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Care Home: Emberbrook Care Home

  • 16 Raphael Drive Thames Ditton Surrey KT7 0BL
  • Tel: 02083983300
  • Fax: 02083983302

Emberbrook Care Centre is a purpose built care home providing nursing care predominately for older people and is operated by Four Seasons Health Care. The Centre has two units specialising in dementia care and a limited number of places in other units for service users from the age of 40 years. Service provision affords permanent and respite placements. The Centre is a two-storey, detached building located in a small, exclusive residential development adjacent to a medical centre. There are local shops and amenities nearby in Thames Ditton village. Living accommodation at the centre is arranged in four wings. Each has all single en-suite bedrooms, kitchenettes, sitting rooms, separate dining rooms and assisted bathing and toilet facilities. All areas are wheelchair accessible. The dementia care units are located on the first floor accessible by two passenger lifts. They share a suitably equipped sensory room. Each living unit has its own dedicated staff group and senior sister or charge nurse responsible for directing and supervising care delivery. Emberbrook Care Centre has a welcoming reception area, hairdressing and office facilities and car park. There is a small-enclosed garden with a furnished patio, aviary and water feature. The weekly fees for self-funding residents range from £920 and £1020 depending on nursing care need.

  • Latitude: 51.384998321533
    Longitude: -0.33599999547005
  • Manager: Rosalyn Wells
  • Price p/w: £970
  • UK
  • Total Capacity: 68
  • Type: Care home with nursing
  • Provider: Four Seasons (No 10) Limited
  • Ownership: Private
  • Care Home ID: 6064
Residents Needs:
Old age, not falling within any other category, mental health, excluding learning disability or dementia, Dementia, Physical disability

Previous Inspections

This may not be the latest inspection for this service as we are having techinical problems updating from CQC - please check directly on the regulators website for the most recent report; bestcarehome hopes to be back to regular updates shortly.

For extracts, read the latest CQC inspection for Emberbrook Care Home.

CARE HOMES FOR OLDER PEOPLE Emberbrook Care Home 16 Raphael Drive Thames Ditton Surrey KT7 0BL Lead Inspector Damian Griffiths Unannounced Inspection 30th January 2008 10:00 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 Emberbrook Care Home DS0000068324.V355847.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. Emberbrook Care Home DS0000068324.V355847.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Emberbrook Care Home Address 16 Raphael Drive Thames Ditton Surrey KT7 0BL 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) 020 8398 3300 020 8398 3302 emberbrook@fshc.co.uk Four Seasons (No 10) Limited Rosalyn Wells Care Home 68 Category(ies) of Dementia (44), Dementia - over 65 years of age registration, with number (2), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (30), Old age, not falling within any other category (14), Physical disability (50), Physical disability over 65 years of age (2), Sensory Impairment over 65 years of age (4) Emberbrook Care Home DS0000068324.V355847.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to 10 beds may be used for intensive rehabilitation for those aged 40 years and upwards 30th April 2007 Date of last inspection Brief Description of the Service: Emberbrook Care Centre is a purpose built care home providing nursing care predominately for older people and is operated by Four Seasons Health Care. The Centre has two units specialising in dementia care and a limited number of places in other units for service users from the age of 40 years. Service provision affords permanent and respite placements. The Centre is a two-storey, detached building located in a small, exclusive residential development adjacent to a medical centre. There are local shops and amenities nearby in Thames Ditton village. Living accommodation at the centre is arranged in four wings. Each has all single en-suite bedrooms, kitchenettes, sitting rooms, separate dining rooms and assisted bathing and toilet facilities. All areas are wheelchair accessible. The dementia care units are located on the first floor accessible by two passenger lifts. They share a suitably equipped sensory room. Each living unit has its own dedicated staff group and senior sister or charge nurse responsible for directing and supervising care delivery. Emberbrook Care Centre has a welcoming reception area, hairdressing and office facilities and car park. There is a small-enclosed garden with a furnished patio, aviary and water feature. The weekly fees for self-funding residents range from £920 and £1020 depending on nursing care need. Emberbrook Care Home DS0000068324.V355847.