Care Home: Enbridge House Care Home

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What the care home does well The home provides care in a well-maintained pleasant and welcoming environment by a well-managed supported, motivated very well trained stable staff team (90% of whom had been trained to at least NVQ level two) who work in a manner that recognises resident`s need for personal privacy and dignity. What has improved since the last inspection? All previous requirements (that are referred to in the main body of this report) have been complied with resulting in improvements especially to the care planning process and the environment. What the care home could do better: Pre inspection assessments of need and risk should include confirmation that the resident or their representative were consulted and participated in the assessment process. Menus should be displayed and produced in more than a written format to ensure all residents can understand them and exercise choice in what they eat CARE HOMES FOR OLDER PEOPLE Enbridge House Care Home Church Road Woolton Hill Nr Newbury Hampshire RG20 9XQ Lead Inspector Peter J McNeillie Unannounced Inspection 11th March 2008 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Enbridge House Care Home DS0000012200.V359330.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. Enbridge House Care Home DS0000012200.V359330.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Enbridge House Care Home Address Church Road Woolton Hill Nr Newbury Hampshire RG20 9XQ 01635 254888 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) kblwork@tesco.net Mrs Mandy Ann Plumb Miss Karen Bolt-Lawrence Mrs Mandy Ann Plumb Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17) of places Enbridge House Care Home DS0000012200.V359330.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Two named residents in the categories of MD(E) and DE(E) may be accommodated. 7th June 2007 Date of last inspection Brief Description of the Service: Enbridge House is a privately owned and managed care home offering support, personal care and accommodation for up to seventeen persons in the older person category. The home is situated in a rural setting in the small village of Woolton Hill near to the town of Newbury within thirty minutes travel to Swindon, Reading and Winchester. There is also easy access to the M4 and M3 motorways via the A34 trunk road. Accommodation is available over three floors served by a passenger lift in a large converted house set in well-maintained grounds with ample parking. The current scale of charges in the home is £585 week. Enbridge House Care Home DS0000012200.V359330.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. This report was written after taking into consideration a number of sources of information and evidence including a site visit to the premises, previous reports, examining residents and staff training records, talking with residents, staff and management, responses by the manager to a pre inspection Annual Quality Assurance Assessment. (AQAA) and the results of in house satisfaction and CSCI satisfaction surveys completed by residents and residents representatives. During this inspection which took place on 11th March between the hours of 9.00 am and 1.30 pm and was the first inspection for the year 2007/08, all previous requirements and all of the designated key standards for older persons were inspected. The results and findings contained in this report will determine the frequency and type of future inspections. What the service does well: What has improved since the last inspection? All previous requirements (that are referred to in the main body of this report) have been complied with resulting in improvements especially to the care planning process and the environment. Enbridge House Care Home DS0000012200.V359330.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Enbridge House Care Home DS0000012200.V359330.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Enbridge House Care Home DS0000012200.V359330.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a system of assessing and identifying residents needs which ensures their safety and assessed needs can be met. Intermediate care is not available. EVIDENCE: The homes admission policy and procedure requires no resident is admitted into the home without a full assessment of need and risk being carried out by the manager or a senior member of the homes care staff in tandem with an assessment by the potential residents external care manager where a referral originated with a local authority. A sample of three residents records viewed confirmed that the residents were admitted in accordance with the admissions policy and procedure but did not include included an acknowledgement that the resident or their representative had contributed to the assessment procedure. Enbridge House Care Home DS0000012200.V359330.R01.S.doc Version 5.2 Page 9 In acknowledging this manager gave a verbal undertaking that any future pre admission assessments carried out would include confirmation that the resident, or the residents representative had been involved in the pre admission assessment process Enbridge House Care Home DS0000012200.V359330.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a well-developed system of planning and reviewing care which reflects residents wishes, aspirations and ensures residents needs are met within a risk management policy and involves residents and residents representatives or relatives in decisions that affect them. EVIDENCE: Following the last inspection a requirement was made that:” The registered manager must ensure care plans are revised with the resident or their representative. This is part of a previous requirement from the last inspection timescale 13/09/06 not met.” A sample of three residents care plans were viewed and a number of residents spoken to individually or in groups. All of the residents spoken with confirmed they were very happy, contented, liked the staff and management, were treated with respect felt wanted and would recommend the home to anyone. Enbridge House Care Home DS0000012200.V359330.R01.S.doc Version 5.2 Page 11 Residents responses to our questions relating to how they were cared for and living in