry door to help ensure that residents cannot gain access when there are no staff in situ. The laundry contains cleaning products, which could be potentially dangerous. Eresby Hall DS0000002354.V327110.R01.S.doc Version 5.2 Page 7 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. Eresby Hall DS0000002354.V327110.R01.S.doc Version 5.2 Page 8 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.V327110.R01.S.doc Version 5.2 Page 9 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 The homes staff ensure that they can meets the assessed needs of prospective residents by obtaining full written assessments prior to their admission to the home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three residents records were assessed as part of this inspection. All the records contained preadmission assessments, which had been completed by the registered manager. Eresby Hall DS0000002354.V327110.R01.S.doc Version 5.2 Page 10 The manager stated that residents are never a admitted without a preadmission assessment. Eresby Hall does not provide intermediate care. Eresby Hall DS0000002354.V327110.R01.S.doc Version 5.2 Page 11 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): 7,8,9,10. Residents individual care plans contain sufficient information and are updated frequently enough to ensure that staff are always aware of what support and assistance each resident requires. The homes medication is well managed and residents are treated with respect. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three residents care plans were viewed as part of this inspection, the care plans appeared to address the issues highlighted in the residents assessment process. All of the care plans had been reviewed and where necessary amended each month. Eresby Hall DS0000002354.V327110.R01.S.doc Version 5.2 Page 12 The residents spoken with during the inspection could not remember if they had been involved in the care planning and review process. However some had clearly signed their care plans to confirm their involvement. Records show the residents health care needs are being appropriately met; this was confirmed by all of the residents spoken with during the visit. The homes medication systems have been very well maintained. The home has a policy on the Self Administration of Medication and appropriate risk assessments are available. One resident confirmed that she had been offered the opportunity to administer own medication but had chosen not to do so. Other residents said that they preferred the staff to administer their medication. Medication is stored securely and all staff that administers medication have received appropriate training. One resident’s medication administration records showed that staff had not always, signed to confirm that they had administered her eye drops, as prescribed by her general practitioner. The senior staff stated that this resident frequently refused to have her eye drops and that a risk assessment had been completed as part of her care plan. The risk assessment was checked and was satisfactory. The staff were reminded that an explanation must be provided on the medication administration records if for any reason, the medication is not given to the residents. The use of codes is acceptable for this purpose. The controlled medication was checked at random and was well maintained, with staff providing two signatures and a stock balanced each time the medication was administered. All of the residents spoken with said that staff are always friendly and respectful and ensure that their privacy and dignity is maintained at all times. The observed interaction between staff and residents was of a very good standard. Eresby Hall DS0000002354.V327110.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): 12,13,14,15. The lifestyle experienced by the residents, in the home appears to match their expectations and preferences. People are encouraged main contact with family and friends and the food provided appeared wholesome and nutritious. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home employs a member of staff specifically to organise activities and entertainment for the residents. (This is good practice). There is an impressive range of activities and entertainment to provide stimulation to the residents. The programme of activities is prominently displayed in the main reception area. Eresby Hall DS0000002354.V327110.R01.S.doc Version 5.2 Page 14 Three of the residents spoken with said how much they enjoy the stimulation provided. One person said that they generally choose not to participate in the planned activities, as they prefer to spend time in their own bedroom. Four people were enjoying a game of whist at the time of this inspection. There is also a small group of visitors who provide additional social activities for the residents each week. All of the residents spoken with said that they can have visitors at any time and that their visitors are always made welcome. They confirmed that visitors are offered refreshments and that they can have a meal with the residents at the home if they wish to. The manager stated that he tries to provide an environment, which encourages resident to make choices. Individual care plans also give details of how residents can be encouraged to make decisions about their daily lives. (This is good practice). The lunch on the day of this inspection appeared wholesome and nutritious. Three of the residents said that they are very satisfied with the food provided by the home; they confirmed that there is always a choice of food and that if they do not want to meals suggested on the menu an alternative will be provided. One person said that she does not always like the way the food is cooked. When this was discussed further she was unable to identify anything she actually disliked about the food. People confirmed that they can eat their meals in either of the two dining rooms or in their bedrooms. One person said that recently she has chosen to have some of her meals in her bedroom. Eresby Hall DS0000002354.V327110.R01.S.doc Version 5.2 Page 15 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): 16,18. The home has a robust, and accessible complaints procedure and staff are ensuring that residents are protected from abuse. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector was informed that all residents had been provided with a copy of the homes complaints procedure. This procedure is also displayed in the main entrance hall. The homes complaints records show that the home has only received two formal complaints, since the last inspection. These were investigated and appropriate action taken. Two residents confirmed that they would contact the manager if they had any concerns all complaints. Both people confirmed that they were confident their complaints would be dealt with appropriately. The manager stated that informal complaints would be dealt with immediately where possible. Consequently they are generally not recorded in a central book or file to provide an overview of the nature and frequency of the complaints received. Eresby Hall DS0000002354.V327110.R01.S.doc Version 5.2 Page 16 The home has a Vulnerable Adults Procedure, which the manager stated was being reviewed at the time of this inspection. There are also copies of a Whistle Blowing Procedure. The member of staff spoken with during the inspection was unclear about her responsibilities in relation to the homes Whistle Blowing Policy. Staff are being provided with “Abuse” training on a regular basis. There have been no allegations or incidents of abuse in the home. Eresby Hall DS0000002354.V327110.R01.S.doc Version 5.2 Page 17 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): 19,26. The accommodation is comfortable & generally well maintained. The accommodation is suitable to meet the needs of the current residents. