CARE HOMES FOR OLDER PEOPLE
Edendale 5-6 The Green St Leonards-on-sea East Sussex TN38 0SY Lead Inspector
Alexis Reilly Key Unannounced Inspection 19th June 2006 1:15 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 Edendale DS0000021092.V291107.R01.S.doc Version 5.1 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. Edendale DS0000021092.V291107.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Edendale Address 5-6 The Green St Leonards-on-sea East Sussex TN38 0SY 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) 01424 429908 Mr Glynn Fettiplace Mrs Andrea Fettiplace Mr Glynn Fettiplace Care Home 31 Category(ies) of Dementia (31), Mental disorder, excluding registration, with number learning disability or dementia (31) of places Edendale DS0000021092.V291107.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. The minimum age of service users on admission will be fifty five years (55). The maximum number of residents to be accommodated is thirty one (31). 19th December 2005 Date of last inspection Brief Description of the Service: Edendale is registered to provide accommodation for up to 31 people of 55 years old and over suffering from dementia or mental illness and admits people with low to high dependency needs. The premise is two large separate detached properties situated in St Leonards. It has 13 single rooms and nine doubles situated on three floors all have a wash hand basin. Residents in one house have the use of a ground floor lounge and a dining room and first floor smaller lounge/diner. In the other house residents have use of a ground floor lounge and dining room and a second floor smaller lounge and dining area. Smoking is allowed in each house in the designated area. The home has a secure rear garden accessed by steps with seating and lawn area for residents to enjoy. Car parking is available to the front of the houses. The buildings are located a five minute walk from the nearest shops and is on a bus route with a bus stop just outside the home. The current fee scale is £366.00 - £470.00 per week. Edendale DS0000021092.V291107.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection began at 1.15pm and concluded at 4.30pm. The Inspector examined various records including care plans, risk assessments, sheets which record the administration of medicines, menus, adult protection, and complaints procedures. The fire safety logbook, accident book, staff recruitment and induction documents were also examined as were health and safety records. The inspector saw numerous residents going about their business within the home. The inspector spoke with two residents briefly, and received comments from residents and relatives in the form of surveys sent out by the Commission for Social Care Inspection, the comments of which are included in this report. What the service does well: What has improved since the last inspection?
The service has a new Assistant Manager in place. The Assistant Manager is a Registered Mental Nurse, (RMN), a NVQ assessor and NVQ internal verifier. She has a NVQ level 4 in Management and in Training and Development. Staff no longer second dispense medication, and medication is administered following the correct procedure.
Edendale DS0000021092.V291107.R01.S.doc Version 5.1 Page 6 Requirements in relation to liquid soap and paper towels or the equivalent being available in communal toilets and bathrooms have been addressed. The freezer highlighted at the last inspection has been cleaned and defrosted. The clinical waste bin has been replaced with a pedal bin. All commodes have lids and are in good order, and the bathmats and toilet seat highlighted have been replaced, as has the pipe work and toilet roll holders. The laundry area has been redecorated since the last inspection. 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. Edendale DS0000021092.V291107.R01.S.doc Version 5.1 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 Edendale DS0000021092.V291107.R01.S.doc Version 5.1 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 the following standard(s): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit to this service. The service ensures it has gained the relevant background information for a resident prior to offering them a place in the service. The service does not offer intermediate care. EVIDENCE: Assessments are carried out by external agencies. Full community care assessments are in place for new residents, intermediate care is not provided. Surveys were received from the residents placed at Edendale the surveys confirmed residents had received a contract, and had information about the home prior to moving in. Comments received from relatives of residents in relation to moving into the home were ‘the best test is a short stay, Edendale was by far the best out of the homes we tried and the information we received was accurate and clear’. Edendale DS0000021092.V291107.R01.S.doc Version 5.1 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 the following standard(s): 7,8,9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit to this service. Residents have plans of care which address their mental and health care needs, however risk assessments must be developed that cover all risks and all the aims identified in the plans of care must be reviewed. Residents are not fully protected by the homes policies and procedures with regard to medication. EVIDENCE: Risk assessments are in place for behaviour and falls. These have been reviewed monthly. However the risk assessments must match the care plans and make reference to all risks. Care plans are currently in the process of being updated, a new system has been put in place. When the care plans are reviewed each month the Assistant Manager must ensure that the review covers all the aims and that each resident has an up to date risk assessment in place. The Assistant Manager who is also a registered nurse has run training courses for staff in the administration and handling of medicines. Staff are also carrying out this training in their NVQ courses. All residents now receive their medication through a monitored dosage system to avoid re-dispensing medicines. The medication policy now includes areas
