Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 03/05/07 for Edensor Nursing and Residential Home

Also see our care home review for Edensor Nursing and Residential Home for more information

This inspection was carried out on 3rd May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The manager undertakes a good pre-admission assessment, which helps to ensure that residents needs can be met by the team at the home. Residents and relatives are happy with the standard of care and services provided by the team at the home and feel that it has improved significantly with the new manager in post. The healthcare needs of residents are met and the meal provision at the home is good. Complaints are dealt with objectively and the manager has an open approach. Staff training in the home is generally good and is steadily improving. The staff team is stable and turnover is low. Recruitment practices for new staff are sound.

What has improved since the last inspection?

What the care home could do better:

Whilst there have been significant improvements, there is still work needed on the provision of care in some areas, particularly social care. The care team need to take a more active role in this aspect of resident care. Some areas of staff training could improve to help ensure that residents needs can be fully met. Despite training in health and safety being provided for the majority of staff, some have failed to take this on board and risks were noted in the home. The quality assurance programme needs developing so that interested parties have the opportunity to give feedback on services and facilities etc.

CARE HOMES FOR OLDER PEOPLE Edensor Nursing and Residential Home 3 - 9 Orwell Road Clacton on Sea Essex CO15 1PR Lead Inspector Diane Roberts Unannounced Inspection 3rd May 2007 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 Edensor Nursing and Residential Home DS0000015322.V342876.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. Edensor Nursing and Residential Home DS0000015322.V342876.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Edensor Nursing and Residential Home Address 3 - 9 Orwell Road Clacton on Sea Essex CO15 1PR 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) 01255 423317 01255 423347 Elder (UK) Limited Mrs Pauline Thornton Care Home 66 Category(ies) of Dementia (26), Mental Disorder, excluding registration, with number learning disability or dementia - over 65 years of of places age (46), Physical disability over 65 years of age (26) Edensor Nursing and Residential Home DS0000015322.V342876.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Persons of either sex aged 40 years and over, who require nursing care by reason of dementia (not to exceed 26 persons) Persons of either sex, aged 65 years and over, who require care by reason of a mental disorder, excluding learning disability or dementia (not to exceed 46 persons) Persons of either sex, aged 65 years and over, who require nursing care by reason of a physical disability (not to exceed 26 persons) 23rd June 2006 Date of last inspection Brief Description of the Service: Edensor provides nursing and personal care with accommodation for younger people with dementia and older people with mental illness and/or physical disabilities. Edensor is owned by a private organisation named Elder (UK) Ltd. The home is located in a residential area within walking distance from the centre of Clacton upon Sea. The home was opened in 2002 and consists of a three-storey building. There are 34 single bedrooms and 16 double bedrooms. There is a passenger lift. The home has gardens to the front of the property and a secure courtyard garden that is accessible to wheelchair users. Edensor is accessible by road and rail and the nearest station is in Clacton on Sea. Parking is available in the small car park and adjacent road. The fees range from £3367.00 -£620.00 weekly, depending upon need. Additional costs apply for chiropody, toiletries, hairdressing and newspapers. Edensor Nursing and Residential Home DS0000015322.V342876.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out as part of the annual inspection programme for this home. The registered manager was available on the fieldwork day of the inspection. The inspection focused upon all of the key standards. A partial tour of the premises was undertaken. Evidence was also taken from the Annual Quality Assurance Assessment completed by the management of the home and submitted to the CSCI. 2 residents, 4 relatives and 3 staff were spoken to during the inspection. Residents and relatives completed feedback sheets and visiting healthcare professionals also gave feedback. All these comments were taken into account when writing the report. Since the new manager has been in post the CSCI acknowledge that a significant amount of work has been undertaken and standards have improved. However there are still areas that require further work and this reflected in the body of the report. It is disappointing to note that there is still an access issue with the laundry that poses a significant risk to some residents in the home. Failure to address this issue will result in the CSCI taking legal action in order to protect residents. What the service does well: The manager undertakes a good pre-admission assessment, which helps to ensure that residents needs can be met by the team at the home. Residents and relatives are happy with the standard of care and services provided by the team at the home and feel that it has improved significantly with the new manager in post. The healthcare needs of residents are met and the meal provision at the home is good. Complaints are dealt with objectively and the manager has an open approach. Staff training in the home is generally good and is steadily improving. The staff team is stable and turnover is low. Recruitment practices for new staff are sound. Edensor Nursing and Residential Home DS0000015322.V342876.R01.S.doc Version 5.2 Page 6 What has improved 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. The summary of this inspection report can be made available in other formats on request. Edensor Nursing and Residential Home DS0000015322.V342876.