Inspection on 28/01/08 for Mount Ephraim House

This inspection was carried out on 28th January 2008.

CSCI found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Mount Ephraim House 20/01/09

Mount Ephraim House 26/07/06

Mount Ephraim House 20/12/05

Mount Ephraim House 21/06/05

Mount Ephraim House 08/02/05

Mount Ephraim House 02/11/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Mount Ephraim House Mount Ephraim Tunbridge Wells Kent TN4 8BU Lead Inspector Gary Bartlett Unannounced Inspection 28th January 2008 07:30 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 Mount Ephraim House DS0000023986.V358673.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Mount Ephraim House DS0000023986.V358673.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mount Ephraim House Address Mount Ephraim Tunbridge Wells Kent TN4 8BU 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) 01892 520316 01892 523180 mountephraim.house@tiscali.co.uk www.greensleeves.org.uk Greensleeves Homes Trust Care Home 38 Category(ies) of Old age, not falling within any other category registration, with number (38) of places Mount Ephraim House DS0000023986.V358673.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th July 2006 Brief Description of the Service: Mount Ephraim House provides personal care and accommodation for up to thirty-eight older people. Greensleeves Homes Trust, a charitable organisation, owns the home. Mount Ephraim House is located in a residential area of Tunbridge Wells. The nearest shops and other usual town amenities are approximately a half-mile away. The home was first registered on 8th March 1991. It consists of a semi-detached property with large secluded gardens to the sides of the premises. There are limited car parking facilities to the front and side of the house. Accommodation currently includes thirty-seven rooms for single occupancy, six of which have shower and WC en-suite facilities. Thirteen of the bedrooms are located on the ground floor; separate facilities can be made available for guests to stay. There are two shaft lifts in the main house enabling wheelchair access to the upper floors in the main house and a stair lift in the annex. There is a staff call system with television points in all the bedrooms. A number of residents have their own phone lines installed. The home employs care, administrative and ancillary staff. Current fees range from £430 to £500 per week for private placements. The fee for local authority placements is £355 per week. Mount Ephraim House DS0000023986.V358673.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This key unannounced inspection was conducted by Gary Bartlett, Regulatory Inspector, who was in Mount Ephraim House on 28th January 2008 from 7:30 am until 3:30 pm and on 29th January 2008 from 3:00 pm until 5:00pm. During that time the Inspector spoke with some residents, 2 visitors, and some staff. Parts of the home and some records were inspected and care practices observed. Greensleeves Homes Trust had completed an Annual Quality Assurance Assessment, from which information was used to inform the inspection process. A number of survey forms were received from residents and staff prior to the inspection. Some statements made are quoted in the text of the report. The Care Homes Regulations 2001 and the National Minimum Standards for Care Homes for Older People refer to people who use the service as “service users”. People living at Mount Ephraim House prefer to be referred to as “residents”. Accordingly this shall be done in the text of this report. The Manager and staff gave their full co-operation and help. What the service does well: The Manager is qualified, experienced and has high expectations of the standards of care for residents. Staff are good at helping new residents to settle in. Residents say they enjoy living at Mount Ephraim House and are happy here. Residents can maintain good contact with family, friends and the community. Residents enjoy the meals. Staff recruitment procedures are robust to ensure only appropriate people work at the home. Mount Ephraim House DS0000023986.V358673.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: 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. Mount Ephraim House DS0000023986.V358673.R01.S.doc Version 5.2 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 Mount Ephraim House DS0000023986.V358673.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4, 5 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The pre-admission procedures must be more closely adhered to so that residents can be confident the home can meet their needs. EVIDENCE: Greensleeves Homes Trust has sound policies and procedures for the assessment and admission of residents. A pre-admission assessment is made of each prospective resident to ensure the home can meet his or her needs. A senior member of staff would usually visit the prospective resident in their home or hospital to ensure the necessary information was current and accurate. Prospective residents, their families, advocates, and relevant health care professionals are involved in the assessment process. Specialist advice Mount Ephraim House DS0000023986.V358673.R01.S.doc Version 5.2 Page 9 should be sought from external sources where required. There is evidence that practice has not always been consistently or well applied at Mount Ephraim House. One of the care plans inspected was of a resident admitted in 2007. The pre-admission assessment shows that person has a particular medical need. It was observed that staff present during the inspection did not have any knowledge of how to support the resident with this and had to request external support. The Manager acknowledges that prior to her taking post, pre-admission assessments had not taken account of staff skills. The Manager understands the necessity for this to be done and said she is arranging for staff to be trained accordingly. There have not been any admissions to the home whilst she has been working there. Residents said they or their families had been able to visit Mount Ephraim House before moving in. They also said staff had been very helpful in assisting them to settle in. Intermediate care is not offered at the home. Mount Ephraim House DS0000023986.V358673.