Inspection on 05/07/05 for Ermine House

This inspection was carried out on 5th 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 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 20/10/05

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 LN2 2EX Lead Inspector Doug Tunmore Unannounced 5 July 2995 09:00 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. Ermine House C53 CO4 S2355 Ermine House V236755 050705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Ermine House Address Laughton Way Lincoln LN2 2EX 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) 01522 529093 The Orders of St John Trust Mrs T Turfrey Care Home 43 Category(ies) of Old Age (OP) - 43 registration, with number of places Ermine House C53 CO4 S2355 Ermine House V236755 050705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 21 March 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 regsiterd 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 C53 CO4 S2355 Ermine House V236755 050705 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 started at 8.30 am. The main method of inspection used was called case tracking, which involved selecting two residents and tracking the care they receive through the checking of their records, discussion with them, the care staff and observations of care practice. A community nurse and two visitors were seen during the course of the inspection. A partial tour of the premises 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. Ermine House C53 CO4 S2355 Ermine House V236755 050705 Stage 4.doc Version 1.40 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 C53 CO4 S2355 Ermine House V236755 050705 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 Ermine House C53 CO4 S2355 Ermine House V236755 050705 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 & 3 The home has not provided residents with a 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. The home has a detailed admission procedure, which identifies the needs of residents coming into the home. One resident said that she was visited prior to admission by someone from the home and that her family were involved in Ermine House C53 CO4 S2355 Ermine House V236755 050705 Stage 4.doc Version 1.40 Page 9 this process. Both residents had a care needs assessment undertaken either by the home, hospital or the Social Services Department. Files seen showed that residents had not received a letter from the home confirming that the home could meet their needs. Two residents commented that they could not 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. Ermine House C53 CO4 S2355 Ermine House V236755 050705 Stage 4.doc Version 1.40 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 standard(s) 7,8,9,& 10 There is good care planning in this home, which helps ensure that the general health and welfare of residents is addressed. Training relating to the delivery of personal care is sufficient to meet the needs of residents. EVIDENCE: All residents have detailed care plans, which describe their health and welfare needs. Care plans outlined risk assessments, nutritional and dependency assessments. Care plans also evidenced that they have been reviewed on a monthly basis or sooner depending on changing needs. The reviews and care plans of residents had been signed and dated by the carer and the resident. Residents and visitors confirmed that they were involved in the care plans. Residents also confirmed that ‘ we are looked after very well here, it’s more like a hotel’. Individual care plans evidenced that accidents are recorded in the home’s accident book and in the resident daily notes. The home also uses body maps for the mapping of any cuts or abrasions to residents. One visiting community nurse confirmed that there was good communication between the home and herself. The community nurse also said that staff were helpful and could follow instructions given to them regarding the care of residents. Files seen confirmed that health care professionals visit the home when required by the residents. Ermine House C53 CO4 S2355 Ermine House V236755 050705 Stage 4.doc Version 1.40 Page 11 A carer was aware of the intimate care needs of residents and those principles regarding maintaining the privacy and dignity of all those people in the home. She also confirmed that she had undertaken National Vocational Training at level 2 in which issues relating to the personal care of residents was addressed. A resident commented that ‘they (the staff) do as much as possible to maintain my privacy’. The pharmacist inspected the home on the 18/04/05 and recorded that storage and administration records of medication is carried out appropriately and recommendations made have been addressed by the home. A number of residents look after their own medication and a lockable facility is available to them for its safekeeping. Risk assessments were seen and had been signed by residents, acknowledging that they can look after their own medication needs. Residents commented that the staff give them their medication when it’s time. Ermine House C53 CO4 S2355 Ermine House V236755 050705 Stage 4.doc Version 1.40 Page 12 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) 12,13 & 15 Limited activities are made available to residents in this home. Relatives and friends of residents are made welcome in this home. Meals are well managed and reflect resident’s likes and dislikes. EVIDENCE: The home does not undertake a variety of activities for the stimulation of residents. Two residents commented that ‘not very much goes on here for us’. The homes notice board showed that bingo is undertaken every Wednesday and Friday night. 