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 Edensor Nursing and Residential Home DS0000015322.V342876.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): 3. Standard 6 is not applicable to this home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The assessment process at the home helps to ensure that the staff only admit residents whose needs they can meet. EVIDENCE: The manager has a pre-admission assessment system in place. The manager undertakes all the assessments and if unavailable a member of the nursing staff would attend. Recent assessments were reviewed and were found to have been completed fully and gave good detail on both physical, mental and social care needs. Assessments, where appropriate, were also supported by nursing needs assessments and assessment documentation from social services. It was possible to speak to a placing Mental Health Social Worker on the day of the inspection that commented that the manager had undertaken a prompt Edensor Nursing and Residential Home DS0000015322.V342876.R01.S.doc Version 5.2 Page 9 assessment and had been very helpful and supportive in arranging the admission. She also felt that the manager gave good advice and she valued her professional input. From discussion with relatives, social workers and from records, it was clear that people had been able to visit the home prior to admission and that they had received the service users guide, which is also available in the main hall along with the last inspection report. Observation of an admission on the day of the inspection showed that a very friendly welcome was given and the admission was relaxed. Staff at the home, including the maintenance man were very helpful and the placing social worker was also in attendance. Edensor Nursing and Residential Home DS0000015322.V342876.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. Care planning continues to improve at the home and residents’ healthcare needs are met. There is still work to do on aspects of the care planning process to ensure consistent positive outcomes for residents. EVIDENCE: Since the manager has worked at the home, she has implemented a new care planning system. This includes use of the assessment tool, care plans and wide range of risk assessments. Aspects of the care planning are very person centred but could be developed further especially in relation to assessment, personal wishes and social care planning. Care plans that had been completed were seen to be detailed and evidenced residents’ personal preferences and choices. Care plans were also maintained up to date. A checklist system is in place to help ensure that staff complete all the required documentation. Edensor Nursing and Residential Home DS0000015322.V342876.R01.S.doc Version 5.2 Page 11 Work needs to be done in relation to the care planning approach for new residents. It was disappointing to note that one resident, who had been in the home 6 weeks, had no care plans or key risk assessments such as manual handling, pressure sores, bed rail use or nutrition, especially when the assessment process identified specific needs and equipment was in place. This must be addressed and a baseline plan put in place for new admissions. The Commission is confident that the manager will address this within a short timescale. Family histories are in place for many of the residents but social care plans were seen to be weak overall. This is discussed further under section 3 – Daily Life and Social Activity. Daily records were seen to be variable in quality. Some were particularly good reflecting the care given, the residents’ day and their general mood and wellbeing, whilst other gave limited, general information. Some good and detailed risk assessments were seen to be in place covering a wide range of subject matters. Where risks are identified, these should link into the care planning process, outlining the action being taken to monitor or reduce the risk. Overall the care planning system continues to improve but there are still areas that require further work and increased staff input. Evidence is needed to show that were possible, residents have been involved in the care planning process or their relative/advocate as appropriate. Relatives spoken to were all very happy with the standards of care given at the home. Comments included ‘staff are excellent’, ‘their relative always looks well cared for and they check and are always happy’, ‘Feel that they can speak to any of the staff at the home and they will know what is going on’. Records show that the health of residents is dealt with in a proactive manner. Health issues noted in the records are dealt with promptly and the appropriate referral made. Record show that residents see doctors, chiropodist, opticians, dentists, practice nurses etc, as required. Staff at the home use an assessment tool with regard to the risk of pressure sore development. The home has a good range of pressure relieving mattresses and other aids in use around the home. At the current time there are no home-acquired pressure sores being treated, only two hospital acquired ones that are steadily improving. Wound management records were reviewed and seen to be in good order, with records giving detailed information. This allows staff to accurately review progression or deterioration. Prescribed care is being followed and appropriate referrals are made to, for example, the diabetic vascular team. At the