Care Home: Eaves Hall

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What the care home does well The way residents were admitted to the home made sure that the needs of people were understood so that a decision could be made about whether or not Eaves Hall was the right place for them to live. Residents felt well cared for in the home. All residents spoken with said they were well cared for. One resident said "you couldn`t wish for a better place" and another said "the staff are very good and look after me well". A recently admitted resident was very happy with everything in Eaves Hall and said she had settled well. A relative spoken with said he "couldn`t praise the staff highly enough" and that "they are professional". Another said that staff were always "caring and compassionate" Contact with friends and family was encouraged. Visitors appreciated this and were made to feel welcome in the home, which was seen as homely and friendly.Eaves Hall has always been well maintained and decorated with good quality furnishings. Residents appreciated this environment. There is a high standard of cleanliness in the home. One relative said that "I visit most days and it is always spotless". There were attractive gardens for the residents to enjoy in the warmer weather. Staff working in the home had been recruited in accordance with legal requirements and these thorough procedures helped to protect the residents from unsuitable staff. Staff were given good training opportunities to enable them to gain the right skills and knowledge for work with older people. Residents and relatives were regularly asked about their views on the home and this information was used to develop the services. The home was a safe place for residents and staff, with staff having appropriate health and safety training and there were measures to protect the residents from water that is too hot and from hot radiators. What has improved since the last inspection? Some legal requirements made at the last inspection had been met, for example there was more useful information written down about residents to help staff look after them. Also some aspects of medication management within the home had improved to ensure safer administration of medication to residents. Training for staff had further improved (see above), with more staff completing the right qualifications and training for working with older people so that they could look after them properly. What the care home could do better: Medication practices and procedures should be further improved especially making sure that all service users take their medication as prescribed unless there is a good reason for not doing so and which is explained in the records. More accurate records of medication could be better kept to help ensure that residents have the right medication and take it at the right time. When people apply to work in the care home more information about their previous work should be found out to help decide whether or not they are suitable. CARE HOMES FOR OLDER PEOPLE Eaves Hall Kiddrow Lane Burnley Lancashire BB12 6LH Lead Inspector Mrs Pat White Key Unannounced Inspection 10:00 7th November 2007 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 Eaves Hall DS0000009495.V346697.R02.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. Eaves Hall DS0000009495.V346697.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eaves Hall Address Kiddrow Lane Burnley Lancashire BB12 6LH 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) 01282 772413 01282 771149 Mrs Srebrenka Macintosh Mr Ian Keith Macintosh Mrs Lynn Elizabeth Kendall Care Home 15 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (1), Old age, of places not falling within any other category (14) Eaves Hall DS0000009495.V346697.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The service must, at all times, employ a suitably qualified and experienced manager who is registered with the Comission for Social Care Inspection. A maximum of 14 service users who fall into the category of OP (Older People) One named service user who falls into the category MD(E). When this person no longer resides in the home, the registered person will notify the Commission so that the registration can revert back to 15 OP. 8th February 2007 Date of last inspection Brief Description of the Service: Eaves Hall is registered to provide care and accommodation for 15 people of either sex over the age of 65. The building is of an older type on the outskirts of Burnley town centre. It is situated in its own private grounds that provide a pleasant area for residents to walk and sit. The home consists of two floors linked by a chair lift. There were 9 single rooms, 7 of which were under10 sq ms, and 3 shared rooms, one of which was slightly under 16 sq ms. The home had a variety of aids and equipment to assist residents with mobility problems. An experienced and qualified person managed the home. The home had a Statement of Purpose and a Service User Guide providing information about the care provided, the qualifications and experience of the owner and staff and the services residents can expect if they choose to live at the home. The weekly fees ranged from £345 - £387 and were inclusive of hairdressing, chiropody, newspapers and magazines and entertainment. Eaves Hall DS0000009495.V346697.