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 2 star. This means the people who use this service experience, good, quality outcomes. The inspection of Emberbrook Care Home took seven and a half hours beginning at 10.00am and ending at 17:30. Mr Damian Griffiths Regulation Inspector completed the visit. The Registered Manager, Ms Rosalyn Wells, representing the establishment, was present throughout the inspection. This key inspection report takes into account information from the Annual Quality Assurance Assessment (AQAA) provided by the agency in November 2007, samples from a number of service user files, staff personnel files, staff supervision records, staff training, medication administration and daily records. Observation of staff practice, equality and diversity issues and feedback from CSCI survey’s completed by service users, relatives and care workers have also been included in this report. The inspector would like to thank service users, their friends and relatives and staff at ‘Emberbrook’ for their time, assistance and hospitality. Comments taken from CSCI surveys, comments received during the inspection and ‘Annual Quality Assurance Assessment’ are in italics and some words have been changed in respect of confidentiality and are featured within (brackets) What the service does well: Prospective residents their relatives received a welcome pack about the home and a care needs assessment prior to moving into the home that ensured that their care needs could be met and residents benefited from care plans containing a comprehensive account of their healthcare needs and correct daily medication requirements. Feedback from resident’s relatives and friends during the inspection and completed CSCI surveys concluded that home provided a good environment for residents, other comments received; I am satisfied that my husband is being cared for sympathetically and in a professional way. Good nursing and attention for my wife. Emberbrook Care Home DS0000068324.V355847.R01.S.doc Version 5.2 Page 6 The registered manager was approachable operated an open door policy and staff consulted felt supported. Comments received from care staff completing the CSCI survey included; I am happy working in Emberbrook care home come and I enjoy helping people. And: The registered manager and kitchen manager have created a nice friendly and understanding atmosphere in a care home. The home had invested in ‘Assisted technology’ such as pressure pads situated inconspicuously in the rooms of residents vulnerable to falls ensured that staff were appropriately warned by the safety alarm. The home provided residents with the opportunity to hold residents meetings and residents; advocates and relatives had the opportunity to discuss home issues at social functions arranged by the home. Health and safety at home was actively promoted and the local authority had presented awards such as Young at Heart for nutritional food and The Gold Standard award. What has improved since the last inspection? What they could do better: The home was required to provide documented evidence, such as a company stamp or signature of a recognised collector of the disposal service used to collect the homes unused medication and that the details correspond with the last collection record of drugs disposed and evidence of certifiable training achievements and progress of NVQ attainments that was not provided in the Annual Quality Assurance Assessment (AQAA) to ensure that at all times suitably qualified competent and experienced persons are working at the care home in such numbers to ensure the health and welfare of the residents Four good practice recommendations were made. These were that the home ensures that all residents and relatives receive a ‘Welcome pack’ as this was not always clearly recorded. That the home review the overall contend of the resident’s files and; show the residents level of participation in the care review notes, ensure hand written notes are readable, daily diaries show evidence of the assessed care needs being met, ensure appropriate documentation is contained and ensure that index systems are consistent. Emberbrook Care Home DS0000068324.V355847.R01.S.doc Version 5.2 Page 7 That the registered manager discusses good staff practice when conducting face-to-face staff supervision relating to residents choices and arrange more training relating to dementia care needs. That the home provides the CSCI and residents with details of the outcome of the homes quality audit when completed. 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. Emberbrook Care Home DS0000068324.V355847.R01.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 Emberbrook Care Home DS0000068324.V355847.R01.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): Standards 1,3 and 6 were inspected and the quality in this outcome area is good. Prospective residents to the home received adequate information and a care needs assessment prior to moving into the home that ensured they received appropriate care support. The home does not support people for intermediate care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents consulted felt they had enough information about the home before the moved in although many residents referred to their relatives who had arranged the move on their behalf. The admission checklist did not always indicate whether the resident received a welcome back it is recommended that this is checked. A relative completing the CSCI survey confirmed that she had to rely on: information on the computer (website). Emberbrook Care Home DS0000068324.V355847.R01.S.doc Version 5.2 Page 10 Five residents files were inspected including files of new residents to the home. Each file was designed to contain a complete record of the residents’ documented needs including full assessment of care need and to a lesser extent social care need prior to entering the home. Please refer to the recommendations section of this report. Emberbrook Care Home DS0000068324.V355847.R01.