Inspection on 15/06/05 for Edendale Residential Care Home

This inspection was carried out on 15th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Edendale Residential Care Home 31/07/07

Edendale Residential Care Home 19/06/06

Edendale Residential Care Home 19/12/05

Edendale Residential Care Home 21/01/05

Edendale Residential Care Home 28/07/04

Similar services:

1 Marten Road

Daubeney House

Three Gables

Deepdene Care Centre

Aldwick House

49 Glendale

Ferndale Residential Care Home

David Gresham House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Edendale 5-6 The Green St Leonards-on-sea East Sussex TN38 0SY Lead Inspector Alexis Reilly Unannounced 15 June 2005 09:15 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 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. Edendale H59-H10 S21092 Edendale V227225 150605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Edendale Address 5-6 The Green St Leonards-on-sea East Sussex TN38 0SY 01424 429908 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr & Mrs Fettiplace Mr & Mrs Fettiplace Care Home 31 Category(ies) of Mental disorder (MD) 31 registration, with number Dementia (DE) 31 of places Edendale H59-H10 S21092 Edendale V227225 150605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The minimum age of service users on admission will be fifty five years (55) 2. The maximum number of residents to be accommodated is thirty one (31) 3. Residents will have a diagnosis of dementia or mental illness on admission Date of last inspection 21 January 2005 Brief Description of the Service: Edendale is registered to provide thirty one places for older people with a mental disorder, including Dementia. The building is near to the town centre and set within its own grounds. The service is divided into two houses with a separate staff group in each house the staff group rotates periodically. Edendale H59-H10 S21092 Edendale V227225 150605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection began at 9.15 and lasted for two hours and 30 minutes. A full tour of the building was carried out and each room was found to be clean and free from offensive odour. Documents for recruitment of staff were examined on the day of the inspection. Accident records within the home were viewed. The Staff rota was viewed. Menus were viewed. Sheets where administration of medication is recorded were examined. Residents appeared happy and settled. Staff were observed interacting with residents. One new resident has been admitted since the last inspection. What the service does well: What has improved since the last inspection? What they could do better: The service must ensure it changes to use the monitor dosage system, and does not continue to secondary dispense medication. Medication should be signed for correctly. Staff employed in the service spend a lot of time interacting with residents. Various activities are provided. These must be recorded. It is then clear what activities individual residents have been involved in on a daily basis. Edendale H59-H10 S21092 Edendale V227225 150605 Stage 4.doc Version 1.30 Page 6 The service must find a way of assessing residents’ views in the home, and formalising a quality assurance system. 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. Edendale H59-H10 S21092 Edendale V227225 150605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Edendale H59-H10 S21092 Edendale V227225 150605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 Edendale gains the appropriate information about a resident, so as to ensure the home can meet that persons needs. EVIDENCE: Edendale have had one new resident move into the home since the last inspection. The service had ensured that they had obtained the relevant information. A letter from the older persons mental health services, and letters from the consultant. Relevant information about the medication the person was prescribed. There was a community care assessment and community care plan in place. Edendale H59-H10 S21092 Edendale V227225 150605 Stage 4.doc Version 1.30 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 & 9 Care plans were up to date and identified risks were recorded apart from in relation to one residents changing needs. However staff were aware of the increased risk around this person. EVIDENCE: Care plans are up to date and recorded appropriately. Risk assessments are comprehensive and have relevant information in with regard to particular identified risks for residents. All accidents are recorded in individual care plans, and risk assessments are updated if necessary. Staff interviewed were aware of the changing needs of the one of service users. However the risk assessment needed to be updated and recorded. One resident requires continued nursing care, this was discussed, and due to mobility and progressing needs a more in depth level of nursing care is required. The service is currently assessing whether they can meet this residents needs and will obtain suitable equipment if necessary. Sheets which record the administration of medicines were examined on the day of the inspection. Significant gaps were evident in them. These were due to staff not signing for medication when it had been given. Some medicines Edendale H59-H10 S21092 Edendale V227225 150605 Stage 4.doc Version 1.30 Page 10 which require two signatures only had one signature. The service is still using the system of secondary dispensing medication. This is an ongoing issue. However the owners are currently awaiting the blister pack system from the pharmacy so