Inspection on 17/08/07 for Esher House

This inspection was carried out on 17th August 2007.

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 no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Esher House 11/02/09

Esher House 29/06/06

Esher House 26/09/05

Esher House 06/04/05

Esher House 09/11/04

Esher House 05/05/04

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

CARE HOME ADULTS 18-65 Esher House 16 Cabbell Road Cromer Norfolk NR27 9HU Lead Inspector Jenny Rose Unannounced Inspection 17th August 2007 09:30 Esher House DS0000027339.V348951.R01.S.doc Version 5.2 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 Esher House DS0000027339.V348951.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 Adults 18-65. 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. Esher House DS0000027339.V348951.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Esher House Address 16 Cabbell Road Cromer Norfolk NR27 9HU 01263 512533 F/P01263 512533 info@prime-life.co.uk info@prime-life.co.ukwww.prime-life.co.uk Prime Life Limited 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) Ms Sara Doherty Care Home 13 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (13), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (1) Esher House DS0000027339.V348951.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th June 2006 Brief Description of the Service: Esher House provides accommodation for up to 13 adults with mental health problems. The philosophy of the home is centred on helping service users to regain/develop social skills with a view to moving on if this is possible. All service users have their own room to which they can retire at any time. Communal accommodation is spacious and one lounge is designated a smoking room. Service users private rooms are located on the first, second and third floors. Service users are encouraged to participate in all aspects of the life of the home and to develop links with the local community if they wish. In this respect the home is well situated: both the town centre and the seafront are just a few minutes walk away. Maintaining and developing contacts with family and friends is seen to be an important aspect of the service users overall pattern of care and at their invitation family members and friends are welcome at all times. The home does not provide accommodation for highly dependent service users and all those in residence have to be fully ambulant as there is no lift. Esher House DS0000027339.V348951.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care Services are judged against outcome groups, which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out, by using information from previous inspections, information from the providers, the residents and their relatives, as well as others who work in or visit the home. This has included a recent unannounced visit to the home. This report gives a brief overview of the service and the current judgements for each outcome group. This was a key, unannounced inspection carried out over a period of 8 hours, during which time a partial tour of the premises was undertaken, care plans, staff files and records for regulation were examined. The Manager had been absent on Maternity Leave since May 2007. The Acting Manager was on Annual Leave. The two senior members of staff in charge were helpful in assisting with the inspection process. The majority of the nine people living in the Home were seen and spoken to. Discussions took place in private with three residents, the two members of staff on duty, and two visitors. Pre-inspection information was limited as the Annual Quality Assurance Assessment (AQAA) had not been returned prior to the inspection, therefore no residents’ nor relatives’ surveys had been received. What the service does well: • The Home is conveniently situated near to the centre of the town and those able to go out independently can take advantage of close-by amenities and the sea front. Residents and staff have made the exterior of the Home attractive with hanging baskets and tubs in a raised decked area to the rear of the Home. There is a friendly, relaxed atmosphere in the Home and in addition to their individual accommodation, there is a variety of communal areas which provide a homely, comfortable environment for the people living there. There are good, original, detailed care plans involving the residents but recent staff shortages have meant that some care plans have not been regularly reviewed resulting in the changing needs of residents not being closely monitored. Residents say they feel treated as individuals with their preferences respected. DS0000027339.V348951.R01.S.doc Version 5.2 Page 6 • • • • Esher House • There are regular residents’ meetings which enable the people living in the Home to make their views heard in the flexible routines and activities in the Home. However, there is room for improvement in a more formal quality assurance assessment taking place in the Service as a whole. Two cats live in the Home and a dog visits on a regular basis, giving pleasure to many of the residents. • What has improved since the last inspection? • Some areas of the Home, particularly the smoking room and lounge area have been redecorated and recarpeted. There is new furniture in the smoking room, which has made it much more comfortable for residents. The Home has sponsored a horse in a horse sanctuary and some residents were looking forward to an outing to see him. There is an aquarium in the conservatory area, which also gives pleasure to some residents. Previous residents in the Home have been supported by the Home to move on and live independently and two such people were visiting the Home on the day of the inspection. A new washing machine had been installed