CARE HOMES FOR OLDER PEOPLE
West Ella House 6 Church Lane Kirkella Hull East Yorkshire HU10 7TG Lead Inspector
Ms Wilma Crawford Unannounced Inspection 18th November 2005 09:00 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 West Ella House DS0000019768.V259049.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. West Ella House DS0000019768.V259049.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service West Ella House Address 6 Church Lane Kirkella Hull East Yorkshire HU10 7TG 01482 659403 01482 653995 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) Kirkella Mansions Company Limited Maureen Tindall Care Home 25 Category(ies) of Dementia - over 65 years of age (25), Old age, registration, with number not falling within any other category (25) of places West Ella House DS0000019768.V259049.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 25th August 2005 Brief Description of the Service: West Ella House is a large grade two listed building that is privately owned. The home provides residential care for 25 older people, some of whom have dementia care needs. The accommodation is of a high standard and 17 of the bedrooms are single, with 11 of these providing en-suite facilities. The home provides ramps and a passenger lift to ensure that service users have access to all areas of the building. The garden is landscaped and provides a safe and easily accessible amenity for service users that includes seating areas and raised flowerbeds. The home is close to local amenities and has car parking facilities. West Ella House DS0000019768.V259049.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over six hours including preparation time. Five residents and two staff were spoken with during the inspection. The manager and the home owner were available throughout,the premises were looked at and the records of three residents and one staff were inspected. The main method of inspection used was called case tracking which involved selecting four residents and tracking the care they receive through the checking of their records, discussion with them, the care staff and observation of care practices. The comments and views of people spoken with are included within this report. What the service does well:
The home looks after service users well, ensuring that all needs are met. The home ensures that service users take part in the day-to-day running of the home through residents meetings and a rigorous quality assurance system. Residents feel at home and a number said that they have no complaints. “ It’s a wonderful home, absolutely wonderful.” They also commented that they are regularly consulted by the owner and the manager about their views, “We’re asked what we think” “ I can do as I want, like I would if I was in my own house.” “Jeff is a good lad, you can talk to him about anything and he will get it sorted.” “Maureen and Jeff often pop in to see me and make sure that everything is alright, they are very kind and caring. I’ve never met people like them.” The home is well presented and comfortable. One resident said, “You can’t fault the home”. Residents are positive about the relationships they have with staff. One resident said, “The staff are quite good and helpful, some are very nice and extra helpful.” “ The staff are very kind, they keep telling me I can do exactly as I like.” “ The staff are all very patient.” Residents feel the staff treat them with respect and dignity. One service user commented; “ I need a lot of help, but I am always respected.” Staff were also complimentary about the residents and were aware of how to ensure that they are given choice. Positive relationships between staff and residents were observed during the inspection. Residents are able to see their friends and families when they wish. One resident has lunch with her son each week in one of the small lounges. West Ella House DS0000019768.V259049.R01.S.doc Version 5.0 Page 6 Residents said that the food was very good. “ The food is very good and there is always a choice, I’m not keen on sponge puddings, so I always have something else.” 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. West Ella House DS0000019768.V259049.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 West Ella House DS0000019768.V259049.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): 2,3,4,5 Residents can feel confident that their assessed needs will be met and are aware of the conditions of residence once admitted. EVIDENCE: Details of chiropody, optical and dental care is now included in residents files. Residents care plans showed that a needs assessment is completed for all residents. This is carried out prior to admission. A newly admitted resident explained that she had been visited at home by the owner and the manager and had her needs assessed before moving into the home. For residents admitted under the care management approach this is in addition to that assessment. The needs assessment addresses all activities of daily living and strengths and needs of residents. There is evidence within the assessment that residents and their families are involved at this stage. All residents enter into a ‘contract’ with the home and a copy of this is held in the care plan or given to the relative for safe keeping. Where a resident would
West Ella House DS0000019768.V259049.R01.S.doc Version 5.0 Page 9 not be able to understand their terms and conditions then representative or a family member is asked to read and sign a copy. a legal A resident spoken with confirmed that this happens. Evidence was seen in the care plans. West Ella House DS0000019768.V259049.R01.S.doc Version 5.0 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 There are appropriate policies and procedures in place to ensure the safe handling and administration of medication for the people who use the service. EVIDENCE: The home has a comprehensive policy and procedure for dealing with medication. The home’s policy for medication is sound and protects residents from potential abuse. Staff are trained in the administration of medication prior to taking on this role. Medication was being administered correctly by staff and records were well maintained. The procedure in relation to returning of controlled medicines has been reviewed, to ensure residents are protected. The manager stated that GP’s review medication, ensuring it remains relevant, at least six monthly and more often if required. She was able to give examples of this in relation to current residents. West Ella House DS0000019768.V259049.