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans and records of care must be more consistently maintained to reflect the quality of care given. More consistent adherence to guidelines for the administration and storage of medicines would better protect residents. Residents’ health needs are met with good liaison with relevant health care professionals. EVIDENCE: Each resident has a care plan and four were inspected in detail. The information contained is not always comprehensive or directive as to how Mount Ephraim House DS0000023986.V358673.R01.S.doc Version 5.2 Page 11 needs are to be met. In some instances the information was difficult to substantiate. The plans seen are not person centred. The Manager has been in post for a short while and is planning a review and overhaul of all the care plans. She is aware that records of daily care need to be more informative to comprehensively reflect the service given and is planning to address this by regularly monitoring them and giving staff guidance as necessary. Most residents are aware that they have a care plan but they are not actively encouraged to be involved in its review or development. Many plans are not signed by the resident concerned. The monthly monitoring reports produced by the Trust show that they are aware of the deficits in care planning and expect improvements to be made. The records of care are not kept securely when not in use, thereby potentially compromising confidentiality. Staff spoken with generally have a good understanding of residents’ individual preferences. There is a key worker system that should contribute to an effective exchange of information about residents’ health and welfare. Risk assessments are not always reviewed or recorded as a result of some incidents or changes in welfare. Many of the residents are independent, largely self-caring and often go out on their own. Consequently, the scope and content of risk assessments needs to be more comprehensive. It is evident from records seen and discussion with residents and staff that residents have ready access to health care professionals as necessary. The room used for the storage of medicines is adequately maintained and medicines are only administered by staff that have been trained. The majority of care staff have been trained. There was some discussion that each shift should have fewer nominated staff members administering medication to lessen the risk of error and to make monitoring and accountability easier. The Medication Record Administration Record (MAR) sheets inspected were correctly completed and included photographs of the residents. The monthly monitoring reports produced by the Trust show that they are auditing medication records and practices and have noted previous errors. Residents feel that staff are kind and gentle, this was confirmed by observation and discussion with visitors. Staff are generally considerate of the age of residents and treat them with courtesy. Mount Ephraim House DS0000023986.V358673.R01.S.doc Version 5.2 Page 12 Mount Ephraim House DS0000023986.V358673.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are able to maintain contact with family, friends and the community. Dietary needs of residents are well catered for with a balanced and varied selection of food that meets their tastes. EVIDENCE: Activities take place regularly and residents are encouraged to take part as much or as little as they like. Residents spoke of having enjoyed a recent Burns night at the home and a Chinese New Year celebration is planed. An activities co-ordinator who was very popular with residents has left and the home is intending to recruit a replacement. Residents maintain links with the community through church attendance and visits to and from friends and relatives. Mount Ephraim House DS0000023986.V358673.R01.S.doc Version 5.2 Page 14 Most people living at Mount Ephraim House are largely self-caring and some go out regularly and independently. As mentioned earlier in the report, risk assessments need to be strengthened to support this. A resident said “We mostly do as we like here. If I want to go out, I do. If I decide to stay in, I find there is enough to keep me occupied”. Residents’ interests are recorded on their care plans but staff do not always consider the need to promote these on an individual basis. For example, one resident’s care plan states “loves to draw and paint”. The action to be taken is “inform (the person) when there are activities”. There is no indication that the resident is encouraged or enabled to pursue their interest as and when they like or is practicable. Discussion with some staff indicates they have not considered the possibility that some residents might like to participate in some meaningful daily tasks around their home, such as preparation for meal times. Residents say they have the confidence to discuss and comment where improvements can be made, although one resident did say “you have to choose your person”. A residents meeting was held on 18 January 2008. The Manager said she takes residents feedback seriously and makes changes where possible, which enables them to enjoy a better quality of life. Two examples she gave of this being the arrival of two cats, Ivana and Nutmeg, and the rewriting of the menus. Family and friends feel welcome and know they can visit the home at any time. During the inspection a number of visitors were seen in the home and the visitors book records regular visits by families, friends and others. The design of the home provides seating areas