Archived: Mount Ephraim House

Updated 28 June 2017

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection checked whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This comprehensive inspection of Mount Ephraim House took place on 23 March 2017 and was unannounced. The inspection was carried out by an inspector and an expert-by-experience. An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service.

Before the inspection, we reviewed information we held about the service including statutory notifications sent to us by the registered manager about incidents and events that occurred at the service. Statutory notifications include information about important events which the provider is required to send us by law. The provider had completed a Provider Information Return (PIR). This is a form that requires providers to give some key information about the service, what the service does well and improvements they plan to make. We used all this information to inform the planning of the inspection.

During our inspection, we spoke with nine people who used the service, two relatives, five care staff, the chef, deputy manager and the registered manager.

We reviewed 10 people’s care plans, risk assessments and their medicine management records. We looked at 10 staff files including recruitment, training, supervisions and appraisals. We reviewed other records held at the service relating to the management of the service including health and safety documents and quality audits. We undertook general observations of how people were supported and received their care in the service. In addition, we used the Short Observational Framework for Inspection (SOFI). SOFI is a way of observing care to help us understand the experience of people who could not talk with us.

After the inspection, we received feedback from three healthcare professionals.

Updated 28 June 2017

Mount Ephraim House is registered to provide care and accommodation for up to 38 older people. On the day of our inspection there were 36 people using the service.

At the last inspection in November 2014, the service was rated Good overall and we rated the service outstanding for our key question, ‘Is the service responsive?’

At this inspection, we found the service remained Good and demonstrated they continued to meet our regulations.

People told us they continued to receive safe care and were happy living at the service. Staff consistently provided care that was responsive to people’s needs. People remained safe from potential harm because staff were regularly trained to identify abuse. Staff understood their responsibility to report any concerns and were aware of safeguarding procedures to follow to keep people safe. Staff continued to assess and manage risks to people’s safety. Risk management plans remained effective and had enough guidance on the action staff had to take to keep people safe from avoidable harm.

Medicines management systems remained effective. People’s medicines were administered safely by trained staff and securely stored. The provider’s recruitment procedures ensured staff employed were suitable to provide safe care. People received appropriate care and support from a sufficient number of staff. Staff were competent in their role because they received support, training, supervision and appraisal to improve their knowledge and skills.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible. Policies and systems in the service supported this practice. Records showed staff respected people’s choices on decisions about their care and supported them to be as independent as possible.

Staff were kind and caring and had developed positive relationships with people. People received care from staff who knew them well and understood how they wanted to be supported. People continued to receive their care as planned and in line with their needs and preferences.

People were involved in the planning and review of their care and support plans. People’s health needs were assessed, reviewed and met in a creative manner. Staff provided care that was responsive to people’s changing needs. Support plans were effective and contained guidance to staff on how they were to provide care in line with people’s wishes.

People enjoyed the food provided at the service and their dietary needs were met. Menu plans showed healthy options and included people’s preferences and choices. Staff continued to support people to access healthcare professionals when needed. Feedback for health care professionals was very positive and confirmed the service remained proactive and worked with them to better people’s lives.

People continued to receive person centred care. People, their relatives and health and care professionals said care at the service was empowering and enhanced people’s quality of life. People remained involved in a wide range of stimulating activities of their choice which they liked. People had access to various unique lounges, communal and recreational areas that allowed them to enjoy different activities, quiet times and receive visitors.

The service was decorated and the environment adorned with people’s artwork and seasonal themes such as a summer at the beach and decorations which kept people stimulated and engaged. People led meaningful lives at the service and were always kept occupied. Care plans provided details of people’s hobbies, interests, preferences and what was important to them and the support they required from staff to achieve their goals. Staff knew people`s needs and ensured they provided appropriate care and support.

The registered manager continued to demonstrate good leadership and commitment to improving the service. They were passionate and determined to continue delivering outstanding care and ensured staff understood the provider’s vision to empower people. People’s views were sought through regular resident meetings, surveys and one to one discussions with the registered manager and staff. People’s feedback was used to drive improvements at the service and the quality of care. People and staff remained complimentary about how the service was managed. People knew how to complain and had easy access to the provider’s complaints procedure.

Staff felt valued at the service and said the registered manager was supportive and approachable. Quality assurances systems remained effective and were consistently used to ensure the safety of the premises and equipment and to improve people’s care and support. There was an open and inclusive culture that ensured staff remained focused on putting people at the centre of service delivery.