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): 14,15 Relatives and friends of residents are made welcome in this home. Meals are nutritious and balanced and offer a healthy diet for service users. EVIDENCE: Residents said that their visitors were made welcome at the home and that the home “had a very good atmosphere.” They also confirmed that they have visitors in their rooms and that they are made welcome by care staff. One resident said “The staff are always polite to my family, they make them welcome and always offer a drink and a biscuit or a piece of cake.” Residents said that they have a choice of meals and they said “The food is very good and there is plenty. We can have what we want to eat, if you don’t like something, the staff always offer alternatives, we can have whatever we want.” One resident explained that their medication had been reduced since moving into the home and felt that it was a result of the high quality wholesome food that had been provided. Staff spoken with had a good knowledge of residents likes and dislikes, as well as specialised diets required by individual residents. The owner, manager and staff spoken with stated that a choice was always available and further alternatives were always offered over and above this. West Ella House DS0000019768.V259049.R01.S.doc Version 5.0 Page 12 Meals can be taken in the dining room or in individual rooms if preferred. One resident has lunch with their son in one of the small lounges every week. West Ella House DS0000019768.V259049.R01.S.doc Version 5.0 Page 13 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Residents are protected by procedures in place for handling complaints and allegations of abuse. Staff were clear in relation to the action to be taken should either event occur. EVIDENCE: The home has a comprehensive complaints policy and procedure. Staff and residents are confident that any concerns would be dealt with appropriately. Both the owner and the manager take an active role in continually seeking residents views.” Maureen and Jeff often pop in to see me and they make sure that everything is alright, they are very kind and caring. I’ve never met people like them.” Staff spoken with had a good understanding of the homes policies and procedures, which are easily accessible to them. Policies and procedures are regularly revisited at staff meetings. Minutes of staff meetings supported this. Staff had an awareness and understanding of their role in reporting allegations of abuse and dealing with complaints. West Ella House DS0000019768.V259049.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): 19,20,21,22,23 The residents live in a comfortable, pleasant and safe environment, with both private and communal space being suitable for their needs. EVIDENCE: A tour of the premises showed that the home was maintained to a good standard internally. The maintenance issues identified at the last inspection had been acted upon. An extension to the date to repair a leaking window was agreed, this and other windows are to be replaced by double glazed units. There are various adaptations around the home to promote peoples independence. Bathrooms and en suite facilities are equipped to meet individual needs, with hoists, grab rails and raised toilet seats. Furnishings are domestic in nature and well maintained. The home is well decorated. The grounds and gardens were well-tended and offer seclusion and privacy from the public.
West Ella House DS0000019768.V259049.R01.S.doc Version 5.0 Page 15 Resident rooms are personalised with personal belongings and photographs. One residents commented” I have brought my bureau from home, you can have whatever you like in the furniture line.” “I’m sure that I have got the best room in the house, I get the morning sun and have a view over the garden.” West Ella House DS0000019768.V259049.R01.S.doc Version 5.0 Page 16 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): 28,30 Staff members are suitably trained, qualified and competent; they undergo an induction programme before commencing their duties. EVIDENCE: The residents were positive about the care they received; one said “ The staff are all very kind.” The staff group is stable. A newly appointed member of staff had received an induction and had a mentor allocated to her. Training records showed that 40 of the care staff had achieved the National Vocational Qualification at Level 2 or 3, and five staff working towards this. The training plan showed that all statutory training was being undertaken, with the most recent training being on Moving and handling, Health and Safety, Safe Handling of Medicines, Fire Training and Food Hygiene. West Ella House DS0000019768.V259049.R01.S.doc Version 5.0 Page 17 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,36 The home is managed competently and the staff are supported and supervised in carrying out their respective roles. EVIDENCE: The manager is a Registered General Nurse; with extensive experience of working with older people. She also has the Registered managers Award. Observations showed that the home had an ‘open door’ policy and the Manager and the home owner are approachable and accessible on a daily basis. The Manager operated a quality control system whereby residents were requested to complete a questionnaire, data from which was then used to create a bar graph showing the responses. These were then analysed and discussed at staff meetings. Residents said that if they had any concerns the owner was always ready to listen and act upon them. Staff records showed that supervision took place and appraisals were held. West Ella House DS0000019768.V259049.R01.S.doc Version 5.0 Page 18 The home has detailed policies and procedures in place. Records are kept appropriately. Some elements of service users records are not in place. Photographs of service users are not kept by the home. The home operates in the best interests of the health and safety of service users and staff. However during the process of inspection, fire doors along a corridor were found to be wedged open, which can present a potential risk to residents. This was discussed with the owner who agreed to seek advice on alternative appropriate devices, with the fire officer. West Ella House DS0000019768.V259049.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 3 3 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 3 3 X X X STAFFING Standard No Score 27 X 28 2 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X X 2 2 West Ella House DS0000019768.V259049.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 OP19 Regulation 12,13,16 Requirement Timescale for action 28/02/06 2. OP28 18 3. OP37 17,25 4. OP38 13(4)( c ) The registered person shall ensurethat the home is conducted so as to promote the health and welfare of service users. The leaking window to the rear of the building should be replaced. A minimum of 50 of trained 01/12/05 care staff(NVQ level 2 or equivalent)is achieved by 2005, excluding the registered manager. The registered person must keep 28/02/06 all records identified in schedule 3 and 4. Care plans must include photographs of service users. Copies of regulation 26 reports must be sent to CSCI. The registered person shall 14/12/05 ensure that unnecessary risks to the health and safety of service users are identified and so far as possible eliminated. Holding doors open by the use of unauthorised means must stop. Advice must be taken from the fire officer as to what devices can be used. The registered person shall inform the Commission in
DS0000019768.V259049.R01.S.doc Version 5.0 West Ella House Page 21 writing of the action taken to address this. 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 West Ella House DS0000019768.V259049.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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