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): Standards 7,8,9 and 10 were inspected and the quality in this outcome area is good. Residents benefited from care plans containing a comprehensive account of their healthcare needs and the attention to their correct daily medication requirements that ensured care needs were being met. Staff supervision and training would enhance and refresh care staff relationships with residents with dementia care needs by promoting staff confidence and experience. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Five residents care plans were inspected for evidence of how residents health and social care needs were being provided and the methods of recording, monitoring and reviewing were in place to ensure all areas of life at the home met the residents individual assessed care needs. Care plans were contained in a ring binder file with index section relating to the area of care need. All details of the resident were located in the one file so that information was easier to locate. Residents were involved with the Emberbrook Care Home DS0000068324.V355847.R01.S.doc Version 5.2 Page 12 reviewing of their care and some care plans showed evidence of resident’s signatures or that of their relative’s involvement, although, many of the residents consulted on the day of the inspection were not really interested in their care plans and in some cases were unaware, all the care plans were upto-date. Care plans contained a range of areas relevant to meeting the residents assessed care needs including; a key worker diary and communication record, multi-disciplinary team communication, a well being profile and social activities list however the care plan document often lacked any details of the resident’s social interests, hobbies, likes and dislikes. Daily records such as the ‘communication record’ were in place and recorded the resident’s activities for example; went out for a walk, to the pub and met daughter, however one ‘key worker diary’ contained no less than thirteen entries stating only that the resident; slept well last night. The home employs an ‘activities co-ordinator’, there was a weekly activities list posted on the residential units and a brief newsletter produced. Residents consulted on the day of the inspection stated that they would like more activities at the home. It was recommended that the home review the overall contend of the resident’s files and; show the residents level of participation in the care review notes, ensure hand written notes are readable, daily diaries show evidence of the assessed care needs being met, ensure appropriate documentation is completed and ensure that index systems are consistent. Health care needs of the residents were predominately catered for by qualified nursing staff for example; in areas such as pressure sore treatment and falls there was evidence of multi-disciplinary working with other healthcare practitioners such as; GP’s, Tissue viability care and the local ‘falls team’. Nursing staff that distributed resident’s daily medication ensured accesses to daily medication was provided as prescribed by the GP. Medication administration records correctly recorded the daily distribution of medication and detailed the prescribed dosage and the nurse who was administered it. Controlled drugs were stored appropriately in a separate metal cabinet secured to a firm surface. Medication no longer required or spoilt was stored in appropriate containers; the remains of destroyed controlled drugs were stored in appropriate sealed containers. All records of medication being disposed was in order however it was not clear how the collection of waste medication was being recorded for example in a smaller home the pharmacy receiving the medication would stamp the returns book. The overall efficiency of the storage and distribution of daily-prescribed medication was greatly enhanced by the staff being able to handle the medication in a quiet and secured purpose built room. Emberbrook Care Home DS0000068324.V355847.R01.S.doc Version 5.2 Page 13 It is required that the home provide documented evidence, such as a company stamp or signature of a recognised collector of the disposal service used to collect the homes unused medication and that the details correspond with the last ‘collection-record’ of the drugs disposed. Residents were well cared for nicely dressed in the clothes of their choice and staff did their best to make sure residents were supplied with tea and coffee and answered residents personal ‘room alarms’ promptly, however, one care staff member was observed not responding in an appropriate way to a resident who was answering a question they had asked resulting in the overall impression that the staff member was patronising and not respecting the residents choices. The staff member was assisting another resident at the time. It was noted that the staff member did have the residents best interests at heart therefore it was recommended that the manager discuss staff practice relating to equality and diversity issues when conducting face to face staff supervision and training. Residents and relatives completing the CSCI surveys were confident of the homes commitment in ensuring equality and diversity was respected. Please refer to the recommendations and requirements section of this report. Emberbrook Care Home DS0000068324.V355847.R01.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): Standards 12,13,14 and 15 were inspected and the quality in this outcome area is good. Residents had regular social activities that were held at the home but more individual focused activities would benefit residents with dementia care needs. Service users are supported and encouraged to maintain contact with family and friends and meals were well balanced and varied with individual choices and preferences as well as special dietary needs being catered for. