Latest Inspection
This is the latest available inspection report for this service, carried out on 6th January 2010. it is an annual review prepared by CQC after examining previous reports and information from the provider. At the time of this report, CQC judged the service to be Good.
The inspector made no statutory requirements on the home as a result of this inspection
and there were no outstanding actions from the previous inspection report.
For extracts, read the latest CQC inspection for Mount Ephraim House.
Annual service review
Name of Service: Mount Ephraim House The quality rating for this care home is: The rating was made on: two star good service 2 0 0 1 2 0 0 9 A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection We do an annual service review when there has been no key inspection of the service in the last 12 months. It does not involve a visit to the service but is a summary of new information given to us, or collected by us, since the last key inspection or annual service review.
Has this annual service review changed our opinion of the service?
No You should read the last key inspection report for this service to get a full picture of how well outcomes for the people using the service are being met. The date by which we will do a key inspection: Name of inspector: Gary Bartlett Date of this annual service review: 0 9 1 2 2 0 0 9 Annual Service Review Page 1 of 6 Information about the service
Address of service: Mount Ephraim Tunbridge Wells Kent TN4 8BU 01892520316 01892523180 mountephraim.house@tiscali.co.uk www.greensleeves.org.uk Greensleeves Homes Trust Telephone number: Fax number: Email address: Provider web address:
Name of registered provider(s): Conditions of registration: Category(ies) : old age, not falling within any other category Conditions of registration: Number of places (if applicable): Under 65 Over 65 0 38 The maximum number of service users to be accommodated is 38. The registered person may provide the following category/ies of service only: Care home only ? (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category (OP). Have there been any changes in the ownership, management or the No service’s registration details in the last 12 months? If yes, what have they been: Date of last key inspection: Date of last annual service review (if applicable): Brief description of the service Mount Ephraim House provides 24 hour personal care and accommodation for up to thirty-eight older people. Greensleeves Homes Trust, a charitable organisation, owns the home. Mount Ephraim House is located in a residential area of Tunbridge Wells. The nearest shops and other usual town amenities are approximately a half-mile away. The home was first registered on 8th March 1991. It consists of a semi-detached property with large secluded gardens to the sides of the premises. There are limited car parking facilities to the front and side of the house. Accommodation currently
Annual Service Review Page 2 of 6 2 0 0 1 2 0 0 9 includes thirty-seven rooms for single occupancy, six of which have shower and WC en-suite facilities. Thirteen of the bedrooms are located on the ground floor; separate facilities can be made available for guests to stay. There are two shaft lifts in the main house enabling wheelchair access to the upper floors in the main house and a stair lift in the annex. There is a staff call system and television points in all the bedrooms. A number of residents have their own phone lines installed. The home employs care, administrative and ancillary staff. Current fees range from £460 to £575 per week for private placements. Annual Service Review Page 3 of 6 Service update since the last key inspection or annual service review:
What did we do for this annual service review? We looked at all the information that we have received, or asked for, since the last key inspection or annual service review. This included: The annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. Information we have about how the service has managed any complaints. What the service has told us about things that have happened in the service, these are called notifications and are a legal requirement. The previous key inspection and the results of any other visits that we have made to the service in the last 12 months. Relevant information from other organisations. What other people have told us about the service. What has this told us about the service? At its last Key Inspection, conducted on 20th January 2009, this care home was rated as a two star good service with judgments of good for all outcome groups. No requirements were made. This tells us that this care home is operating well within the regulatory framework. The last key inspection site visit did make one recommendation. This was that the care planning process be further improved. The Annual Quality Assurance Assessment, (AQAA), states action has been taken to address this. The home sent us their AQAA when we asked for it. It was clear and gave us all the information we asked for. We looked at the information in the AQAA and our judgment is that the home is still providing a good service and that they know what further improvements they need to make. There is evidence from the AQAA that the home is continuing to look at ways of improving what it does to ensure good outcomes for those living there. This includes an improvement to the care plans, they have ensured that cleaning staff achieve an NVQ 2 in cleaning and support services, redecoration and refurbishment around the home, improved fire safety and they have dedicated a particular room for activities. Quality assurance systems are robust. The home consults with the residents and acts on their feedback. Residents are invited to residents meetings that are held quarterly. At these meetings their opinions on the service are recorded. Copies of the minutes are given to each resident. There is also a residents sub-committee, which meets in between the general meetings. At these meetings, they make known the opinions of all residents. Changes of menu and choice of food have been made following feedback from residents meetings. Also, there is a wider range of activities and outings. Themed evenings have been introduced and maintained. The home has purchased a wide Annual Service Review Page 4 of 6 screen wall-mounted Television and a Wii machine including a Wii fit. The home also obtains the views of other stakeholders. A quality audit questionnaire is given to every resident and their family and health care professionals. The AQAA states the home actively encourages an open door policy for residents and their relatives to speak to any member of staff should they have any concerns. The AQAA indicates the home received eight complaints in the last twelve months. All were upheld and dealt with in a timely manner. The Commission has not directly received any information about complaints regarding the service in that time. There have not been any safeguarding alerts since the last inspection. The home actively promotes equality and diversity. Mount Ephraim encourages recruitment from various nationalities and promotes an equal opportunities policy. Currently all staff are white British but this is in line with the demographics of the area. The AQAA indicates the home employs people of a wide range of ages and of both genders. Mount Ephraim has retained Investors in People, gold star from environmental health and has recently been one of five finalists in NAPA Breath of Fresh Air Week. The Manager has attended training in the Mental Capacity Act and Deprivation of Liberty Safeguarding. Training is being arranged for other staff. What are we going to do as a result of this annual service review? We are not going to change our inspection plan, and will do a key inspection by 20th January 2011. However we can inspect the service at any time if we have concerns about the quality of the service or the safety of the people using the service. Annual Service Review Page 5 of 6 Reader Information
Document Purpose: Author: Audience: Further copies from: Annual service review CQC General Public 0870 240 7535 (national contact centre) Our duty to regulate social care services is set out in the Care Standards Act 2000. The content of which can be found on our website. Helpline:
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