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A partial tour of the premises was completed as part of this visit. The purpose-built accommodation has been maintained to a good standard. Many areas of the home have been redecorated since the last inspection. Eresby Hall DS0000002354.V327110.R01.S.doc Version 5.2 Page 18 It was noted that some of the carpets throughout the communal areas were badly worn. The manager stated that new carpets have been ordered and that these will be re-placed in the very near future. The resident’s bedrooms were comfortably furnished and people had clearly been encouraged to bring personal possessions such as photographs, ornaments and small items of furniture. All of the residents spoken with stated that they are happy with their bedrooms and confirm that they could use them at any time. People said that the home is always kept spotlessly clean. The laundry is a reasonable size and is well equipped with washable floor and wall coverings. It was noted that the laundry door did not have a lock fitted and there was washing powder and other cleaning products left out in this room. The manager stated that residents do not have access to this part of the building. However as the rooms were unattended residents could potentially gain access and their health and safety could be put at risk. The inspector was informed that the home has operated for many years and to date there has never been a problem in this area of the home. The COSH data sheets for the cleaning products used in the Laundry were kept in the main office & consequently were not available, where the products were actually being used. Since the last inspection risk assessments have been completed on the wooden safety gate on the first floor and the practice of residents using door wedges to wedge open their bedroom doors. Eresby Hall DS0000002354.V327110.R01.S.doc Version 5.2 Page 19 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): 27,28,29,30. Sufficient staff are being employed to meet the assessed needs of the residents and the homes recruitment policies and practices are supporting and protecting the residents. The registered person was able to demonstrate a commitment to staff training and development. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The rota provided prior to this inspection and those viewed for the week of this inspection showed that sufficient staff are being provided to meet the assessed needs of the residents. Three of the residents spoken with during the inspection said that although the staff appear busy they do respond promptly when people require assistance. One resident said that sometimes, particularly when staff are very busy she has to wait to get the assistant she desires. This resident did acknowledge that the staff do have to help and support a number of other residents. Staffing levels have increased since the last inspection. (This is good practice). Eresby Hall DS0000002354.V327110.R01.S.doc Version 5.2 Page 20 All new members of staff complete an appropriate induction-training programme. The member of staff spoken with during the inspection confirmed this. The staff training records show that out of a total of 24 care staff 10 people had completed NVQ level 2 or above. Other members of staff are currently completing this training. The staffs training records are comprehensive and show that an impressive training programme is being provided. The personal records of two members of staff were assessed as part of this visit. Both of the records contained all the required information, to ensure that the recruitment process within the home is supporting and protecting the residents. Eresby Hall DS0000002354.V327110.R01.S.doc Version 5.2 Page 21 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): 31,33,35,38. The home is well managed and run in the best interests of the residents. Where checked the health and safety of residents and staff are promoted and protected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The homes manager is very experienced and is currently completing the registered managers award. Residents and staff said that the manager is very Eresby Hall DS0000002354.V327110.R01.S.doc Version 5.2 Page 22 approachable and that he seeks their views about the way in which the home is run. The home has an impressive quality monitoring system in place. An internal audit was completed in January 2007 and the home was independently assessed in February 2007. A letter was produced following the independent audit, which stated that no action was required to improve the services provided. The staff administers some residents personal allowances. The records were checked at random and were well maintained. The residents spoken with all stated that they were happy with the way their finances are managed. The aspects of health and safety, assessed as part of this visit had been well maintained. The homes kitchens were judged as excellent following an Environmental Health Officers visit in 2006. Eresby Hall DS0000002354.V327110.R01.S.doc Version 5.2 Page 23 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 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 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 4 X 3 X X 3 Eresby Hall DS0000002354.V327110.R01.S.doc Version 5.2 Page 24 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. 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. Refer to Standard OP16 Good Practice Recommendations It is recommended that the registered person records all complaints in a central book of file to provide an overview of the nature & frequency of complaints received. It is recommended that staff are regularly reminded to read the homes Whistle Blowing Policy, to ensure that they are clear about who to inform if they witness any abuse to residents. It is recommended that a lock be fitted to the laundry room door so that residents cannot gain access when there are no staff in situ. It is recommended that the COSH data sheets are kept in the areas where the staff are actually using the cleaning products. DS0000002354.V327110.R01.S.doc Version 5.2 Page 25 2. OP18 3. OP26 4. OP26 Eresby Hall Eresby Hall DS0000002354.V327110.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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. 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