CARE HOMES FOR OLDER PEOPLE
West Ella House 6 Church Lane Kirkella East Yorkshire HU10 7TG Lead Inspector
Sarah Urding Unannounced 25 August 2005 09:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. West Ella House 20050825 West Ella House IR J53 v246455 S19768 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service West Ella House Address 6 Church Lane Kirkella East Yorkshire HU10 7TG 01482 659403 01482 653995 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Kirkella Mansions Company Limited Maureen Tindall Care Home 25 Category(ies) of DE(E) Dementia - over 65 25 registration, with number OP Old age 25 of places West Ella House 20050825 West Ella House IR J53 v246455 S19768 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 26th January 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 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 20050825 West Ella House IR J53 v246455 S19768 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place over seven hours and was unannounced. The inspector looked round all parts of the building and a number of records were inspected. Thirteen residents and five members of staff were spoken to. What the service does well: What has improved since the last inspection? What they could do better:
The assessment of and care planning for residents is not as detailed as is required. The home does not evidence well that all the needs of residents are met in the areas of foot, dental and eye care. These are basic needs and the home must identify how these health care needs are to be met by staff. The medication system is not being operated in a way that ensures it is free from misuse. Controlled drugs are not being stored appropriately when
West Ella House 20050825 West Ella House IR J53 v246455 S19768 Stage 4.doc Version 1.40 Page 6 waiting to be returned to the chemist and recording of drugs does not always correspond with actual drugs held in stock. The manager must ensure that this system is safe. The recruitment of staff was not as rigorous as it should be. In some instances references for staff were missing. It is vital that the home secures all the necessary checks to ensure that the protection of service users is not compromised. Some maintenance issues were identified in the course of the inspection and the manager must ensure that these issues are addressed. These include the refitting of a loose carpet and the repair of a damp bath panel and leaking window. Also, in shared rooms service users toothbrushes must be stored in separate containers to ensure that there is no cross infection. 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 20050825 West Ella House IR J53 v246455 S19768 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection West Ella House 20050825 West Ella House IR J53 v246455 S19768 Stage 4.doc Version 1.40 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3, 6 Service users are well informed by the home’s statement of purpose and service user guide. The assessment that the home carries out on service users prior to admission is not comprehensive enough to ensure that all of their needs will be met. EVIDENCE: On admission the home provides comprehensive information to service users and their families about the facilities on offer so that they can make an informed choice about where to live. Some service users who had been in the home for a long time did not recall having seen the brochure about the home. When working with people with dementia and memory loss this is to be expected so it would be good practice if staff revisit this with them on a regular basis. A copy of the service user guide should be available to all service users in the home. The assessment of service users covers most aspects identified in standard 3.3. However, this does not include reference to how dental, foot and optical care needs will be met. In order to ensure that these basic needs are met for West Ella House 20050825 West Ella House IR J53 v246455 S19768 Stage 4.doc Version 1.40 Page 9 all service users, reference should be made to these aspects of care however routine. The home does not offer intermediate care to service users. West Ella House 20050825 West Ella House IR J53 v246455 S19768 Stage 4.doc Version 1.40 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10 Service users are well cared for and treated with respect but shortfalls in the assessment and medication system have the potential to place them at risk. EVIDENCE: Care plans are in place for all service users which identify how assessed needs are to be met by staff. These plans are reviewed regularly and clear in format. Service users are involved in the reviews of their care. Individual risk assessments based around identified need are in place. This protects service users from harm. Not all areas of care are identified in the care plans of service users. Dental and foot care needs are not addressed as a matter of course although it was clear from reading service users records that access to dental and chiropody services is made available. The home must address these shortfalls so that staff are clear about how to meet all aspects of care for service users. Service users spoken to were positive about all of their health care needs being met. Records inspected demonstrated that service users received appropriate health care based around their needs. Service users receive health care privately in their rooms and are able to register with a GP of their