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As a care home strongly geared up for nursing care the manager admits to the need for more emphasise and focus on the individual social care needs of the residents. To this end staff have recently completed training with a recognized body specialising in the promotion of individualised and group activities for residents with especial regard to dementia care. Staff completing the CSCI survey commented: Residents really enjoy trips out and it maybe a good idea to arrange trips out more often than once a month. The majority of residents were white and English however residents whose first language was not English could converse with staff that spoke a number of different languages. The home’s policy was to respect all religions and Emberbrook Care Home DS0000068324.V355847.R01.S.doc Version 5.2 Page 15 seek to ensure that residents’ diverse needs would be supported. Residents attending church found that they could not hear and that the churches were cold and preferred to attend the services at home that are ‘multi-faith’ services. Staff, residents and relatives completing the CSCI surveys on the day of the inspection concluded that they had no concerns relating to cultural and diversity issues, however, care staff need to receive regular disability awareness training referred to in the previous section and paragraph four. The balance between residents and community was good and residents, mostly with confusion, physical disability and dementia preferred receiving services and activities at home for example the hairdresser was at work with a resident on the day of the inspection. The home encouraged family and friends to visit the home without appointment and this was observed during the inspection. The inspector was able to meet visitors to the home and discuss any reservations or compliments about the home. Comments received from relatives completing the CSCI survey included: I am very satisfied with the standard of care and They provide a caring service. Weekly menus were available and displayed in each section of the home. Staff consulted residents daily about what they would like to eat and residents had the opportunity of choosing a different meal. The inspector joined residents for dinner and was able to consult and observe staff practice and the quality of the food being presented. Meals were attractively presented and residents looked forward to enjoyed their meal however one resident who clearly stated he did not want his meal was ignored by staff who stated that they were concerned about his weight. The resident had clearly made a decision and was exercising his choice that he did not want it. Some residents consulted found it difficult to consider what meals they liked at the beginning of the day and agreed that they would find it more helpful if the home could provide a collection of photographs of all of the chefs meals to ensure that residents received an informed choice whenever possible. This was discussed with the manager who agreed that it would be helpful to implement this for residents with memory and dementia care needs and will apply to the organisation for a digital camera to begin this project. The home had received awards for food hygiene and food quality from the local authority. Emberbrook Care Home DS0000068324.V355847.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): Standards 16 and 18 were inspected and the quality in this outcome area is good. The home had produced a clear and accessible complaint procedure and ensured that safeguarding practice was followed to promote the health and safety of the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s complaints procedure had been placed in the entrance lobby in an attractive frame near the signing in book that encouraged all visitors to sign in. Residents and their relatives completing the CSCI survey all knew how to make a complaint and one commented; Information (was) given at the time of admittance. Regular social events organised at the home as well as residents meetings also give residents and their relatives the opportunity for concerns to be aired. There had been no complaints about the home received by CSCI or reported during the inspection. There had been two reported safeguarding cases since the last inspection involving staff and residents at the home. Both had been thoroughly investigated by the home and the local Social Care Team. The home had followed the guidelines as set out by the Surrey multi-disciplinary agency procedures and risk assessment monitoring put in place as required. Staff had access to whistelblowing procedure and in-house training. Emberbrook Care Home DS0000068324.V355847.R01.S.doc Version 5.2 Page 17 Call systems were linked from residents’ rooms to a central nursing station to ensure that the staff could attend residents without delay. The home had invested in ‘Assisted technology’ such as pressure pads situated inconspicuously in the rooms of residents vulnerable to falls ensured that staff were appropriately warned by the safety alarm. Emberbrook Care Home DS0000068324.V355847.