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection site visit to Eaves Hall was carried out on the 7sth November 2007. The site visit was part of an inspection to determine an overall assessment on the quality of the services provided by the home. This included checking important areas of life in the home that should be checked against the National Minimum Standards for Older People, and checking the progress made on the matters that needed improving from the previous key inspection. The inspection included: talking to residents, touring the premises, observation of life in the home, looking at residents’ care records and other documents and discussion with some senior carers and the office manager. Six residents spoken with gave their views on the home. In addition survey questionnaires from the Commission were sent to residents, relatives, staff and health professionals asking them for their opinion of the home. All 15 residents, four relatives, and 2 members of staff returned these questionnaires. None of the visiting professionals contacted had returned a questionnaire at the time of writing this report. Some of the views of these people are included in the report. In addition the home provided the Commission with written information about the residents, staff and services provided, and some of this is also included in the report. What the service does well: The way residents were admitted to the home made sure that the needs of people were understood so that a decision could be made about whether or not Eaves Hall was the right place for them to live. Residents felt well cared for in the home. All residents spoken with said they were well cared for. One resident said “you couldn’t wish for a better place” and another said “the staff are very good and look after me well”. A recently admitted resident was very happy with everything in Eaves Hall and said she had settled well. A relative spoken with said he “couldn’t praise the staff highly enough” and that “they are professional”. Another said that staff were always “caring and compassionate” Contact with friends and family was encouraged. Visitors appreciated this and were made to feel welcome in the home, which was seen as homely and friendly. Eaves Hall DS0000009495.V346697.R02.S.doc Version 5.2 Page 6 Eaves Hall has always been well maintained and decorated with good quality furnishings. Residents appreciated this environment. There is a high standard of cleanliness in the home. One relative said that “I visit most days and it is always spotless”. There were attractive gardens for the residents to enjoy in the warmer weather. Staff working in the home had been recruited in accordance with legal requirements and these thorough procedures helped to protect the residents from unsuitable staff. Staff were given good training opportunities to enable them to gain the right skills and knowledge for work with older people. Residents and relatives were regularly asked about their views on the home and this information was used to develop the services. The home was a safe place for residents and staff, with staff having appropriate health and safety training and there were measures to protect the residents from water that is too hot and from hot radiators. What has improved since the last inspection? What they could do better: Medication practices and procedures should be further improved especially making sure that all service users take their medication as prescribed unless there is a good reason for not doing so and which is explained in the records. More accurate records of medication could be better kept to help ensure that residents have the right medication and take it at the right time. When people apply to work in the care home more information about their previous work should be found out to help decide whether or not they are suitable. Eaves Hall DS0000009495.V346697.R02.S.doc Version 5.2 Page 7 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. Eaves Hall DS0000009495.V346697.R02.S.doc Version 5.2 Page 8 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 Eaves Hall DS0000009495.V346697.R02.S.doc Version 5.2 Page 9 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): 1, 2, 3, 4 & 5. Standard 6 was not applicable Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s admission procedures, including written information about the home, pre admission assessments and prior visits by prospective residents and relatives to the home, helped to determine whether or not the home could meet people’s needs. Residents and relatives were confident that the home could meet their needs. EVIDENCE: The home had up to date written information about the home, the Statement of Purpose and the Service User Guide, and this provided useful information to residents and relatives. These documents were reviewed and updated regularly. The residents who completed survey questionnaires said that they had enough information prior to moving into the home and had received a contract. The relatives also in the questionnaires said that they had enough information to help them make decisions. Eaves Hall DS0000009495.V346697.R02.S.doc Version 5.2 Page 10 Records showed that an in house assessment was carried out prior to people being admitted to the home. Copies of the social workers’ assessments had been obtained for those residents admitted through “care management” arrangements. These provided more useful information. After admission the assessment was developed in more detail and a care plan was generated. The inspection indicated that residents and relatives were confident that Eaves Hall could meet residents’ needs. Residents