choice. West Ella House 20050825 West Ella House IR J53 v246455 S19768 Stage 4.doc Version 1.40 Page 11 The home has a comprehensive policy and procedure for dealing with medication. This is not always followed however. Some areas of current practice have the potential to place service users in a vulnerable position and leave the medication system open to misuse. The recording of controlled drugs held in the home was not accurately maintained. One record identified that there were seven tablets of Temazepam. In checking the medication eight tablets were in stock. Also controlled drugs had been inappropriately stored by the home for over a month whilst waiting to be returned to the chemist. This must be addressed so that service users are safeguarded. Service users were positive about the way in which staff look after them. They felt that their dignity was maintained at all times and that staff respected their privacy. This was observed during the inspection also. West Ella House 20050825 West Ella House IR J53 v246455 S19768 Stage 4.doc Version 1.40 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15 Social activities are well organised, creative and provide stimulation and interest for people living in the home. Meals are nutritious and balanced and offer a healthy and varied diet for service users. EVIDENCE: Service users lifestyle in the home satisfied their social, cultural religious and recreational needs. This was evidenced in care plans and in talking to service users. A range of weekly activities was offered in the home by an identified activities worker. However, Some service users spoken to did not know what activities were on offer. Staff should make available to service users a plan of activities for their reference. Religious needs are identified and met by the home. Service users are able to attend church services in the community. Service users were involved directly in making decisions through residents meetings. Service users are taken out by staff for walks on a regular basis. Contact with family and friends is promoted well by the home. Service users were positive about being able to see their friends and family when they wish. Service users are encouraged to maintain choice and control over their lives on a daily basis. Staff spoken to described how they ensure that service users are consulted with and empowered to make their own decisions. This ensures that service users maintain their independence for as long as possible and that staff are aware of treating people in a positive and inclusive manner.
West Ella House 20050825 West Ella House IR J53 v246455 S19768 Stage 4.doc Version 1.40 Page 13 A number of people in the home commented about the food and how good it was. One service user said, “It’s A1”. Menus were found to be well balanced and varied. Choice was offered at every meal. West Ella House 20050825 West Ella House IR J53 v246455 S19768 Stage 4.doc Version 1.40 Page 14 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 18 The regular reviewing of service users complaints ensures that they are confident that their issues will be listened to and acted upon. The lack of understanding for some staff about the vulnerable adults procedure does not ensure that people in the home are protected from abuse. EVIDENCE: Service users spoken to said that they had no complaints about the home but felt confident to raise issues of concern if they arose. Complaints are recorded in the diary and addressed by the manager. They are then reviewed at the end of every month as part of the quality assurance system and recorded appropriately. The home has a clear complaints procedure in place. The home has an appropriate policy in place for the protection of vulnerable adults. The local authority guidelines fro the protection of vulnerable adults are also in place. Staff are aware of these guidelines and receive training on them. Service users spoken to said that they felt safe when being looked after by staff. Not all staff demonstrated a clear understanding of how to deal with allegations of abuse. Training should be revisited on a regular basis to ensure that all staff are aware of how to deal with allegations. The uncertainty at the present time leaves service users in a vulnerable position. West Ella House 20050825 West Ella House IR J53 v246455 S19768 Stage 4.doc Version 1.40 Page 15 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 24, 25, 26 Service users live in a comfortable and clean environment that is well maintained. Some matters outstanding place the health and safety of service users at risk. EVIDENCE: The home is clean, presented well and is homely. A planned programme of maintenance is in place. Some areas of maintenance require attention so that the environment is a safe and comfortable place for service users. The carpet in room five is loose and requires refitting to prevent injury; a bath panel in the downstairs bathroom is damp. This must be looked at; two service users toothbrushes were being kept in the same cup in one of the shared rooms. This must be addressed so that cross infection does not occur; a window is leaking on the upstairs landing and on closer inspection the frame was found to be rotten. The manager is aware of this and there are plans for new windows to be fitted. This matter should be given priority. Service users bedrooms meet their needs and are individualised to taste. Service users are offered all of the required facilities on admission and are able