within the communal areas of the home where residents can entertain their visitors, in addition to the privacy of their own room. Residents are encouraged to take responsibility for their own financial affairs and to use their money as they wish. Residents can choose to bring personal effects with them on admission to the home and are encouraged to keep personal items that are important to them in their own room. Meal times are set for practical reasons but can be flexible to accommodate residents’ needs as necessary. Residents are complementary of the food served and say their tastes are met as best possible with a choice of menu always being offered. The menus have been rewritten recently. The meals are generous in portions and look appetising. Mealtimes are relaxed; staff are patient and helpful and allow residents the time they need to finish their meal comfortably. There are facilities around the home for residents and their visitors to make hot drinks and hot and cold drinks are served through out the day, as well as snacks. Mount Ephraim House DS0000023986.V358673.R01.S.doc Version 5.2 Page 15 Mount Ephraim House DS0000023986.V358673.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by a robust complaints system and service users and relatives feel their views are listened to and acted upon. The home has robust adult protection policies and procedures to ensure that residents are protected from abuse. EVIDENCE: The complaints procedure is readily available to residents and their relatives. They said they feel confident that they would be listened to and any necessary action would be taken. A visitor said: • “They always listen and resolve problems as quickly as they can”. The Manager described how she has had to remind senior staff what records should be kept in the complaints file. The Annual Quality Assurance Assessment received prior to the site visit indicates there have been 5 complaints received by the home in the last 12 months. Four were upheld and Mount Ephraim House DS0000023986.V358673.R01.S.doc Version 5.2 Page 17 in a timely manner and one was waiting for an outcome. The Commission has not received any formal complaints about the home in that time. There are procedures for responding to suspicion or evidence of abuse or neglect to ensure the safety and protection of residents. The Manager and other staff spoken with have a sound understanding of adult protection procedures. There have been no alerts raised in the last 12 months. Mount Ephraim House DS0000023986.V358673.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ quality of life would be enhanced by improvements to the environment in which they live. EVIDENCE: Mount Ephraim House is a large building close to Tunbridge Wells town centre and overlooking the Common. Accommodation is on 3 floors and these are served by 2 shaft lifts and a stair-lift. The home has car parking to the front and side of the house. Due to the age of the building some areas and bedrooms can only be accessed via a step or a few extra stairs on landings. Mount Ephraim House DS0000023986.V358673.R01.S.doc Version 5.2 Page 19 This is can be a problem for those less mobile, especially as their frailties increase. Residents say they find Mount Ephraim House to be a generally comfortable place in which to live. It is a grand building with some imposing rooms, such as the lounge and dining rooms and the entrance hall. There is also a library that should be kept clear of unnecessary clutter to make it a more attractive and safer area for service users. The age of the building is reflected in those areas that have damaged plasterwork. Some areas, including some bedrooms, have cracked ceilings, and stained and/or flaking paint-work. Damaged plaster and paint on walls and ceilings in high infection risk areas such as the kitchen, laundry, some bathrooms and toilets must also be made good. Carpets in some areas are worn and in need of replacement. The Manager stated that the Trust had agreed funding for the repair and refurbishment of the home to commence from April 2008, but a plan of work had not yet been devised. The refurbishment was necessary bedrooms were largely furnished with “mix and match” furniture, some of which is damaged or looking worn. The Manager said she is going to undertake an audit to ensure residents have beds appropriate to their needs. Whilst residents can enjoy the services of a visiting hairdresser, this would be enhanced if the room used was warmer and more inviting. Carpet is not the most hygienic floor covering for this area. The home has robust procedures for moving soiled items to the laundry, which is necessary, as they have to be carried past food storage areas and the kitchen. Residents consider the bathing and toilet facilities to be adequate. Support frames around toilets are not secured, posing a potential hazard for residents. The Manager undertook to arrange for these to be made safe. Stained baths should be made good or replaced. Most areas are fitted with staff call points. Some are fitted with extension leads that are thin white cords and not easily discernable, especially for people with sight difficulties. The home is set within extensive, attractive grounds that residents enjoy to walk in. It is recommended more external exits are fitted with grab rails to facilitate easier and safer use by service users. The path from the staff room to the smoking area is uneven and a potential trip hazard. Mount Ephraim House DS0000023986.V358673.R01.S.doc Version 5.2 Page 20 Mount Ephraim House DS0000023986.V358673.