and relatives were given the opportunity of visiting the home prior to making a decision about whether or not it was suitable, and the manager visited them in their place of residence when undertaking the pre admission assessment. Relatives and prospective residents could visit the home to help them make a decision about whether or not it was the right place to live. One resident stated that she had visited the home with her daughter and that they both liked the “feel and the friendliness of the place”. Another resident said he “couldn’t wish for a better place to live”. There was evidence that people’s individual needs were met and staff had training for example in dementia to help them look after people with memory loss and confusion. In the questionnaire surveys nine residents said they “always” received the care and support need and 6 said they “usually” did. The 4 relatives who completed the questionnaires said that the needs of their relative were “always” met and 3 said that the diverse needs of individuals were “always” met in the home and that people were supported to live the life they chose. However there was evidence through discussion and from a questionnaire that one resident might benefit from more equipment to assist her independence. This was subsequently discussed with the manager who agreed to address this matter. Eaves Hall DS0000009495.V346697.R02.S.doc Version 5.2 Page 11 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 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of the residents were met and in general the medication procedures and practices ensured the safe adminsitration of medication. The residents’ rights to privacy and dignity were upheld. EVIDENCE: The viewing of records showed that all residents had a written plan of care and that in most matters they were completed in sufficient detail to guide staff in caring for individuals. People’s preferred routines and likes and dislikes were recorded so that staff knew what was important to individuals. The care plans contained appropriate risk assessments, including one for the prevention of falls, the use of the stair lift and vulnerability to pressure areas. Some management/preventative measures for pressure areas were recorded on the care plans but on one viewed there was a lack of clarity about the intervention required and the involvement of the district nurse. Also for one resident there was no suitable written assessment of risk, or guidelines to staff for managing aggressive behaviour, such as throwing things. This was rectified subsequent to the site visit. Eaves Hall DS0000009495.V346697.R02.S.doc Version 5.2 Page 12 The care plans were being reviewed every few months, and there was evidence that residents, and their relatives, were involved in this process. There was also evidence that the care plans and risk assessments were updated when care needs changed. The inspection methods including the records viewed, resident and relative surveys showed that residents had all medical and nursing attention they needed, including psychological care. Good nutritional assessments were completed after admission that identified food likes and dislikes and any problems with eating. These risk assessments were reviewed. Continence requirements were also recorded. The residents’ questionnaire survey indicated that in general they were satisfied with the care at Eaves Hall. Nine said they “always” had the care and support they needed and 6 said “usually”. One resident said “the staff are busy people but they come when they can” and one resident was concerned that she sometimes had to wait too long to be assisted to the toilet. Ten said they “always” get medical attention when needed and 5 said “usually”. In the home’s own quality survey the General Practitioners and District Nurse who completed questionnaires were satisfied with the home’s management of residents’ health care. All the relatives who completed the questionnaire surveys and the one who was spoken with at the time of the site visit stated that they were satisfied with the care given to the residents. One said “ Staff are always available”, and someone else said that due to the care and professionalism of the staff his mother had improved since going to live at Eaves Hall Eaves Hall had policies and procedures to assist staff to manage and administer residents’ medication safely, and some areas had improved according to legal requirements made at the previous inspection. There were some areas of good practice, including the staff training for those administering medication, checking the prescriptions prior to dispensing, the recording of the criteria for “when required medication” (PRN) should be given and the management and administration of controlled drugs. However practices could be further improved to safeguard residents’ health. The records of medication coming into the home were not recorded correctly. They were recorded monthly on the Medication Administration Records (MARs). Records not made at the time of receipt means that mistakes are less likely to be identified and this was rectified immediately following the site visit. On the Mars viewed and the medication checked there were two occasions when medication that had not been given to two different residents. The evening medication of one resident had not been given but had been signed as given. On the morning before the site visit one resident had not taken her medication. The MAR for one of the tablets had