Edendale DS0000021092.V291107.R01.S.doc Version 5.1 Page 10 such as homely remedies, over the counter medicines, administration and arrangements for medicines in the event of a death of a resident. No one self administers medication. There is now in place a clear step-by-step written procedure for staff to follow for medication administration including recording, controlled drugs, ordering and returns of medicines and storage. Medication prescribed as and when required, now has clear written instruction for staff as what it is for, how and when it should be administered including any maximum/minimum quantities and any authorisation that is required by staff before it can be administered. There is now a signature list of staff competent to administer medication. Staff are subject to disciplinary proceedings if medication is not administered correctly. The Assistant Manager has now completed a list of drugs in use at Edendale. The home has obtained the Royal Pharmaceutical Society’s “The Administration and Control of Medicines in Care Homes”. The home must obtained a bound book to record the administration of a controlled drug. The charts which record the administration of medicines now show a full audit trial of all medication that comes into and leaves the home and reflect up to date medication for each resident. However two medicine cupboards must be installed and the oxygen cylinder used for one resident must be handled and stored in line with BOC guidance. Accidents are recorded using the correct forms but must be stored individually to protect residents confidentiality. Health care needs are met and currently GP’s, the District Nurse, Community Psychiatric Nurses and the continence advisor support the home. A chiropodist visits the home six weekly. Residents weight is now recorded in the care plan to enable the monitoring of any weight loss or gain. Edendale DS0000021092.V291107.R01.S.doc Version 5.1 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 the following standard(s): 12,13,14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit to this service. Residents have opportunities for a variety of appropriate leisure activities, are able to access the wider community and maintain good links with friends and families. Daily routines are very flexible with residents able to exercise choice. Residents enjoy their meals. EVIDENCE: Records now reflect activities residents are offered and participate in. In house activities include listening to music, radio or tapes, daily newspapers and magazines and watching television. Some residents are able to go out independently shopping and visiting friends; Staff also accompany other residents for walks. Outside entertainment comes into the home including a music man singing and playing a keyboard; a Nostalgia group singing which bring in instruments for residents to play, a music and movement session is also held each week. The hairdresser visits every two weeks. Seasonal activities include visiting carol singers and a Christmas meal out. Contact with families and friends is encouraged. A volunteer visits the home twice a week to spend time talking to residents. Edendale DS0000021092.V291107.R01.S.doc Version 5.1 Page 12 Menus rotate six weekly, although there is no choice residents confirmed that alternatives are available. The cook is aware of likes and dislikes and an alternative that the resident would like is cooked. Edendale DS0000021092.V291107.R01.S.doc Version 5.1 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 the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit to this service. The service has an accessible complaints procedure in place, and service users feel their complaints are taken seriously and acted upon. Service users are protected from abuse by the policies in the service and by suitably trained and supervised staff. EVIDENCE: Complaints within the service are taken seriously and dealt with appropriately. Protection of Vulnerable Adult training and Train the Trainer Adult Protection Training is arranged for staff to complete early next month. Edendale DS0000021092.V291107.R01.S.doc Version 5.1 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 the following standard(s): 19,22,25 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a site visit to this service. Residents live in a comfortable, homely and well-maintained environment. Improvements have been made since the last inspection to ensure residents safety and a hygienic environment. EVIDENCE: The home is clean, warm, spacious, comfortable and homely. There is on going maintenance to maintain the environment. The home is in keeping with local properties and the grounds are safe, well maintained and accessible to residents. The one radiator which remained unguarded has since been covered. The Inspector viewed the fire safety logbook, which evidenced that the alarms had been tested to the required frequencies and that all call points were randomly tested. The fire extinguishers are visually checked monthly and recorded. The Fire Safety Officer has been contacted in relation to fire safety
Edendale DS0000021092.V291107.R01.S.doc Version 5.1 Page 15 and the front door, which is kept locked. Fire lecture training has been arranged for the 20th and 22nd of June 2006. Requirements in relation to liquid soap and paper towels or the equivalent being available in communal toilets and bathrooms have been addressed. The freezer highlighted at the last inspection has been cleaned and defrosted. The clinical waste has been replaced with a pedal bin. All commodes have pot lids and are in good order, and the bathmats and toilet seat highlighted have been replaced, as has the pipe work and toilet roll holders. The laundry area has been redecorated since the last inspection. The Assistant Manager is in the process of setting up an environmental audit of the home and is caring out a full environmental risk assessment. Edendale DS0000021092.V291107.