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents feel there are usually adequate numbers of staff on duty and that the staff are caring people. EVIDENCE: Recent months have been very unsettled for the staff. The previous Manager left in September 2007 and other staff have left since then. Three night staff have left and one is on long term sick leave. Consequently, the home is reliant on day staff and agency staff to fill the gaps in the staffing roster. A night shift had to be covered at short notice during the inspection and this clearly caused stress. A resident said their room is not regularly cleaned because cleaning staff are being used to give assistance in the kitchen. There have been changes in work-allocations and daily routines. Staff morale is currently low. Survey forms completed by staff and returned to the Commission included the comments: Mount Ephraim House DS0000023986.V358673.R01.S.doc Version 5.2 Page 22 • • • • • “Sometimes staff would work better if they worked as a team, not against each other”. “If people pulled together and get on with the jobs things would be a lot better and things would be a lot happier”. “I think the office staff should work together and support each other more. Have more staff meetings”. “Sometimes we get a morning report or before a night shift but sometimes we don’t.” “Communication could be improved, more regular staff”. A survey form completed by a resident included the comment: • “The staff are always very busy in the early morning and cannot devote their time to individuals”. The Manager stated a reconfiguration of the staffing structure and work practices is being developed. She said this will include cleaning staff being employed at weekends and kitchen assistants in the evenings and the recruitment of night staff. The staff rosters seen indicate staffing levels are geared to peak times of activity. Residents and visitors say staff are generally to hand if needed. Records seen indicate the home has robust recruitment procedures and the Manager understands the necessity to ensure the home employs only staff that have been properly vetted. Staff are required to undertake an induction programme. The Manager explained that where there is not a record of existing staff having completed the induction programme, they would be required to undertake it again. Agency staff are given an induction when they first work at the home but it is not recorded. As stated earlier in this report, it is not always evident that staff have the skills to meet residents’ needs. The Manager said she has recently completed a training analysis of all senior staff and of care staff and the results of this had been sent to Skills for Care. She is now undertaking a similar exercise for all remaining staff. A training matrix is used to give a management overview of staff training needs, and the Manager said this is currently being updated to include recent courses attended. Resident’s and their relatives speak highly of the staff and of the care given. Mount Ephraim House DS0000023986.V358673.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. More diligent adherence to health and safety guidelines would better protect residents. EVIDENCE: The Manager has been in post since October 2007. Application for her registration as Manager has been submitted. She has extensive experience in residential care, having been a registered Manager at other homes, and is a Registered Nurse, has a Diploma in Management, and a Certificate in Mount Ephraim House DS0000023986.V358673.R01.S.doc Version 5.2 Page 24 Supervisory Management. The Manager speaks of a commitment to delivering a high quality service. There is a sound system of holding and recording service users’ cash, which is regularly checked by the Trust as part of their audit process. Residents and their representatives or relatives are regularly asked for their views. The Manager is monitoring the quality of records made by staff with the aim of achieving a higher level of consistency. As noted earlier in this report, care plans are not stored securely when not in use. The standard of cleanliness in the kitchen and surrounding area could be better and copies of recently completed cleaning schedules could not be located. Food is not always stored as directed. For example, bottles of tomato ketchup and salad dressing are not refrigerated after opening as required. There are many refrigerators around the home and temperature records could not be located for one of them. The Manager could not locate records to show that all staff have attended fire drills/training at regular intervals. Two staff spoken with could not recollect having taken part in a fire drill. The Manager undertook to arrange for all staff to receive fire training at the soonest possible time. The Annual Quality Assurance Assessment indicates the Trust regularly reviewes policies and procedures to ensure they comply with current legislation and good practice advice and that records of maintenance and safety checks are up to date. These were not inspected on this occasion. Mount Ephraim House DS0000023986.V358673.R01.S.doc Version 5.2 Page 25 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 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 N/A DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 2 2 X 2 X 2 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 2 2 Mount Ephraim House DS0000023986.V358673.R01.S.doc Version 5.2 Page 26 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 OP7 Regulation 14(2)(b), 15(2), 17 Schedule 3, Schedule 4 Requirement The registered person shall maintain records as specified in Schedules 3 and 4. The registered person shall keep the service user’s plan under review in that service users’ individual plans and records must be kept and be up to date in that they must be consistent and specific in detail of information required. All service users must have an accurate care plan by the given timescale, if not sooner, which is thereafter maintained. The registered person shall ensure that unnecessary risks to the health and safety of service users are identified and so far as possible eliminated in that risk assessments must be more comprehensive and recorded in response to incidents and