Inspection on 23/11/05 for Ernest Luff Home

This inspection was carried out on 23rd November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Ernest Luff Home 08/09/08

Ernest Luff Home 06/09/07

Ernest Luff Home 22/07/05

Ernest Luff Home 02/06/04

Ernest Luff Home 18/03/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Ernest Luff Home 2-4 Luff Way Garden Road Walton On Naze Essex CO14 8SW Lead Inspector Ray Finney Final Unannounced Inspection 23rd 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 Ernest Luff Home DS0000017812.V267275.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. Ernest Luff Home DS0000017812.V267275.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ernest Luff Home Address 2-4 Luff Way Garden Road Walton On Naze Essex CO14 8SW 01255 679212 01255 674414 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) The Ernest Luff Homes Limited Mr Derek William Carpenter Care Home 65 Category(ies) of Old age, not falling within any other category registration, with number (65) of places Ernest Luff Home DS0000017812.V267275.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd July 2005 Brief Description of the Service: The Ernest Luff home is located in Walton-on-the Naze and consists of two residential units housed on one site. The home was originally established to run along Christian principles and still has a strong Christian ethos. Overall the home can accommodate 65 older people. The majority of the rooms have ensuite facilities. Bedrooms are located on the ground and first floors in each building with access to the first floor by passenger lift or stairs with seated stair lifts. There are ample communal lounges and dining areas. The home has well-maintained grassed areas and an enclosed garden. Parking is available at the front of the property. Opposite the home is a shopping centre and a church; public transport is close by. Ernest Luff Home DS0000017812.V267275.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine unannounced inspection took place on 23rd November 2005 for a total of 5.5 hours. Service users in the home preferred to be known as residents. The inspection process included discussions with three residents, three members of staff and the relatives of a resident. The inspection also included a tour of the home, observations of interactions between residents and members of staff and evidence gathered from samples of records. On the day of the inspection the atmosphere in the home was relaxed and calm. Residents and the relatives spoken with were highly complimentary about the home. The inspector was given every co-operation during the inspection process from the registered manager, Mr Derek Carpenter. What the service does well: What has improved since the last inspection? What they could do better: Some of the statutory requirements identified at the last inspection had not been met. A controlled drugs cabinet had been purchased but had not yet been put up. The information from quality assurance questionnaires needed to be collated and presented as a report. The staff supervision process had not been updated to meet the requirements of the National Minimum Standards. Please contact the provider for advice of actions taken in response to this Ernest Luff Home DS0000017812.V267275.R01.S.doc Version 5.0 Page 6 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ernest Luff Home DS0000017812.V267275.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 Ernest Luff Home DS0000017812.V267275.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): 3 (Standard 6 does not apply) Residents’ needs were assessed before moving into the home. EVIDENCE: On the day of the inspection four residents files were examined. All contained evidence of a pre-admission and admission assessments and risk assessments around residents’ manual handling needs. Ernest Luff Home DS0000017812.V267275.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, 8 and 10 The needs of residents were set out in individual plans of care and healthcare needs were fully met. Residents felt that they were treated with dignity and respect. EVIDENCE: Health care information was provided by one of the two care officers. A dentist came to the home when required to meet the oral health needs of residents. When necessary glycerine swabs and mouthwash were used and this was recorded on a chart in the resident’s care plan. At the time of the inspection there were no residents in the home with pressure sores. Preventative measures were used for one resident who was in bed for most of the time, such as being turned regularly and using skin creams to reduce the risk of pressure sores; a special mattress was also in place. District nurses visited regularly on Mondays, but also came in when requested. The home also used the services of the local Primary Care Trust’s continence advisor. Psychological health needs were addressed through a G.P. referral to the consultant at Clacton Hospital or Community Psychiatric Nursing Services. There were no residents with a history of falls, however, the care officer showed and awareness of procedures to use should residents become unsteady, such as Ernest Luff Home DS0000017812.V267275.R01.S.doc Version 5.0 Page 10 using the falls prevention team for advice. The care officer said that it was important to ensure residents had regular drinks and that residents should have regular weight checks. There were two local G.P.s used by the home and residents had a choice of which to use. G.P.s came promptly when called out by the home, but if a visit to the surgery were necessary, staff would accompany the resident. A chiropodist and an optician visited the home. Members of staff checked hearing aids regularly and replaced batteries where necessary. The records of four residents were examined. Care plans were comprehensive and covered areas such as bathing, mobility, personal care, eating needs and preferences, continence and bedtime routines. Files contained charts for recording weight and blood pressure. All files examined contained evidence of regular and recent review. One resident spoken with was highly complimentary with the support the home had given around depression and psychological difficulties and was enthusiastic about how living at the home had helped sort out the problems and improved the quality of the resident’s life. Residents spoken with spoke highly of the standard of care delivered by the home. Observations of interactions between members of staff and residents showed that people living in the home were treated with dignity and respect. Ernest Luff Home DS0000017812.V267275.