a few days prior to the inspection. • • • • What they could do better: • In general, residents feel well supported by staff, but staff shortages in recent months have meant that those unable to go out unaccompanied have had some of their activities , links with family and the community curtailed. It was evident that staff were committed to the care of the people living in the Home, but staff shortages, with no substitutes, have meant that the remaining staff have been working long hours, which was evident on the day of the inspection. Some care plan reviews have not been kept up to date, resulting in residents’ changing healthcare needs, together with the associated risks, not being closely monitored, particularly in regard to residents’ mobility.. • Esher House DS0000027339.V348951.R01.S.doc Version 5.2 Page 7 • The keyworking system cannot operate satisfactorily when there are staff shortages and residents’ needs, wishes and choices are not so readily promoted. Although there is on-going maintenance in the Home, further areas are in need of, redecoration and refurbishment, particularly in the entrance hallway. Staff supervision has not been regularly carried out in recent months, which is another means of measuring the quality of the service. Although residents’ meetings take place regularly the notes from these meetings were not available on the day of the Inspection. There is room for improvement with regard to a more formal process for obtaining feedback and views from residents, families and healthcare professionals who have involvement with the Home at a local level. This is borne out by the absence of the pre-inspection information in the form of the Annual Quality Assurance Assessment (AQAA). • • • • 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. Esher House DS0000027339.V348951.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Esher House DS0000027339.V348951.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this Service. People who use this service and/or their representatives have their differing needs assessed and the opportunity to visit the Home before they move in. EVIDENCE: There have been no new admissions since the last inspection, although people have stayed for respite care for short periods. However, the previous inspection showed evidence that there was good practice in this area. This was confirmed by the assessments contained in the care plans of the present residents. Information was obtained beforehand by an experienced member of staff and the assessment made involving the individual and their family or representative where appropriate, taking into account information from other professionals. Residents are gradually introduced to the Home where possible, first visiting for tea, staying the day, overnight and then for a week in order to make an informed decision as to whether the Home meets their aspirations and needs. Care plans were based on this assessment. Esher House DS0000027339.V348951.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The original care plans are good, but in the last few months some people living in the Home have not had their changing needs reviewed or risks assessed on a regular basis. EVIDENCE: Because of the absence of an AQAA, there were no comment cards from people living in the home, nor from relatives nor healthcare professionals in this area (see elsewhere in this Report under “Management”). Four care plans were examined and they contained detailed information and evidence that a full assessment had been carried out prior to each person moving into the Home, with the involvement of the resident This information enables staff to give appropriate individual support and there is a keyworker system to assist this. There was also information regarding changing needs, personal goals, risk assessments and reviews, until a few months ago, since when, although Daily Progress notes were up to date, some care plans and therefore some residents’ changing needs, have not been reviewed. This Esher House DS0000027339.V348951.R01.S.doc Version 5.2 Page 11 absence of reviews coincides with staffing shortages in the Home (see elsewhere in this Report under “Staffing”). There is therefore a requirement that all care plans must be reviewed on a regular basis and in particular with regard to residents’ changing mobility and the risks associated with this. Some of the risk assessments examined, together with their action plans, were concerned with drinking, managing finances, smoking, medication, going out and personal healthcare/hygiene. It was evident that people living in the Home are supported to take risks and to live their lives as independently as possible and there was evidence of residents being involved in these risk assessments, although some of them had not been reviewed on a regular basis. As a result of requirements from previous inspections, every effort has been made to enable individuals to open their own bank accounts and if necessary to have independent advocates to help them. However, one resident spoken to said that she had specifically requested that the Home assist her in managing her bank account. Esher House DS0000027339.V348951.