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): Standards 19 and 26 were inspected and the quality in this outcome area is good. Residents and staff enjoyed in living and working in a homely, clean and pleasant environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home presented a welcoming aspect to residents and visitors who were encouraged to follow fire safety regulations by signing themselves into the visitors book that was positioned in a space that had been thoughtfully designed for ease of use, the visitor was able to stand comfortably and sign in. The entrance lobby was welcoming, clean and airy and fresh flowers were visible throughout the home. Emberbrook Care Home DS0000068324.V355847.R01.S.doc Version 5.2 Page 19 The inspector met residents and domestic staff whilst conducting a tour of the premises. Communal areas such as lounges dining areas and bathrooms were clean and tidy, however, some work was required in the bathroom areas due to the damp environment as mould was apparent. Storage areas for equipment such as hoists could be found throughout the home and special rooms were in use for medication storage and preparation for administration. Staff had use of their own rooms and separate bathrooms and rest rooms. Overall attention was required to rectify general wear and tear that was apparent in bathrooms store rooms and places of general use. There were no complaints about the condition of the home and residents and staff agreed that the home was a nice working environment. The registered manager was confident that a rolling programme of repairs and decoration would be implemented. Staff using sluice rooms had access to proper washing facilities and rooms were kept reasonably clean. The laundry room and area was very busy and well organised. The housekeeper in charge was aware of the importance of residents receiving the correct laundered clothes and had ensured a workable system was in place and that hygiene and infection control measures practiced. A resident completing the CSCI survey commented; my mother is always dressed well. Emberbrook Care Home DS0000068324.V355847.R01.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): Standards 27,28,29 and 30 were inspected and the quality in this outcome area is adequate. Care workers and nursing staff met the immediate healthcare needs of residents as assessed but required more training to ensure ‘resident-focused’ activity plans were implemented. Certification of training was not in evidence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four staff files where inspected for details of robust recruitment procedures, staff qualifications and skills relevant to the residents in their care. The skill mix of staff on duty on the day of the inspection matched the care needs of residents, but as stated on page fifteen of this report more training and daily recording of individual residents social activity needs was required. Generally, staff were observed working sensitively with residents requiring dementia care and assisting with personal care needs without fuss. Some care staff had received training from a nationally recognised training body and one commented in the CSCI survey stating: Staff will be stimulated to do more activities with the residents, as I have learned, activities are very important and essential to anybody, it helps exercise the body and mind and keeps people from becoming depressed. Emberbrook Care Home DS0000068324.V355847.R01.S.doc Version 5.2 Page 21 Other areas of training included; first aid, safe manual handling, safeguarding residence, infection control food handling. Staff and residents were consulted throughout the inspection and it was clear that staff understood what their care responsibilities involved. Some care staff were studying to achieve their national vocational qualifications (NVQ) however figures were not available from the home relating to staff attainments of this award. Staff files where inspected for details of good recruitment practice. All files had the required documentation available for inspection such as criminal record checks and job references. New staff files were inspected and these contain the necessary documentation and showed evidence of induction training. Staff received the bulk of their training from qualified nursing care staff, however, there was no evidence of whether these members of staff had themselves received any form of ‘Train-the-Trainer’ input as required to ensure consistency of training. A reputable company had completed staff training in the area of safe administration of medication; however, there was no certification in evidence. The home is required to provide evidence of certifiable training achievements and progress of NVQ attainments that was not provided in the Annual Quality Assurance Assessment (AQAA). Care staff completing the CSCI survey commented; we have lots of training that corresponds with our job I have just finished my NVQ. And;On every shift there is one more experienced staff with a very good knowledge who I can ask about the needs of our residents. A relative completing the CSCI survey commented on whether staff had the right skills and experience to look after his relative he stated; from my observations, yes. Please see the requirements section of this report. Emberbrook Care Home DS0000068324.V355847.R01.