the home were all very positive and included comments such as “ I like it here,” I am well looked after” We want for nothing” Hotel service”” Well satisfied”,” Care is very good”. During our visit we observed staff treat residents with respect, and dignity, talk to residents in a non-patronising manner and knock on bedroom doors and wait, only entering when asked to do so. All of the care plans viewed which were based on pre admission assessments of need were reviewed on a regular basis, updated to reflect changing needs and included confirmation that residents were consulted about and participated in the production of the plan. We are therefore satisfied the previous requirement has now been complied with. Residents spoken with confirmed they were able to see the doctor or any other health and social care professional of their choice when they needed to. Resident’s choice is limited re choice of a doctor due to the rural location of the home; however, residents are still able to consult a doctor of the same gender as himself or herself if they wish. Records were kept of appointments with GPs, dentist, optician, chiropodist and any other external health and social care professional and included details of an advice and treatment given by them. To ensure equality and diversity are promoted within the service the home informed us in their AQAA that “No discrimination against any person either living or working at Enbridge is tolerated. All religious denominations are catered for”. Residents also informed they are able to exhibit choice over all matters that affect their day to day lives eg, bedtimes what and when to eat, whether they receive visitors” Medication records seen confirmed that all prescribed drugs and medicines, which are securely stored, are dispensed by a pharmacist at the local surgery and administered by trained staff. The record of drugs and medicines administered to residents and unwanted drugs disposed of were complete and accurate. We were informed that a procedure that ensures residents who wish may assume responsibility for their own medication subject to a risk assessment was available. Residents spoken with informed us they preferred the home to take care of their medication. Enbridge House Care Home DS0000012200.V359330.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The social activities, family contacts and the provision of varied and nutritious meals were well managed and reflected residents interests and choices. EVIDENCE: A selection of recreational activities was available to residents who informed us they are able to exercise choice whether or not to participate. These include visiting entertainers, clothes shows cards etc. Residents spoken with told us their preferences were identified during the assessment process. This information is included in the individual’s care plan ensuring staff are aware of what residents like doing. We were informed that many residents also liked going out on a one to one basis, and this can be arranged. Local shopping being very popular. Residents confirmed they were fully consulted and were able to exercise choice in all aspects of their lives for example; when to get up and go to bed, mealtimes and where meals are taken, visiting times and were able to receive and converse with visitors and free to make and receive telephone call when they wished in private. A number had arranged to have a personal private phone installed in their room. Enbridge House Care Home DS0000012200.V359330.R01.S.doc Version 5.2 Page 13 The quality, quantity, presentation and choice of food based on residents choice, likes and dislikes came in for particular praise from the residents. Whilst a written daily menu based on resident’s likes and dislikes was available this was not displayed. A verbal undertaking was given to us that in future a daily menu will be displayed. Whilst the home is not registered to admit persons with dementia, we highlighted the need to ensure that should a resident develop dementia in the future they may not be able to read and understand a written menu. Consequently, there is a need to ensure that the menu is displayed in format that all residents would understand. This is of prime importance for persons with dementia who may find the addition of pictures would be beneficial to their understanding when making choices. The manager gave a verbal undertaking she would look into the way menus were displayed in future. Enbridge House Care Home DS0000012200.V359330.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has clear policies and procedures in place which ensures residents are protected from abuse. The complaints procedure was satisfactory with evidence that residents feel their views will be acted upon. EVIDENCE: An in house Adult Protection policy and procedure that operates in tandem with the policy and procedure produced by Hampshire County Council designed to safeguard residents from abuse was available. Records viewed and staff spoken with confirmed they had received training in recognising various types of abuse. All were able to demonstrate they knew the procedure to follow should they witness or suspect the abuse of any resident. The homes complaints procedure, which included information on how to contact The Commission for Social Care Inspection (CSCI), was seen, as was a record of complaints. No complaints had been received by CSCI since the last inspection. Enbridge House Care Home DS0000012200.V359330.