time of the inspection, there are no wounds, being cared for, that have developed in the home. Edensor Nursing and Residential Home DS0000015322.V342876.R01.S.doc Version 5.2 Page 12 Records show that overall, residents’ weights are monitored regularly, but again it was noted that new admissions had not been weighed and this must be addressed. The home uses a blister pack and bottle to mouth system. This was reviewed and found to be maintained in good order. Mar sheets were neatly maintained, medications were checked in and reviews and changes were evident. When using omission codes staff do need to record the reason for the admission on the Mar sheet. A medication disposal system is in place and dates of opening are noted on individual medications. Interaction between staff and residents was seen and heard to be respectful and friendly. Residents spoken to said that staff were polite and respected their privacy. Relatives spoken to felt that residents were treated as individuals and that their rights were respected. Residents were observed to be given choices and exercise their opinions regarding their care whilst the regulation officer was at the home. Edensor Nursing and Residential Home DS0000015322.V342876.R01.S.doc Version 5.2 Page 13 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 adequate. This judgement has been made using available evidence including a visit to this service. Whilst the provision of activities has steadily improved, individual resident needs are not always met and care staff miss opportunities. Mealtimes could be a better experience for some residents in the home. EVIDENCE: The home has an activity officer in post, who is currently undertaking a distance learning course on providing activities for people in care homes. This member of staff is providing a range of primarily group activities. Records are maintained on specific forms, which contain information on participation by the resident, resident interaction during the session; resident engagement in the activity; their physical ability to undertake the activity; memory recall of activity and if it helps or hinders their mood/well-being. Whilst these are good records, more work needs to be done on the completion of social care plans which identify individual needs and bring the activity officers and care team work together. A more person centred approach is needed. More work is also needed on completion of social and family histories, which will help to inform Edensor Nursing and Residential Home DS0000015322.V342876.R01.S.doc Version 5.2 Page 14 the social care planning. The manager identifies in her annual quality assurance assessment that a wider range of activities needs to be offered. Activities are listed up on the wall in one of the dining areas. The manager has recently purchased more equipment for the activity officer to use with residents and a craft morning has been introduced once a week. On touring the home it was noted that care staff cover the lounges. Staff were observed just standing in the lounge not interacting with residents at all. This is a missed opportunity for providing individual or group activities that could improve the quality of life for residents. The manager is aware that this is an issue that she needs to address. The manager identifies in the homes annual quality assurance assessment that she needs to encourage key workers to develop activities with residents’ and plan more activities that enable residents to go out of the home. One relative said ‘the home could improve by taking my relative out more’. The routines of the day are resident led as far as possible. Personal preferences regarding rising times, care preferences and individual abilities was seen in the care plans. Where possible residents attend local resources to spend time out of the home and some residents are able to go out into the town without care staff. The home has an open visiting policy and relatives spoken to say that they felt welcome in the home. Records show that residents are now on the electoral register. Records show that some residents do have access to advocates and records also show that staff have read official letters to residents, helped them to understand them and supported them with subsequent decisions. Lunch was observed in two dining areas. Residents were being sensitively assisted and appeared to be enjoying their meals. A choice was available and on discussion with staff they were well aware of individual residents preferences. The menu was seen to be varied and the manager plans to develop a pictorial menu for residents with cognitive impairments. It was noted that one dining room, where residents have a higher dependency in relation to dementia, was set differently from other dining areas. For example, no condiments or flowers etc. This should be reviewed as residents were seen to be ‘segregated’ because of this. Residents spoken to were positive regarding the range and quality of the food provided. They said ‘good fresh veg’, ‘the meals, feels are healthy and there is plenty of it’, ‘good breakfast, cereal, toast, fruit and egg/bacon, yoghurts – a wide range’. Edensor Nursing and Residential Home DS0000015322.V342876.R01.S.doc Version 5.2 Page 15 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 adequate. This judgement has been made using available evidence including a visit to this service. The home has systems in place that help to ensure that residents’ complaints would be listened to objectively. The home manages any adult protection issues promptly but the lack of staff training on this subject could adversely affect the welfare of residents. EVIDENCE: The home has a satisfactory complaints procedure in place. This is displayed in the home and can be found in the service users guide. Residents and relatives spoken