changes in residents welfare. Comprehensive risk assessments must be in place by the given timescale, if not sooner, and maintained thereafter. “The registered person shall, having regard to the size of the DS0000023986.V358673.R01.S.doc Timescale for action 30/04/08 2. OP7 13(4) 30/04/08 3. OP19 23(2)(b) 31/03/09 Page 27 Mount Ephraim House Version 5.2 care home and the numbers and needs of service users ensure that the premises to be used as the care home are of sound construction and kept in a good state of repair externally and internally” in that: 1. Damaged and stained ceiling and wall surfaces in residents’ bedrooms and communal areas must be made good. 2. Worn carpets must be replaced 3. All external paths must be free from trip hazards To be completed by the given timescale, if not sooner, and maintained thereafter. “The registered person shall 30/11/08 having regard to the number and needs of the service users ensure that equipment provided at the care home for use by service users or persons who work at the care home is maintained in good working order” in that all worn and damaged furniture must be made good or replaced where necessary. To be completed by the given timescale, if not sooner, and maintained thereafter. The registered person shall 31/07/08 make suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home, in that: 1. Damaged plaster and paint on walls and ceilings in high infection risk areas such as the kitchen, laundry, bathrooms and toilets must be made good. DS0000023986.V358673.R01.S.doc Version 5.2 Page 28 4. OP24 23(2)(c 5. OP26 12(1), 13(3)(4) (c) 16(2)(j) Mount Ephraim House 2. Fixtures and fittings in food preparation areas must be of good repair. To be completed by the given timescale, if not sooner and maintained thereafter. “The registered person shall, 28/02/08 having regard to the size of the care home, the statement of purpose and numbers and needs of service users – (a) ensure that at all times suitably qualified, competent and experienced persons are working at the care home in such numbers as are appropriate to the health and welfare of service users” in that a review of staff levels must be undertaken to ensure they are appropriate to the needs of the service users at the home. The result of this review and of the Trust’s staffing plans, with timescales, must be received by CSCI by the given date, if not sooner. “The registered person shall, 31/03/08 having regard to the size of the care home, the statement of purpose and numbers and needs of service users ensure that the persons employed by the registered person to work at the care home receive training appropriate to the work they are to perform including structured induction training” in that the home must be able to produce evidence of an induction programme undertaken by agency staff working at the home. To be completed by the given timescale, if not sooner and maintained thereafter. “The registered person shall DS0000023986.V358673.R01.S.doc 6. OP27 18(1)(a) 7. OP30 18(1)(c) 8. OP37 12(4)(a) 28/02/08 Page 29 Mount Ephraim House Version 5.2 make suitable arrangements to ensure that the care home is conducted in a manner which respects the privacy and dignity of service users”, in that records of care must be stored securely when not in use. To be completed by the given timescale, if not sooner and maintained thereafter. “The registered person shall 28/02/08 make suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home” in that all foodstuffs must be stored in accordance with their directions. To be completed by the given timescale, if not sooner and maintained thereafter. 31/03/08 “The registered person shall after appropriate consulation with the fire and rescue authority make arrangements for persons working at the care home to receive suitable training in fire prevevtion; and to ensure, by means of fire drills and practices at suitable intervals, that the persons working at the care home and, so far as is practicable, service users, are aware of the procedure to be followed in case of fire, including the procedure for saving life” in that the home must be able to produce evidence that all staff are attending fire drills/training at least at the frequency required by the Fire Safety Officer. To be completed by the given timescale, if not sooner and maintained thereafter. Mount Ephraim House DS0000023986.V358673.R01.S.doc Version 5.2 Page 30 8. OP38 13(3) 16(2)(j) 9. OP38 23(4)(d)( e) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations It is strongly recommended that each shift has fewer nominated staff members administering medication to lessen the risk of error and to make monitoring and accountability easier. It is strongly recommended that service users are encouraged or enabled to pursue their individual interests as and when they like or is practicable. It is strongly recommended that service users’ autonomy and choice is further promoted by offering them the opportunity and support needed to participate in meaningful daily tasks around the home. It is recommended the library is kept clear of unnecessary clutter to make it a more attractive and safer area for service users. It is recommended better hairdressing facilities are provided with more hygienic floor covering. It is recommended stained baths are made good or replaced. It is recommended more external exits are fitted with grab rails to facilitate easier and safer use by service users It is strongly recommended staff call points are fitted with extension leads that are more visible, taking particular account of people with poor sight 2. OP12 3. OP14 4. 5. 6. 7. 8. OP19 OP19 OP21 OP22 OP22 Mount Ephraim House DS0000023986.V358673.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Oxford Office 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU 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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