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A safe, well maintained, clean and suitably furnished home is provided for residents which meets their needs. EVIDENCE: Following the last inspection the following requirement was made:” The registered manager must ensure that a programme of redecoration and maintenance is planned and acted upon. This is an amended requirement from the inspection of 1/11/05 and a repeat from the last inspection timescale 13/08/06 not met.” We observed all areas of the home were clean and free from unpleasant odours. Furniture was comfortable, homely and met residents needs. Enbridge House Care Home DS0000012200.V359330.R01.S.doc Version 5.2 Page 16 Since the last inspection the entrance hall, lounge, stairs, four bedrooms and the kitchen have been redecorated. We were shown a plan for future maintenances, redecoration and replacement of furniture this included the removal of a toilet no longer in use in the first floor bathroom. Externally whilst some work has been undertaken the building appears rather shabby in contrast to the pleasant interior. We were informed no major exterior work has been undertaken due to redevelopment plans that are under consideration. Any changes being dependent on decisions yet to be made. We are satisfied the previous requirement has been complied with. Assessment to ensure that any equipment and personal aids required by residents are available has been carried out. Aids currently in use within the home include hoists (various) special chairs; special beds raised toilets, ramps, passenger, walking frames and handrails. Whilst throughout the home there was an improvement, we were concerned to notice a trip hazard in the form of a loose carpet in an area known as the annex. We were given an assurance this matter would be dealt with within seven days. We have since been informed the matter has now been corrected and the hazard removed. Enbridge House Care Home DS0000012200.V359330.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30. Quality in this outcome area is good. Resident’s needs are met by sufficient numbers of well trained and supported staff who are recruited and selected using a procedure designed to protect all residents. EVIDENCE: At the time of our visit the three care staff on duty who also were supported by a cook/cleaner, appeared to be adequate to meet resident’s needs. Residents said there are always enough staff on duty, that know how they like to be cared for, staff said that they felt there are enough staff on duty on each shift. It was evident through observation that staff had developed a good relationship between themselves and residents. Staff turnover in the home is very low. Only one new member of staff (who has since left) had been employed since the last two inspections. We viewed three staff recruitment and training files of current and past staff, all of which included evidence that staff are employed in accordance with a robust recruitment, equal opportunities and selection procedure which is designed to protect residents. This involves the completion of an application form, the signing of a rehabilitation of offender’s declaration, an interview, and satisfactory Criminal Record Bureau (CRB) disclosure, Protection of Vulnerable Adults (POVA) and reference checks. Enbridge House Care Home DS0000012200.V359330.R01.S.doc Version 5.2 Page 18 Following their appointment, records seen confirmed all staff are subject to an in house and induction and compulsory training programme that include first aid, handling medication, moving and handling, POVA infection control and dementia. All staff are expected to undertake a National Vocational Qualification (N V Q) course. Currently 90 of staff has been trained to at least NVQ level two of these three have obtained NVQ level three and one level four. This is a very creditable result for which the homes management are to be congratulated. Enbridge House Care Home DS0000012200.V359330.R01.S.doc Version 5.2 Page 19 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 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home ensures the health, safety and welfare of residents and staff are promoted and the home is run in the best interests of the residents whose views about living in the home are formally sought. EVIDENCE: Following the last inspection a requirement was made that: “The registered manager must ensure that arrangements are made for staff to receive suitable training in working with residents’ who have a mental disorder. This is part of a previous requirement from the last inspection timescale 13/08/06 not met”. Currently only one resident has a mental disorder referred to which is monitored by a community psychiatric nurse. Enbridge House Care Home DS0000012200.V359330.R01.S.doc Version 5.2 Page 20 To ensure compliance and in the absence of a suitable course, following the advice of the CPN, the care plan of the individual has been updated to include signs and symptoms and procedure to follow if the individual’s mental state appears to be changing. In view of the steps taken we are satisfied the requirement has been complied with. The result of the previous non-compliance resulted in a judgement being made “That the manager does not discharge her responsibilities to meet requirements”. As can be seen from this report this is no longer the case. All previous requirements have been complied with by the manager who has many years experience in caring for older persons, is a qualified nurse and is qualified to NVQ level four. To monitor the quality of the service delivered, a comprehensive quality assurance system was in place and views were sought every two months from service users, their families and external health and social care professionals. Results from these surveys form part of a management action plan to improve the existing service. We were informed no money is being held on the behalf of residents. A health and safety policy was in place to ensure the day-to-day safety of staff and residents. Procedures include, regular health/ safety checks, the regular servicing of equipment, staff training in the techniques of moving and handling infection control, control of substances hazardous to health (C.O.S.H.H.) first aid, health and safety, reporting accidents and procedures to follow in the event of fire (including evacuation). All of the hot water supplies to baths were fitted with thermostatic controls are set at 43 degrees centigrade and all radiators and hot pipes covered. Enbridge House Care Home DS0000012200.V359330.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Enbridge House Care Home DS0000012200.V359330.R01.S.doc Version 5.2 Page 22 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Enbridge House Care Home DS0000012200.V359330.R01.S.doc Version 5.2 Page 23 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 Enbridge House Care Home DS0000012200.V359330.R01.S.doc Version 5.2 Page 24 - 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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