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in the Home have had opportunities for personal development, education, employment and leisure activities, but shortages of staff in the last few months have curtailed these in some cases. Residents enjoy their meals and are involved in choice of menus. EVIDENCE: Because of the absence of an AQAA, there were no comment cards from the people living in the home, nor from relatives nor healthcare professionals in this area. (see elsewhere in this Report under “Management”). Residents spoken to on the day mentioned that they were encouraged and supported to live their lives as independently as possible, although in the main residents are in a mature age range and therefore were not seeking employment. However, several residents said they enjoyed the activities offered in and outside the Home and being involved in planning what they wanted to do. However, some residents spoken to mentioned shortages of staff and although they understood the reasons, it was evident that some of Esher House DS0000027339.V348951.R01.S.doc Version 5.2 Page 13 their activities could not take place, especially if residents needed staff support. Although there are a number of people living in the Home who prefer their own company and are able to go out independently, there are others who need staff support to go out.(see elsewhere in this Report under “Staffing”) Two visitors were paying a visit to the Home on the day of the inspection, both of whom had been residents in Homes within the Group, including Esher House. They said that they had been well supported by the Home to move to independent living and it was evident there was mutual pleasure in their visit. to the friends they had made whilst living in the Home. From one care plan examined it was evident that one resident has responsibility for caring for the two cats living in the Home and another resident was seen watering the hanging baskets and tubs which he and the staff had planted in the front and back of the Home. Several residents spoken to said they were looking forward to a party to be held in a few days’ time. One resident said she was helping with preparations and family members and friends had been invited. One resident spoken to said that she had staff support in cleaning her room and doing her own laundry; this was confirmed by a member of staff. Staff take it in turns to prepare meals and two residents spoken to confirmed that arrangements have been made by the Acting Manager for residents to have a taxi to the local supermarket on occasions in order to be able to help with the food shopping and select their own preferences. A menu was available and residents were seen telling a member of staff of their choices. Some make their own sandwich lunch, but for those residents in the Home at lunch time there was also a choice of light lunches. Residents are able to prepare a snack and hot drink in the residents’ kitchen area off the dining room at any time. At weekly residents’ meetings menus are chosen and notes are taken of residents’ favourite meals. Although these notes were not seen, this was confirmed by a resident. One resident spoke of especially enjoying the buffet meal which staff prepare on Sundays. There was evidence from care plans and on the day of Inspection that staff were aware of residents’ dietary requirements, including diabetic and weight reducing diets, which were recorded in care plans. However, some of these plans had not been reviewed in recent months. Esher House DS0000027339.V348951.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in the Home say they are happy with the way staff deliver their care, but the gaps in care plan and risk assessment reviews in some cases could mean that changing needs are not being met. EVIDENCE: Because of the absence of an AQAA, there were no comment cards from the people living in the Home, nor from relatives nor healthcare professionals in this area. (see elsewhere in this Report under “Management”). At least two of the people living in the Home who were spoken to had complex healthcare needs, but were satisfied that they received personal care in a manner with which they were happy and that their privacy and dignity were respected. One resident said that the Home had ‘given her back her life’. There was evidence from discussion with staff and residents and examination of care plans and the daily progress notes that the healthcare and emotional needs of the residents were attended to. Staff encourage individuals to be independent and to take responsibility for their own personal hygiene and to Esher House DS0000027339.V348951.R01.S.doc Version 5.2 Page 15 monitor where more support may be needed. However, in some cases (as mentioned elsewhere in this “Individual Needs and Choices”), the lack of care plan reviews means that the monitoring of some residents’ changing needs and physical health has not taken place. It is of some concern that gaps in care plan reviews could mean that the changing healthcare needs of some people living in the Home may not be recognised and addressed, thereby not receiving appropriate attention in the longer term. The conduct of staff in the care of a resident who had been ill during the night and on the day of the Inspection was appropriate and is not in question. The administration of lunch time medication was observed. Policies and procedures are in place and properly organised. A monitored dosage system is used and kept in a locked cupboard with a double lock for controlled drugs. Medication was administered by both members of staff, who are trained in medication administration. The medication administration records (MAR) are signed as the medication is administered to reduce the risk of errors and homely remedies are recorded in a separate book and on the MAR sheets. Risk assessments are in place for those two people who were self medicating These people receive their medication through a monitored Domiciliary Dosage system on a weekly basis and audited. Esher House DS0000027339.V348951.