been left blank, but had been Eaves Hall DS0000009495.V346697.R02.S.doc Version 5.2 Page 13 signed as given for two other medications. Incorrect recording of, and not signing, the MARs could be partly as a result of the MARs not being taken to the residents with the medication. Staff appeared aware of the importance of respecting residents’ privacy and dignity. Staff were observed at the site visit treating people respectfully. Residents spoken with said staff treated them properly. One relative described an incident that he had witnessed when he was very impressed with the care staff’s attitude and how the resident’s dignity was upheld. Eaves Hall DS0000009495.V346697.R02.S.doc Version 5.2 Page 14 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 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Routines were flexible enough to suit individual preferences. There were suitable activities for some of the residents. The visiting arrangements encouraged and enabled residents to maintain contact with family, friends and the wider community. Residents had certain choices in their everyday lives, and the meals served were healthy and usually suited their preferences. EVIDENCE: Discussion with residents indicated that routines were flexible enough to suit individual needs and preferences. “Preferred routines” were recorded on the care plans and covered such things as preferred rising and retiring times and food likes and dislikes. Residents confirmed that they could get up and go to bed when they wanted. Residents’ interests and hobbies were recorded on the care plans. Some residents spoken with confirmed that there were some activities such as bingo and parties to celebrate residents’ birthdays. In the resident questionnaire survey 6 said that there were “always” suitable activities, 7 said “usually” and 2 said “sometimes”. There had been no trips out since the previous inspection but residents were encouraged to go out with relatives if possible. Residents were enabled to follow their religious practice and church ministers visited the home. The information supplied to the Eaves Hall DS0000009495.V346697.R02.S.doc Version 5.2 Page 15 Commission prior to the inspection, and the records kept of activities, indicated that various activities were organised such as, dominos, skittles, “cinema afternoons” and birthday parties. Contact with families, friends and the community was encouraged. Relatives felt the home was a friendly and welcoming home. The relatives who completed the questionnaires said felt that there was good communication between the home and them –selves. Contact with the local community was encouraged, and church ministers visit and entertainers visited the home. Residents confirmed that they had some choice in certain matters. Residents’ meetings were held, and people were invited to discuss choices about the food served, and the leisure activities, either at these meetings or as individuals with their key worker. There was information about advocacy in the home. Residents’ bedrooms were personalised with small items of furniture and furnishings and residents could manage their finances with help from relatives if needed. The meals served appeared to suit the tastes of the majority of the residents. Menus were planned frequently depending on residents known likes and dislikes and were mainly traditionally English dishes. The food served appeared healthy and nutritious. Three full meals were served each day, with the main, two course meal served at lunch - time. There was no choice of main meal but residents confirmed that if they did not like what was being served they could have something else. Drinks and snacks were served throughout the day and fresh fruit was available. Different sorts of diet were catered for, such as soft and blended food and food for those with diabetes. Dietary requirements were recorded on the care plan and linked to the nutrition assessments. One resident spoken with said she liked the food and that on the whole it was good - “I never leave anything”. Another resident said, “the food is very good”. In the residents’ questionnaire survey five said they “always” liked the meals, 9 said “usually” and one said “sometimes”. One comment made in the questionnaires was that “I eat all my meals but I long for something different”. Eaves Hall DS0000009495.V346697.R02.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 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and relatives knew who to speak to if they had any concerns. People felt confident that their concerns would be taken seriously. However the home’s, procedures and practices were in accordance with Government guidance and would help to protection residents from abuse. EVIDENCE: The home had a complaints procedure which was in the Service User Guide and accessible to residents and relatives. In the questionnaire survey 14 residents said that they knew how to make a complaint and who to speak to if they were not happy with anything. One said they did not. Two relatives who completed a questionnaire stated that they were aware of this procedure and knew how to make a complaint. One said that they had never had to make a complaint and a relative spoken with at the time of the site visit said that there had been “no concerns in two and a half years”. There were no recorded complaints since the previous inspection and none had been made to the Commission about the home. Residents spoken with at the time of the inspection