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): Standards 31,33,35 and 38 were inspected and the quality in this outcome area is good. The registered manager was well qualified, experienced, aware of strengths and weaknesses of the service and was committed to seeking the views of relatives and people involved with the home to ensure that the continuing quality of care met the national minimum standards. The health, safety and welfare of residents were promoted and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager was approachable and supported an open door policy and staff consulted felt supported. Comments received from care staff completing the CSCI survey; I know and understand (that) management and Emberbrook Care Home DS0000068324.V355847.R01.S.doc Version 5.2 Page 23 staff are not only concerned about the business but above all the residents welfare. And: The registered manager and kitchen manager have created a nice friendly and understanding atmosphere in a care home. As mentioned in previous sections throughout the report the manager’s attention was required in the following areas; The content and condition of the resident’s files, The home review the overall contend of the resident’s files and; show the residents level of participation in the care review notes, ensure hand written notes are readable, daily diaries show evidence of the assessed care needs being met, ensure appropriate documentation is contained and ensure that index systems are consistent. Monitoring and action to improve and refresh care staff attitudes, training and practice relating to equality and diversity issues. Provide evidence of certificated training including attainment of ‘Train the Trainer’ or similar status. Evidence that medication/drug disposed are appropriately collected and legitimately recorded by a reputable collection service. Feedback from resident’s relatives and friends during the inspection and comments received in the CSCI surveys concluded that home provided a good environment for staff, residents, friends and relatives. Other comments received; I am satisfied that my (husband) is being cared for sympathetically and in a professional way. Good nursing and attention for my (wife). The Annual Quality Assurence Assessment submitted to CSCI said; … at Emberbrook care home our key measure is resident satisfaction as evidenced through our quality audit processes and annonymous customer surveys. There was no eveidence to verify the completion of the surveys. The registered manager informed the inspector that the ‘Four Seasons’ organisation has developed an overall quality assurance audit for their care homes that will be available for scrutiny in the near future. The home provided residents with the opportunity to hold residents meetings and residents; advocates and relatives had the opportunity to discuss any concerns and home issues at social functions arranged by the home. It was recommended that the home provide the CSCI and residents details of the outcome of the homes quality audit when it was completed. Residents who were unable to manage their money received the support of relatives. Four files were inspected showing the homes fees and contracts had been completed and signed appropriately. Emberbrook Care Home DS0000068324.V355847.R01.S.doc Version 5.2 Page 24 Health and safety at home was actively promoted and awards such as Young at Heart and Gold Standard award had been attained. Certificated were in place for registration and Insurance water temperatures and all areas throughout the home had received monthly health and safety checks. An excellent quality rating is within the capability of this home if attention to detail is made. Please see the requirements section of this report. Emberbrook Care Home DS0000068324.V355847.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 3 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 2 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 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Emberbrook Care Home DS0000068324.V355847.R01.S.doc Version 5.2 Page 26 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 It is required that the home provide documented evidence, such as a company stamp or signature of a recognised collector of the disposal service used to collect the homes unused medication and that the details correspond with the last collection record of drugs disposal. The home is required to provide evidence of certifiable training achievements and progress of NVQ attainments that was not provided in the Annual Quality Assurance Assessment (AQAA) to ensure that at all times suitably qualified competent and experienced persons are working at the care home in such numbers to ensure the health and welfare of the residents. Timescale for action 30/04/08 2. OP30 18 (1)(a) 30/04/08 Emberbrook Care Home DS0000068324.V355847.R01.S.doc Version 5.2 Page 27 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 OP1 OP7 Good Practice Recommendations It is recommended that the home ensure that all residents receive a ‘Welcome pack’. It was recommended that the home review the overall contend of the resident’s files and; show the residents level of participation in the care review notes, ensure hand written notes are readable, daily diaries show evidence of the assessed care needs being met, ensure appropriate documentation is contained and ensure that index systems are consistent. That the registered manager discusses good staff practice when conducting face-to-face staff supervision relating to residents choices and arrange more training relating to dementia care needs. It was recommended that the home provide the CSCI and residents details of the outcome of the homes quality audit when it was completed. 3. OP10 4. OP33 Emberbrook Care Home DS0000068324.V355847.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Emberbrook Care Home DS0000068324.V355847.R01.S.doc Version 5.2 Page 29 - 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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