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People living in the Home feel their views are listened to and acted on and they are protected from abuse as much as is possible. EVIDENCE: Because of the absence of an AQAA, there were no comment cards from the people living in the home, nor from relatives nor healthcare professionals in this area. (see elsewhere in this Report under “Management”). Discussions with residents provided evidence that they were aware of how to make a complaint or their concerns made known. The complaints book contained one complaint, which showed that the appropriate procedure had been followed and the matter resolved. Staff spoken to on the day of Inspection had a clear understanding of safeguarding adults and there was evidence in staff files of training in this area. There was also evidence seen in care plans of the risk assessments and action plans showing how the people living in the Home are helped to be protected from abuse, neglect and self harm as much as possible. Esher House DS0000027339.V348951.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Esher House provides a homely, comfortable environment for the people living there; although there has been redecoration and refurbishment improvements could still be made. EVIDENCE: Because of the absence of an AQAA, there were no comment cards from the people living in the home, nor from relatives nor healthcare professionals in this area. (see elsewhere in this Report under “Management”). A full tour of the building was not undertaken because this would have taken staff away from other tasks on the day of the Inspection. Following a recommendation from the previous inspection the smoking lounge has been redecorated, refurbished and recarpeted. The other lounge has been redecorated and also has paintings by residents and staff. However, the ceiling in this room is cracked and stained resulting from a water leak from the room above. Although there is a maintenance schedule, it is recommended that attention be given to all areas needing redecoration and repair, especially in the entrance hall area and to the ceiling in the lounge area. Esher House DS0000027339.V348951.R01.S.doc Version 5.2 Page 18 Invitations to visit two residents’ rooms showed that they had been personalised and the residents were pleased with them. One resident said that staff help her keep her room clean, but it was noted that cleaning equipment was kept on the ground floor, thus there is a recommendation that consideration should be given to providing lighter equipment upstairs, to avoid staff/residents carrying awkward equipment up and downstairs. The areas of the Home seen were in the main clean and tidy and cleaning was taking place during the inspection, but staff reported that cleaning was difficult when there were staff shortages. There is a requirement that all risks are identified with regard to people smoking within the Home and the appropriate action plans put in place. There is a recommendation that encouragement should be given to all residents, where appropriate, to attend one of the fire safety courses. Esher House DS0000027339.V348951.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35,36 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People living in the Home are in the main satisfied with the care they receive from trained staff, but staff shortages could mean that some of their changing needs are not being met. EVIDENCE: Because of the absence of an AQAA, there were no comment cards from the people living in the home, nor from relatives nor healthcare professionals in this area. (see elsewhere in this Report under “Management”). The staff on duty on the day of Inspection were experienced, having NVQ 2 qualifications and other training. It was observed that they knew the residents and their individual needs well, had a good rapport with them and their commitment to the Home was appreciated by residents spoken to. However, from speaking to residents and staff and examination of the staff rotas and time sheets, there have been staff shortages for several months, which has meant long working hours for those on duty, including sleeping in and some broken nights, with no substitute staff allocated. Esher House DS0000027339.V348951.R01.S.doc Version 5.2 Page 20 At the previous inspection, the Manager had ensured that there were always sufficient staff on duty to allow residents to be taken out, sometimes on a oneto-one basis and leaving two staff on duty in the home 4-5 days a week. From the present staff rota, it was evident that this has not been happening since the Manager had been on Maternity Leave in May 2007. The most recent member of staff has only been in post three weeks and is not yet working without supervision; there had been no relief staff allocated in the absence of the Acting Manager on annual leave. There is therefore a requirement in this area. All the staff training records were seen and there was evidence of courses attended such as Safe Handling of Medication, Safeguarding of Adults, NAPPI, Fire Safety, Food Hygiene, First Aid, Moving and Handling and COSHH. One member of staff on duty was undertaking her NVQ3 qualification. However, there was no evidence seen that staff were receiving regular supervision since May 2007. There is also a requirement in this area. Minutes of Staff Meetings were seen to be held on a regular basis, the last being on 9.8.07 when fridge and freezer temperatures food labelling and cleaning, especially in the smoking lounge, were discussed. All the staff files, except one contained the relevant records such as References, Application Forms, identification and clear enhanced Criminal Records Bureau (CRB) disclosures, but in the file for the most recent member only one written reference was seen. There is therefore a requirement in this area. Esher House DS0000027339.V348951.