stated they had no complaints and knew who to speak to if they were not happy with any aspect of their care. Since the previous inspection the policies and procedures to protect people, and guide staff in the correct procedures, had been developed in accordance with Government guidelines. Staff had also undertaken training in this matter, which should further help protect residents from abuse. However subsequent to the site visit some information was received by the Commission in a survey Eaves Hall DS0000009495.V346697.R02.S.doc Version 5.2 Page 17 questionnaire which was passed to Social Services under the “Safeguarding Adults” procedures. The allegations were investigated according to Government guidelines, and were not substantiated. Therefore no further action needed to be taken. Eaves Hall DS0000009495.V346697.R02.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, 24, 25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Eaves Hall provided pleasant, comfortable, well – maintained, clean and safe, accommodation that suited the residents’ needs. Refurbishment and renewal tasks were carried out in a planned and prioritised way. EVIDENCE: The tour of the premises confirmed that the home was well maintained and furnished and decorated to a high standard. It provided safe and pleasant accommodation. Furnishings and carpets were of a good quality, comfortable and homely. Audits of the property were carried out regularly to ensure that renewals and repairs were carried out rapidly. The grounds were accessible to residents in wheelchairs and were a pleasant area in which residents could sit and walk. According to the information supplied to the Commission prior the site visit routine refurbishment had carried on but there had been no major changes to the premises. A fire safety inspection of the premises had been Eaves Hall DS0000009495.V346697.R02.S.doc Version 5.2 Page 19 undertaken early in 2006 and subsequent action ensured that the home met the fire regulations. Communal space consisted of 2 lounge / dining areas and a sitting area between the two. The home was bright, and lighting in the communal areas facilitated reading and other activities. The bedrooms were pleasantly decorated and furnished and personalised with small personal possessions. The residents spoken with stated that they were satisfied with their private accommodation, though some bedrooms were smaller than the recommended National Minimum Standards for older people, and some were shared. Also some bedroom doors still did not have suitable locks to enhance the privacy of the residents. The home was comfortably warm on the day of the inspection and the central heating radiators were fitted with safety guards. Hot water outlets were fitted with pre set valves to ensure that residents were protected from the hazards of water that is too hot. The water system was safe from the spread of Legionella. All parts of the home were clean and fresh with no offensive odours. The laundry procedures ensured that the residents’ standards with respect to personal dress were maintained. All residents who completed the questionnaire survey stated that the home was “always” fresh and clean. Relatives also confirmed that this was the case. One said, “I visit the home most days and it is always fresh and clean”. Eaves Hall DS0000009495.V346697.R02.S.doc Version 5.2 Page 20 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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had sufficient staff on duty to meet the needs of the residents. The staff - training programme was being developed according to the needs of the residents and staff to ensure that staff were qualified and competent. Staff recruitment procedures helped to protect residents from unsuitable staff. EVIDENCE: The rotas supplied and observations on the day of the inspection showed that there were sufficient members of staff on duty to meet the needs of the residents and enable good standards of cleanliness and hygiene to be maintained. All the relatives who completed questionnaires said they felt the staff had the right skills and experience to look after older people and one relative spoken with thought the staff were very “professional”. Each resident had a key worker that helped communication with residents and the understanding of their needs. The information supplied by the home to the Commission stated that 10/17 care staff, that is 59 , were qualified to at least NVQ level 2, and that others were undertaking the training. Staff members spoken with confirmed that they had completed and were completing, NVQ courses. Records showed that staff had undertaken a wide range of other courses such as dementia, skin care and challenging behaviour, which assisted them to understand and meet the needs of the people they look after. In addition all Eaves Hall DS0000009495.V346697.R02.S.doc Version 5.2 Page 21 staff had training in moving and handling and fire safety. All those involved in food preparation had training in food hygiene training. The records of two members of staff, recruited since the previous inspection, were looked at. These records, and discussion with the office manager showed that thorough recruitment procedures were followed which helped to protect residents from unsuitable staff. Staff did not start work until the Protection of Vulnerable Adults check and two satisfactory employment based references had been obtained. Records kept and discussion with staff showed that on commencing