West Ella House 20050825 West Ella House IR J53 v246455 S19768 Stage 4.doc Version 1.40 Page 16 to choose whether they would like a key to their room. None of the current service users have requested this. Laundry facilities in the home are appropriate and meet the needs of the service users. Service users commented on the cleanliness of their clothes on the return from the laundry. West Ella House 20050825 West Ella House IR J53 v246455 S19768 Stage 4.doc Version 1.40 Page 17 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29, 30 Service users needs are met by the good level of staffing and training provided in the home. Service users safety is compromised by the lack of rigour involved in the recruitment process. EVIDENCE: The home is well staffed at all times. Three staff are on duty throughout the day supported by housekeepers, laundry assistances, an activities worker and a cook. Two staff are on duty at night. A senior member of staff is on duty at all times supported by a member of the management team. Recruitment practice in the home requires improvement in order to safeguard service users. CRB checks are in place prior to staff starting work. However two written references are not in place for all members of staff. This must be addressed with priority. Staff are trained appropriately and receive a thorough induction. Vulnerable adults training should be revisited on a regular basis as identified earlier in this report. West Ella House 20050825 West Ella House IR J53 v246455 S19768 Stage 4.doc Version 1.40 Page 18 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35, 37, 38 High levels of consultation and regular reviews by the manager ensure that service users are looked after in an environment that is both safe and inclusive. Some minor areas require attention in order to ensure that service users are safeguarded in all aspects of care. EVIDENCE: The home operates an effective quality assurance system that seeks the views of service users and staff on a regular basis. There is a monthly audit system in place that looks at key areas aimed at improving standards. This is good practice and meets regulation 26. However the registered provider is required to send a copy of this report to CSCI for information. This is not currently taking place. Service users are protected by the financial procedures of the home. The home does not act as appointee for any service users and looks after money
West Ella House 20050825 West Ella House IR J53 v246455 S19768 Stage 4.doc Version 1.40 Page 19 appropriately. Written records of all transactions are accurately maintained. 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 and as previously identified not all aspects of care are covered by the home’s assessment. Regulation 26 reports must also be compiled. The home operates in the best interests of the health and safety of service users and staff. All safety checks are carried out within the specified time frame and policies are in place for safe working practice. The emergency lighting check record was not available for inspection but the director assured the inspector that this is carried out regularly. All staff receive health and safety training. West Ella House 20050825 West Ella House IR J53 v246455 S19768 Stage 4.doc Version 1.40 Page 20 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 2 x x x x 3 3 2 STAFFING Standard No Score 27 4 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x 3 x 3 x 2 3 West Ella House 20050825 West Ella House IR J53 v246455 S19768 Stage 4.doc Version 1.40 Page 21 NO 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. 2. Standard 3 9 Regulation Requirement Timescale for action Sept 30th 2005 Immediate and ongoing 3. 19 4. 26 5. 6. 29 37 12, 13, 14 The assessment of service users must cover all aspects of standard 3.3. 12, 13 Controlled drugs must be stored appropriately at all times. An accurate record must be maintained for the administration of controlled drugs. 12, 13, 16 The maintenance issues identified in the report must be carried out. To include the refitting of the carpet in room 10; repair to leaking window and bath panel. 12, 13, 16 Procedures must be followed to control the spread of infection. Separate tooth brush holders must be provided for all sevrice users. 12, 18, 19 Two written references must be secured for all staff prior to starting work. 17, 26 The registered person must keep all records identified in schedule 3 and 4. To include photographs of service users. Copies of regulation 26 reports must be sent to CSCI. Oct 31st 2005 Immediate and ongoing Immediate and ongoing Oct 31st 2005 West Ella House 20050825 West Ella House IR J53 v246455 S19768 Stage 4.doc Version 1.40 Page 22 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. 3. Refer to Standard 1 12 18 Good Practice Recommendations Staff should ensure that all aservice users are familiar with the guide for the home. A reference copy should be made available to service users at all times. An activities plan should be available for service users reference. Vulnerable adults training should be revisited regularly with all staff. West Ella House 20050825 West Ella House IR J53 v246455 S19768 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection First Floor Unit 3 Hesslewood Country Office Park Ferriby Road Hessle East Yorkshire HU13 0QF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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