Inspection on 20/10/05 for Ermine House

This inspection was carried out on 20th October 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

Ermine House 23/05/06

Ermine House 05/07/05

Ermine House 21/03/05

Ermine House 07/07/04

Ermine House 09/02/04

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 Ermine House Laughton Way Lincoln Lincs LN2 2EX Lead Inspector Mr Doug Tunmore Unannounced Inspection 20th October 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 Ermine House DS0000002355.V258734.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. Ermine House DS0000002355.V258734.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ermine House Address Laughton Way Lincoln Lincs LN2 2EX 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) 01522 529093 The Orders Of St John Care Trust Mrs Tracy Turfrey Care Home 43 Category(ies) of Old age, not falling within any other category registration, with number (43) of places Ermine House DS0000002355.V258734.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5 July 2005 Brief Description of the Service: Ermine House is situated on the Ermine Estate in the City of Lincoln and is approximately one and a half miles from the City Centre. The home is close to local shops, library and church and is on a direct bus route into Lincoln. The home is registered for 43 residents over the age of 65. Accommodation is provided on two floors, which is accessible via a shaft lift or stairs. Lounges are situated on both floors with the dining room situated on the ground floor. The homes statement of purpose states that the home aims to provide its residents with secure, relaxed and a homely environment in which their care, wellbeing and comfort are of prime importance. The home is a group of homes run by the Order of St John Trust, (OSJT) which is a registered charitable organisation. Limited car parking is to the front of the building for the use of visitors and care staff. Ermine House DS0000002355.V258734.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 started at 9.30 am. The main method of inspection used was called case tracking, which involved looking at policies and procedures relating to maintaining the safety and general welfare of residents. Residents were spoken to as well as visitors, the manager and care staff and observations were made of care practices. A partial tour of the home took place. What the service does well: What has improved since the last inspection? What they could do better: The home has not amended its service users guide so as to give prospective residents all the information they require in choosing a home. This is an outstanding requirement. The homes complaints format does not allow for complainants to sign so as to signify whether they agree with the outcome of their complaint or not. This is an outstanding recommendation. The homes personnel files did not contain the interview notes of applicants who had been interviewed for a post at this home. Ermine House DS0000002355.V258734.R01.S.doc Version 5.0 Page 6 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. Ermine House DS0000002355.V258734.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 Ermine House DS0000002355.V258734.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&3 The home has not updated the service users guide, which enables them to make an informed choice about coming to live at this home. Residents are admitted into the home only after a full needs assessment has been carried out either by the home or health care or social care agencies. EVIDENCE: The home has a “Resident’s Handbook” which does not include all the information required to meet those regulations and standards pertaining to the Service Users guide. There must be a document provided that meets all service user guide requirements including a brief description of the accommodation and services provided, the age of prospective service users that the home can admit, (65) or over, service users fees charges, service user views and key contract terms including method of payment of fees. Residents commented that they had received a booklet from the home when they were admitted. Ermine House DS0000002355.V258734.R01.S.doc Version 5.0 Page 9 The home has a detailed admission procedure, which identifies the needs of residents coming into the home. One resident said that he was an emergency admission and had not been seen prior to coming into the home. However, his file contained the homes assessment carried out when he was admitted and the Social Services ‘Easy Care Assessment’ carried out by a social worker. Files seen showed that residents had received a letter from the home confirming that the home could meet their needs. Some residents spoken to at lunch commented that they could remember receiving a letter from the home prior to admission. One care worker knew about the care needs of residents and was aware of the homes admission procedures. An overseas visitor commented that ‘out of the care homes that she had seen this home was superior in every way’. Ermine House DS0000002355.V258734.R01.S.doc Version 5.0 Page 10 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): These outcomes were not looked at. EVIDENCE: Ermine House DS0000002355.V258734.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): 12,13 & 14 A variety of activities are available and residents are able to make choices about their participation. Relatives and friends of residents are made welcome in this home. Residents are enabled to choose their preferred lifestyle. EVIDENCE: The home undertakes a variety of activities for the stimulation of residents. The homes notice board showed that on a number of days during the week stimulating activities are made available both by care staff and outside activity workers. Painting, arts and crafts are undertaken as well as entertainers visit the home. One resident commented that ‘I like Friday night when we play bingo and the bar opens’. The hairdresser also visits twice weekly and the vicar pays monthly visits to take communion. The manager commented that the home has advertised for an activities worker and interviews are to be held on the 27/10/05. On the day of the inspection six residents were off on a trip to a garden centre where they are to have lunch. A resident stated that he chooses not to join in activities and this is his choice. Two visitors confirmed that they are made welcome at the home. Both visitors made positive comments about the care provided at this home. The minutes of the residents meeting held on the 30/09/05 showed the dates of when forthcoming entertainments would take place at the home. Ermine House DS0000002355.V258734.R01.S.doc Version 5.0 Page 12 Each resident is consulted about their likes and dislikes and they have the opportunity to express their views and offer ideas at the residents meetings. Ermine House DS0000002355.V258734.