work new staff carried out suitable Induction training to further prepare them for their work. However for one member of staff whose records were viewed there was not a full employment history so it was unclear what most of her previous work experience had been. . Eaves Hall DS0000009495.V346697.R02.S.doc Version 5.2 Page 22 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 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was well managed by an experienced qualified manager and a stable staff team. The home had quality assurance measures that took into account the views of residents and relatives. The health and safety of the residents and staff were promoted. EVIDENCE: The current registered manager is qualified, experienced and competent to run the home, with over 13 years experience in managing a care home. She always demonstrates a clear commitment to Eaves Hall. Mrs Kendall has successfully completed NVQ level 4 in “Management” and “Care” and had attended numerous other courses relevant to her post, such as looking after people with dementia, risk assessments and palliative care. Eaves Hall DS0000009495.V346697.R02.S.doc Version 5.2 Page 23 There were clear lines of accountability within the home including regular unannounced monitoring visits to the home by the registered provider under Regulation 26 of the Care Homes Regulations. The home carried out annual quality monitoring exercises involving residents’ questionnaires, the views of relatives and visiting professionals. The last survey showed that residents were satisfied with life in the home. The visiting professionals also indicated satisfaction in the way the residents’ health care was managed (see “Health and Personal Care”). There were residents meetings about four times a year to try and involve residents in the running of the home. There was no residents’ money kept in the home, and the record of the fees charged and paid indicated that fees were managed efficiently and safely in the home. Appropriate (computer) records were kept of fees charged and paid, and the respective contribution of residents and Social Services. The home was a safe place for residents and staff to live and work. The information about the home supplied to the Commission prior to the inspection indicated that all maintenance and servicing of installations, appliances and equipment had been carried out appropriately. Residents were also protected from the hazards of hot water and hot surface temperatures. Nearly all staff had undertaken appropriate health and safety training, such as first aid training, fire safety moving and handling, infection control and food hygiene. The fire precautions were satisfactory and all staff had attended an external fire safety course. There had been a fire safety inspection on in Feb 2006. Some recommendations had been complied with, and the fire risk assessment was satisfactory. Records showed that the fire equipment was tested and maintained appropriately and that fire drills were held at appropriate intervals. Accidents were recorded appropriately according to Data Protection so residents’ rights to confidentiality were respected. However the Commission was not being notified of all “notifiable incidents”, for example accidents resulting in medical intervention, so the Commission could not monitor accidents in the home. Eaves Hall DS0000009495.V346697.R02.S.doc Version 5.2 Page 24 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 x x x 2 3 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 2 Eaves Hall DS0000009495.V346697.R02.S.doc Version 5.2 Page 25 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 OP9 Regulation 13 (2) Requirement All medication must be given according to the instructions and not omitted, unless there is a good reason for not doing and of which there is a written explanation. Records of medicines administered to residents must be accurate to show that medicines are being given to residents correctly Timescale for action 30/11/07 2. OP9 17(1)(a) Schedule 3 3(i) 30/11/07 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 OP7 Good Practice Recommendations Information about pressure areas and the intervention should be clear so that staff have the correct information to assist them in their work. The records of medication coming into the home should always be made at the time they are received and not in advance on receipt of the monthly Medication Adminstration Records. DS0000009495.V346697.R02.S.doc Version 5.2 Page 26 OP9 Eaves Hall 3. 4. OP9 OP24 5. 6. OP29 OP38 The Medication Administration Records should be taken with the medication to residents and signed at the time of administration. It is recommended that a further review is undertaken regarding the fitting of suitable locks to the bedroom doors to establish which residents would like locks in order to enhance their privacy if they wish. Applicants’ full employment history should always be documented and any gaps in employment should be fully explored and also documented. The Commission should be notified of all incidents/ accidents affecting residents that result in medical intervention. Eaves Hall DS0000009495.V346697.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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. Extracts may not be used or reproduced without the express permission of CSCI Eaves Hall DS0000009495.V346697.R02.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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