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Home has the management support of the wider organisation, but in the absence of managerial leadership within the Home and of a formal quality assurance system locally, people living there cannot be fully assured that their needs and views are taken into account in the running of it. EVIDENCE: Although an Acting Manager had been appointed in the Manager’s absence, she was on annual leave for a week on the day of the Inspection and no replacement had been arranged in the numbers of the staff team. Although the two experienced members of staff were acting in her place on the day, the most recent member of staff was also on leave and on her return would not have been able to work unsupervised, creating further staff shortages (see elsewhere in this Report “Staffing”). Esher House DS0000027339.V348951.R01.S.doc Version 5.2 Page 22 The Operations Manager of the wider organisation had paid his monthly visit to the Home on 16 August 2007, had reviewed care plans, spoken to all the residents and had not reported any issues or concerns (report seen) Although staff and residents reported that residents’ meetings were held on a regular basis, at which residents are able to put forward their views about the running of the Home, no notes of these meetings were seen. There is therefore a recommendation in this area that these Minutes are recorded and become part of the quality assurance process. Although one resident said that she had spoken to the Operations Manager the day before, and had previously completed a questionnaire for the wider organisation; there was room for improvement of a more formal process for obtaining feedback and views from the residents, families/representatives and healthcare professionals who have involvement with the Home locally. In the absence of an AQAA, there were no comment cards from the people living in the home, nor from relatives nor healthcare professionals in this area received by the Commission. A requirement has therefore been made that a more formal quality assurance process must be established, including the auditing of care plans. The submission of a duly completed Annual Quality Assurance Assessment is a legal requirement. On this occasion – the first year since its implementation – the Commission will not take any formal enforcement action. A failure in respect to any future request could, however, result in a prosecution. Not all areas of the Home were seen on the day of the Inspection (see elsewhere in this Report under “Environment”) but the Home has a good record of organised procedures for keeping residents safe and a sample of records seen were up to date. The Accident Book was seen to be appropriately completed. Staff training in areas relating to Health and Safety was also seen to be up to date. However, there is a requirement that risk assessments should be carried out on the use of the stairs, particularly for those residents who are less mobile. Esher House DS0000027339.V348951.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 Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 1 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 2 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 2 X 2 X X 2 X Esher House DS0000027339.V348951.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. 1. Standard YA6 Regulation 12(3) Requirement All people living in the Home must have their care plans reviewed involving significant professionals, family, friends and advocates as agreed with the resident and updated to reflect changing needs; and agreed changes are recorded and actioned, particularly in regard to their healthcare needs and mobility. Managers must ensure that the Home has an effective staff team with sufficient numbers and complementary skills to support the people living in the Home at all times. Managers must not employ a person to work in the Home until all checks listed in Schedule 2 are completed Managers must ensure that staff receive the support and supervision they need to carry out their jobs. Timescale for action 30/09/07 2. YA33 18(1)(a) 17/08/07 3. YA34 19(1) 17/08/07 4. YA36 12(5) 30/09/07 Esher House DS0000027339.V348951.R01.S.doc Version 5.2 Page 25 5. YA39 24 6. YA42 13 7. YA42 13 8. YA42 13 A more formal process must be established and maintained for obtaining feedback and views from the people living in the Home, families/representatives and other professionals who have involvement with the Service, including auditing of care plans. All risks are identified with regard to the use of the stairs particularly for the people living in the Home who are less mobile. All risks are identified with regard to people smoking within the home and appropriate action plans put in place to ensure that there is no fire hazard. The smoking lounge must be checked regularly to ensure the safe disposal of the ashtray contents and ensure that there is no fire hazard. 31/10/07 30/09/07 30/09/07 17/08/07 Esher House DS0000027339.V348951.R01.S.doc Version 5.2 Page 26 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 YA8 YA24 Good Practice Recommendations It is recommended that notes from house meetings are recorded and filed appropriately as part of the quality assurance process. It is recommended that redecoration and repair is considered, especially in the entrance hallway and the crack in the lounge ceiling to make for a more pleasant environment for those people living in the Home. It is recommended that consideration be given to providing lighter cleaning equipment upstairs in order to avoid residents and staff carrying awkward equipment up and down stairs It is recommended that consideration be given to people living in the Home being encouraged to attend one of the fire safety courses. 3. YA42 4. YA42 Esher House DS0000027339.V348951.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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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