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): 16 The home needs to amend its complaints policies and report to empower residents. EVIDENCE: The home has displayed the service users guide, which contains the homes complaints procedures in the main entrance. The home has a detailed complaints procedure. The homes complaints log was seen; one complaint had been made since the last inspection. However, the complaints log did not have a space for complainants to sign confirming that their complaint had been addressed satisfactorily or not. A resident said that the staff and manager were approachable and felt confident in talking to them if he had an issue of concern. Visitors said that they were happy with the attitude of staff, which was very good. Ermine House DS0000002355.V258734.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): 26 The home is clean and tidy, with a pleasant smell throughout. EVIDENCE: A partial tour of the home by the inspector found it to be clean and it smelt fresh. Residents and visitors alike said that the home is always clean and there are no unpleasant smells. One domestic worker stated that she has undertaken training in moving and handling, infection control, first aid and completed her NVQ (National Vocational Training) level one. Ermine House DS0000002355.V258734.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): 27, 29 &30 Residents are protected by robust recruitment practices. Residents benefit from a staff team who are well trained and work well together and compliment each others skills. EVIDENCE: Two personnel files seen contained CRB checks (Criminal Record Bureau), references, application forms but not interview notes. All care workers have been given The General Social Care Council Codes of Practice, which sets out their responsibilities as care workers looking after vulnerable adults. The homes training record was seen which showed that, ten care workers had NVQ (National Vocational Qualifications) level 2, five of these having NVQ 3, nine workers are currently undertaking NVQ level 2 training. Five domestic workers have NVQ 1 and another has an NVQ in catering and hospitality. This home meets the standard for having 50 of staff trained to NVQ level two by 2005. Statutory training such as fire training, moving and handling and first aid are undertaken at this home. Other training undertaken included; food hygiene, first aid, health and safety, dementia training, tissue viability and adult protection. One care worker demonstrated a clear understanding of her role and responsibilities. She confirmed that she is currently undertaking NVQ level 2. Ermine House DS0000002355.V258734.R01.S.doc Version 5.0 Page 16 The duty rota showed that adequate staff numbers are on duty to meet the needs of residents in this home. There are three waking night staff on duty on alternate nights with a senior who can be contacted if required. A visitor stated that he feels ‘that there seems to be plenty of staff on duty’. Comments received during this inspection from residents were that staff are very kind and helpful’. Ermine House DS0000002355.V258734.R01.S.doc Version 5.0 Page 17 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 The registered manager is suitably qualified and experienced to carryout her tasks. Records seen show that residents’ health and general welfare and safety are promoted. The home ensures that that the residents have the opportunity to voice their views and opinions. Accurate records are kept of residents’ monies. EVIDENCE: Comments from staff, visitors and residents were that the manager has a visible presence in the home and is approachable. The registered manager has experience in working in homes for older people and is suitably qualified to carryout her tasks. The home conducts a quality assurance report. The quality assurance report has been posted on the homes notice board for the information of residents and visitors, as is the last Commission for Social Care Inspection report. The Ermine House DS0000002355.V258734.R01.S.doc Version 5.0 Page 18 quality assurance report is also included in the information pack for prospective residents. Those questionnaires competed by residents/visitors was seen and positive comments were made in relation to the way this home is managed. The minutes of the last residents meeting held on 30/09/05 and showed that residents are encouraged to voice their views and are actively involved in issues relating to the running of the home. Residents seen at lunchtime said that the manager is very approachable and they see her in the home every day. The home only deals with personal allowances of residents, which are kept at the home. All other monies relating to funding are paid into the homes bank account on a standing order by relatives. Residents’ personal allowances were seen and it was found that an accurate record is kept and receipts are available for any monies spent, with signatures also obtained from the hairdresser or the visiting chiropodist. A visitor commented that his sister dealt with his mother’s monies. One resident confirmed that he keeps her own petty cash and that she can get money when he wants it. There are a range of policies and procedures available in the home relating to fire safety and fire risk assessments. There was also evidence that fire alarm, fire drills and emergency lighting checks are carried out. Staff also receive fire training as part of the homes initial training and as a regular training event. The homes self-assessment shows that ‘policies and procedures are read and signed by staff and that they inform practice’. Certificates were available showing that the shaft lift, bath hoists, water temperatures and wheelchairs had been serviced. All wheelchairs seen on the day of the inspection had footplates, which were in use. Ermine House DS0000002355.V258734.R01.S.doc Version 5.0 Page 19 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 2 x 3 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 4 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 x x x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 2 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 4 x 3 x x 3 Ermine House DS0000002355.V258734.R01.S.doc Version 5.0 Page 20 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 OP1 Regulation 5 Requirement It is a requirement that the service users guide must be reviewed to ensure that it meets all the matters listed in regulation 5 (1 & 2). (Timescale of 21st October 2004 not met. Timescale for action 23/03/06 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 OP16 OP29 Good Practice Recommendations The homes complaints form should have a space for complainants to sign regarding their agreement with the outcome or not. The home should keep all interview records as matter of best practice for future reference. Ermine House DS0000002355.V258734.R01.S.doc Version 5.0 Page 21 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 Ermine House DS0000002355.V258734.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. 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