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. The homes visitors signing in book was seen and showed that a number of visitors attend this home on a daily basis at differing times of the day. Two visitors confirmed that they are made welcome and added that their ‘friend is very well looked after in this home’. The community nurse also confirmed that she is always made welcome when she visits. One resident said that she ‘has regular visits from her son and that a cup of tea is made for him or he can make his own if he wants’. Ermine House C53 CO4 S2355 Ermine House V236755 050705 Stage 4.doc Version 1.40 Page 13 The inspector joined two residents for lunch and found the meal provided to be hot and delicious. Residents said that they have a choice of meals and they particularly like the food served in tureens so that they could help themselves. The cook was spoken to and recorded in her files the likes and dislikes, as well as specialised diets required by individual residents. The cook has undertaken intermediate food hygiene training and National Vocational Training at level 1 and 2 in food preparation. Ermine House C53 CO4 S2355 Ermine House V236755 050705 Stage 4.doc Version 1.40 Page 14 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 takes the issue of addressing complaints very seriously and has a comprehensive complaints policy. Staff are aware of how to respond to a complaint or an adult protection allegation. 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 and the Commission had been made aware of this complaint by the home. However, the complaints log did not have a space for complainants to sign confirming that their complaint had been addressed satisfactorily or not. Residents commented that if they had a complaint they would see a senior carer or the manager, who they felt was approachable. None of the residents spoken to said that they had problems with any care worker. Visitors commented that they were aware of the homes complaints procedure and felt able to talk to the manager. A carer commented that she was aware of the meaning of abusive practices and would report any incidents to a senior carer of the manager. Staff received adult protection training as part of their ongoing training on 27th April 2005. A resident commented that she ‘felt safe and that if you were unwell they would look after you’. Ermine House C53 CO4 S2355 Ermine House V236755 050705 Stage 4.doc Version 1.40 Page 15 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) 16 & 26 The home is well maintained, the standard of the environment and its facilities are appropriate to the needs of residents. The home is clean and free of unpleasant odours. EVIDENCE: The home has a maintenance record which records work that has been undertaken and projected work for the coming year. Since the last inspection five bedrooms have been decorated, eleven re-carpeted, new soft furnishings for eight rooms, dining room completely refurbished and new sluice and offices and upper lounge decorated. Residents seen during the tour of the building said that they like their rooms and are able to personalise them with their own possessions. One resident commented that she sits in the garden with her son when he visits and ‘its lovely’. Residents’ files showed that risk assessments were available which highlighted risks to residents posed by the homes environment and action to be taken. Ermine House C53 CO4 S2355 Ermine House V236755 050705 Stage 4.doc Version 1.40 Page 16 The home employs five cleaners and tour of the home found it to be clean with no offensive odours detected. Residents and visitors alike said that the home is always clean and there are no unpleasant smells. Ermine House C53 CO4 S2355 Ermine House V236755 050705 Stage 4.doc Version 1.40 Page 17 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 The numbers of staff are sufficient to meet the needs of all of residents. EVIDENCE: The staffing roster was seen and evidenced that adequate staff numbers are maintained for the needs of residents. Relative’s commented that there seems to be enough staff although they are always busy. One of the two residents said that there is enough staff with the other resident feeling that the home ‘could do with one or two more’. She also said that ‘they come when the buzzer is rung’. The manager commented that the home has advertised for a new member of staff to cover one of the busiest times of the day from 6.00pm to 9.00 pm. A care worker said that the 6.00 pm to 9.00 pm shift is a bit tough at the moment as they need an extra worker. Ermine House C53 CO4 S2355 Ermine House V236755 050705 Stage 4.doc Version 1.40 Page 18 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) These outcomes were not looked at. EVIDENCE: Ermine House C53 CO4 S2355 Ermine House V236755 050705 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 x x x x x 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 Standard No 16 17 18 Score 2 x 3 x x x x x x x x Ermine House C53 CO4 S2355 Ermine House V236755 050705 Stage 4.doc Version 1.40 Page 20 yes 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 1 Regulation 5 Requirement It is a 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. All prospective residents must be written to by the home confirming that the home can meet their needs. Timescale for action 16/09/05 2. 3 14(d) 16/09/05 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 12 16 Good Practice Recommendations Residents should be offered opportunities for stimulation through in house recreational activities. The homes complaints form should have a space for complainants to sign regarding their agreement with the outcome or not. Ermine House C53 CO4 S2355 Ermine House V236755 050705 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection 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 C53 CO4 S2355 Ermine House V236755 050705 Stage 4.doc Version 1.40 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!