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 and 15 The lifestyle in the home satisfied the social, cultural, religious and recreational interests and needs of residents. Family and social contacts were encouraged and residents were supported to make choices. The home provided residents with an appealing and balanced diet that was served in pleasant surroundings. EVIDENCE: The inspector saw evidence of a programme of activities. A pianist visited regularly and was there on the day of the inspection. This was seen to be popular with residents, some were singing along and one member of staff was waltzing with a resident. The manager also said there was a programme of games, reminiscence activities and church related activities such as prayer readings. Three dolls houses were being built and furnished in different styles – a modern house, a ‘20s’ style house and an ‘upstairs/downstairs’ style house – to help with reminiscence work. Residents were encouraged to take part in armchair fitness exercises. Relatives of a resident spoken with “could not speak highly enough” of the home. They visited every day and said that they were always made welcome; their relative was so happy living there that they said there was no desire to return ‘home’. Ernest Luff Home DS0000017812.V267275.R01.S.doc Version 5.0 Page 12 Evidence was seen during a tour of the premises that some residents had items of furniture in addition to those supplied by the home and other personal possessions, such as photographs and ornaments. Residents spoken with were complimentary about the food provided by the home. The dining area was light and airy and the inspector observed that the lunchtime meal on the day of the inspection was a pleasant, social occasion. Ernest Luff Home DS0000017812.V267275.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): 18 The home ensured residents were protected from abuse. EVIDENCE: The home’s policies and procedures were examined. There was a procedure around ‘abuse’ and copies of Guidelines for the Protection of Vulnerable Adults were on file. The policy on ‘Gifts, Gratuities and Bequests to Staff’ was examined. Staff were provided with a Code of Conduct, which contained information around the policy on receiving gifts. Residents were protected from financial abuse by the home’s procedures around finances (see evidence for standard 35). Ernest Luff Home DS0000017812.V267275.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): 21 and 24 The home provided sufficient and suitable lavatories and washing facilities to meet the needs of residents. Residents’ bedrooms were safe and comfortable and contained personal possessions. EVIDENCE: A tour of the premises showed that the standard of cleaning in the home was good and there were no offensive odours anywhere in the home. Residents’ rooms contained fitted furniture and all had a lockable facility for valuables. In addition some residents also had some items of their own furniture and there was evidence of personal possessions. The manager confirmed that the Jacuzzi bath and showerheads had been cleaned since the last inspection. Ernest Luff Home DS0000017812.V267275.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, 28 and 30 Residents’ needs were met by staff who were appropriately trained and competent to do their jobs. Staffing levels were appropriate for the numbers of people living in the home. The home ensured residents were in safe hands. EVIDENCE: The manager explained that they had used the ‘residential forum’ to establish appropriate staffing levels, but they actually provided more staff than indicated by the residential forum. Staff rotas were examined on the day of the inspection and staffing levels were seen to be good. Staff spoken with confirmed that staffing levels were good; if care staff were unable to come in, the care officers who were ‘supernumerary’ would step in to cover. Of the 45 care staff in the home 21 had completed NVQ level 2 in care and another member of staff had just started. Six care staff had been registered for a long time with a training provider, but they were having difficulties with getting assessors. Nine care staff were completing NVQ level 3. The manager was suitably qualified as a duel registered nurse and also had completed NVQ level 4. Records were examined relating to staff training. The home had a programme for statutory training that had just been completed. Care staff received training in Manual Handling, Health and Safety, Food Hygiene and Infection Control. Kitchen and ancillary staff also received training in Food Hygiene, Infection Control and Control of Substances Hazardous to Health (COSHH). Ernest Luff Home DS0000017812.V267275.R01.S.doc Version 5.0 Page 16 Some training had also been delivered around dealing with aggression. As part of the induction process staff received information about the Protection of Vulnerable Adults. Three members of staff were spoken with, two carers and a member of the kitchen staff. All staff spoken with said they received a lot of training. Staff said they were supported by the management structure and they knew how to carry out their jobs. Ernest Luff Home DS0000017812.V267275.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): 33, 35 and 36 Overall the home was run in the best interests of the residents, although the home would benefit from reflecting residents’ views through the quality assurance system. The home did not meet the national minimum standard around appropriate supervision of staff. The home ensured that the financial interests of residents were safeguarded. EVIDENCE: Information from the manager indicated that not all of the requirements from the last inspection report had been actioned. Some work had been carried out on the Quality Assurance process but the information gathered from completed questionnaires had still not been collated and presented as a report. Although staff spoken with said that they felt supported, the supervision process had not been updated to meet the requirements of the National Minimum Standards, which was identified as a requirement at the last inspection. The manager stated that work on this was in progress. Ernest Luff Home DS0000017812.V267275.R01.S.doc Version 5.0 Page 18 At the time of the inspection the home did not manage the finances of any of the residents; they were either “self-managing” or had family representatives to manage monies. The home kept small amounts of money for residents, which were stored individually and kept securely in a lockable filing cabinet. Documentation was examined, which showed that recording was appropriate and receipts were in place. Residents’ rooms had a lockable facility for safe storage of valuables. Ernest Luff Home DS0000017812.V267275.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 X X 3 X X N/A 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X 3 X X 3 X X STAFFING3 Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 1 X X Ernest Luff Home DS0000017812.V267275.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 OP33 Regulation 24 (1)(a)(b) (2)(3) Requirement The registered person must ensure that information gathered from the Quality Assurance procedure is collated and presented as a report, which is submitted to the Commission. This is a repeat requirement for the second time The registered person must ensure that care staff receive formal supervision. This is a repeat requirement for the second time Timescale for action 31/12/05 2 OP36 18(2) 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ernest Luff Home DS0000017812.V267275.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Ernest Luff Home DS0000017812.V267275.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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