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit to this service. Residents’ needs are meet by suitably experienced and supervised staff. An internal NVQ training programme is in place to ensure staff are trained to NVQ level 2 in sufficient numbers. EVIDENCE: Staff are receiving training on the General Social Care Council code of conduct and practice and this is due to be taught in December this year. The newly created induction pack now matches the specifications of skills for care and is a very detailed and comprehensive document. New staff job descriptions are in place, and a new application form is in the process of being completed. All staff have Criminal Record Bureau checks and Protection of Vulnerable Adult checks prior to employment within the service. Two members of staff have NVQ level 2, and two staff are currently completing NVQ level 2 training. The Assistant Manager is running a level 2 and level 3 NVQ training programme for all staff from September 2006 onwards. Staff meetings are held once a month, and new policies are discussed at these meetings. There is a staff supervision policy in place and the supervisions are monitored and scored. The Assistant Manager supervises the senior staff members the cook and the domestic staff and the senior staff will supervises the rest of the staff team. Training for staff in the coming months includes, control of infection, GSCC code of practice training. Fire safety training is being carried out for all staff within the coming week. The Assistant Manager is due to complete train the
Edendale DS0000021092.V291107.R01.S.doc Version 5.1 Page 17 trainer manual handling training and will then train the rest of the staff. Staff completed care planning training in April, and in May the Administration of Medicine and Food Hygiene training was carried out. Further planned training is Administration of Medicine, Supervision and Fire training, Vulnerable Adults training, Stress Management training and in August Manual Handling and Basic Care Skills. Training planned for September is Fire Prevention, Communication and an Introduction to Level 3 NVQ in care. Training for October is an introduction into dementia and caring for the elderly. Edendale DS0000021092.V291107.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,37 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit to this service. The service is run and managed sufficiently and run in the best interests of the service users with their rights and best interests protected. EVIDENCE: The service has a new Assistant Manager in place, the Assistant Manager is a Registered Mental Nurse, (RMN), a NVQ assessor and NVQ internal verifier. They have a NVQ level 4 in Management and in Training and Development. In the last twelve months they have completed the following courses, Employment Practice, Adult Protection Basic Awareness and Train the Trainer Adult Protection training. The Assistant Manager has introduced a comprehensive induction program, which meets the required standard and is training staff in NVQ levels 2 & 3. Good progress has been made with regard to the management of medicines within the home, and work is progressing on care plans and risk assessments.
Edendale DS0000021092.V291107.R01.S.doc Version 5.1 Page 19 Surveys were received form the residents placed at Edendale. The surveys confirmed residents had received a contract, and had information about the home prior to moving in. Staff listen and act on what residents said and are available when needed. Responses confirmed that residents receive the medical support they need and that residents usually took part in the activities offered in the home particularly enjoying the music. Residents knew who to talk to if they were unhappy and knew how to make a complaint. The home was always clean and fresh and residents enjoy the meals and always have a choice. However one resident stated they would like more choice. Further comments received were ‘It is my home and I am happy to be looked after’ and ‘I have been here for a number of years this is my home and this is where I shall die’. Comments received from relatives of residents were ‘the best test is a short stay, Edendale was by far the best out of the homes we tried and the information we received was accurate and clear’, ’My mother has excellent care and has been very happy at Edendale, the staff are very alert and responsive and kind they are always cheerful. Staff are available and they are quick to respond to any needs in the kindest and most patient manner’, ‘The meals are excellent, they keep my relative well feed and happy’, ‘We have no complaints my relative and I are very close, so I would soon be aware of anything that might be unsatisfactory’ and ‘We would like to thank all the staff and managers at Edendale for the kind and efficient care they have given to my relative. It has given us peace of mind and given my relative some extra, happy years in spite of being mentally infirm’. Quality assurance forms are being created and will be evaluated later this year. Fire alarms are tested weekly and the last equipment test was carried out in September 2005. The date of the most recent fire drill was 6th December 2005. Edendale DS0000021092.V291107.R01.S.doc Version 5.1 Page 20 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 2 8 2 9 2 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 3 X X 3 3 STAFFING Standard No Score 27 X 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X X 3 3 Edendale DS0000021092.V291107.R01.S.doc Version 5.1 Page 21 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 OP7 Regulation 15(1) Requirement Timescale for action 01/10/06 2. 3. OP8 OP9 13(4) 13(2) 4. OP33 24(1)(a) (b)(2) The service needs to ensure that the care plans in existence are comprehensive and when reviewed all the aims identified are reviewed and assessed. Risk assessments must contain 01/10/06 all risks, be dated and evidence review. The service purchases the 01/10/06 required medicine cabinets, a bound book for recording the administration of controlled drugs, and ensures oxygen is stored in line with BOC guidance. The service must implement an 01/10/06 effective quality assurance and monitoring system that meets the requirements set out in this standard (previous timescale of 01/09/05 not met). Edendale DS0000021092.V291107.R01.S.doc Version 5.1 Page 22 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 Edendale DS0000021092.V291107.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection East Sussex Area Office 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
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