the correct procedure for administration of medication will be followed. Edendale H59-H10 S21092 Edendale V227225 150605 Stage 4.doc Version 1.30 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 The home provides adequate activities. Staff interact with residents very well, and involve them in day to day activities within the home. EVIDENCE: Activities were discussed in the home. Activities are being provided for residents. However these are not recorded appropriately. Activities carried out the week of the inspection were as follows: on Wednesday a Nostalgia group. This is when three people, visit the service they bring a keyboard and sing. Musical instruments are given to resident to play and join in. The group play for a hour in each house. On Friday a women plays a keyboard for one hour for a movement and music session. Again she spends one hour in each house. On Tuesday a visiting performer visits the service and plays the keyboard. Again he plays for one hour in each house. The hairdresser visits once a week on a Sunday. Staff will sit and talk to residents. Staff could relay information about what a resident enjoys and what their interests are. Dominoes and Bingo are played with residents if they wish, and staff will read newspapers to them. Staff will take individual residents to the local library if they wish. Four residents access the community independently. Other residents are taken for walks or out in car journeys with staff. Ice creams are served in the garden during the good summer weather. Seasonal activities are offered, such as pantomimes at Christmas. Staff ensure they spend time with residents who are less able to initialise contact with staff. Staff will take time in the afternoon sitting with residents who choose to spend Edendale H59-H10 S21092 Edendale V227225 150605 Stage 4.doc Version 1.30 Page 12 time in their rooms. However throughout the inspection, staff were seen with residents at all times. They were either spending time with residents in administration of self care, or involving residents whilst carrying out general care duties. The staff were observed initiating contact with residents and would always speak to them and never walk past a resident seated, unless they spoke to them. Edendale H59-H10 S21092 Edendale V227225 150605 Stage 4.doc Version 1.30 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None of these standards were assessed during the inspection. EVIDENCE: Edendale H59-H10 S21092 Edendale V227225 150605 Stage 4.doc Version 1.30 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 26 The home was clean and free from offensive odour. EVIDENCE: All areas of the two buildings were viewed on the day of the inspection. Each resident’s bedroom was entered. The home was clean and free from offensive odour on the day of the inspection. Edendale H59-H10 S21092 Edendale V227225 150605 Stage 4.doc Version 1.30 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 The service is on target to ensure that 50 of the staff are trained to NVQ Level 2 or above. EVIDENCE: On the day of the inspection on duty there were a senior carer from 8am – 5pm, and three carers from 8am – 8pm. One carer from 8am – 2pm, and a cook from 8am – 2pm. In the other house were two carers from 8am – 2pm, two carers from 2pm – 8pm and one care staff member from 8am – 8pm. One new staff member had been employed since the last inspection. The staff assured the inspector that POVA and CRB checks had been completed for this person, although they were not available to view on the day. The service has 24 care staff in total. Out of these 3 staff are starting NVQ level 2. Three have completed NVQ level 2. The service employees 6 nurses, there registration is not recognised in the UK. One senior carer has completed NVQ level 3. Edendale H59-H10 S21092 Edendale V227225 150605 Stage 4.doc Version 1.30 Page 16 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None of these standards were assessed. EVIDENCE: Edendale H59-H10 S21092 Edendale V227225 150605 Stage 4.doc Version 1.30 Page 17 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 x COMPLAINTS AND PROTECTION x x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x 3 x x x x x Edendale H59-H10 S21092 Edendale V227225 150605 Stage 4.doc Version 1.30 Page 18 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 15(1) Requirement The service needs to ensure that the care plans in existence match the criteria and cover the topics set out in Standard 7, this is particularly relevant to the activities offered within the service, and will help to identify which service users participate in which activity and how often they do this. The service follow the recommendations as set out by the pharmacy inspector. The service must implement an effective quality assurance and monitoring system that meets the requirements set out in this standard. Timescale for action 1st August 2005 2. 3. OP9 OP33 13(2) 24(1)(a) (b)(2) 1st September 2005 1st September 2005 4. 5. 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. Edendale H59-H10 S21092 Edendale V227225 150605 Stage 4.doc Version 1.30 Page 19 Refer to Standard Good Practice Recommendations Edendale H59-H10 S21092 Edendale V227225 150605 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection Ivy House, 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 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 Edendale H59-H10 S21092 Edendale V227225 150605 Stage 4.doc Version 1.30 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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