to said that they knew who to raise any concerns with and were comfortable to do this. Since the last inspection the manager has introduced ‘Customer Feedback Forms ‘ and this also allows people to comment on standards in the home. Forms were seen to be available in the main hallway. Since the last inspection there have been 7-recorded complaints and records relating to these were reviewed and discussed with the manager. Complaints were seen to be investigated and responded to promptly, with the appropriate actions being taken. Records show that the manager has an objective approach to complaints and generally manages to ensure that the homes policy regarding timescales is kept to. The manager stats in her annual quality assurance assessment, submitted to the CSCI that she plans to further increase staff awareness on the management of complaints and to ensure that Edensor Nursing and Residential Home DS0000015322.V342876.R01.S.doc Version 5.2 Page 16 all staff have a positive and objective approach to dealing with them. Letters and cards of compliment were seen and positive comments were noted from relatives regarding the kindness and care shown by staff to residents. The home has the appropriate adult protection policies and procedures in place. Staff training records show that less than 50 of the staff have received adult protection training at the home. This should be addressed to ensure that all staff are aware of adult protection issues and procedures. Edensor Nursing and Residential Home DS0000015322.V342876.R01.S.doc Version 5.2 Page 17 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 adequate. This judgement has been made using available evidence including a visit to this service. Standards in the home are generally good, however attention to health and safety needs to be taken on board by all the staff team to ensure that residents are not placed at risk. EVIDENCE: A partial tour of the home was undertaken, reviewing all the communal areas and a number of bedrooms, at random. The home was seen to be clean and no odours were noted. No odour was noted in the downstairs shower room where there had previously been an issue. Redecoration and re-carpeting of some of the communal areas has been undertaken in the last year and some bedrooms have also been re-carpeted. Communal areas and bedrooms were seen to be in a good state of repair. New chairs and curtains have been purchased for Edensor Nursing and Residential Home DS0000015322.V342876.R01.S.doc Version 5.2 Page 18 some of the lounges and the fish pond, that was in the main lounge, has been removed and now holds plants. This had previously posed a risk to residents. Bathrooms and toilets are fit for purpose but could be made to be less clinical and more homely. This was discussed with the manager. It was noted that the lighting in an upstairs corridor was poor and that the main strip light bulb had gone. This was raised with the manager on the day of the inspection. Residents and relatives spoken to were happy with the facilities at the home and felt that the home was kept clean. Twenty one out of the thirty nine staff employed have had training in infection control, mainly in 2006. Thought could be given to providing further training on this subject. Since the last inspection new lifting hoists, slings and items such a bed rail bumpers have been purchased and on touring the home these were seen to be in a good condition. The laundry was again found unoccupied and unlocked with COSHH products present and the steam iron left on. This is a high risk to some of the residents in the home. This was discussed with the manager on the day of the inspection in relation to risk and this being a previous agenda item. It was a concern to note that the member of staff working in the laundry, that the manager spoke to, did not appear to understand the risks due to her limited understanding of the English language. Since the last inspection the small, enclosed area at the back of the home, where residents could sit out, has been improved. Overgrown plants have been cut back, some new furniture and planters have been purchased. The manager plans to continue to develop this area with regard to furniture and planting. The home has documentation in place to show that the fire alarm and associated systems/equipment have been maintained to a satisfactory standard. A fire risk assessment was completed in April 2006, which now needs a review. A recent fire officer visit noted some minor faults, which the manager is currently attending to. Records show that a fire drill has recently been carried out with a good number of staff attending. Weekly fire alarm checks are generally done but were seen to be a little inconsistent at times. This should be addressed. The home employs a maintenance man and records show that items identified by staff are attended to appropriately. In the manager’s annual quality assurance assessment, she plans to provide residents with locks to their rooms. Edensor Nursing and Residential Home DS0000015322.V342876.R01.S.doc Version 5.2 Page 19 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. This judgement has been made using available evidence including a visit to this service. The home has a stable staff team that the manager is steadily developing in order to ensure they have the range of skills required to meet the needs of the residents in the home. EVIDENCE: Since the last inspection the manager has reviewed the staffing levels at the home in relation to resident dependency. Nursing hours have been increased during the day and carer hours have increased at night. Staffing levels are now: a.m. – 2 registered nurses and 8 care staff. p.m - 2 registered nurses and 8 care staff. Night – 1 registered nurse and 4 care staff. One of the night carers also stays until 09.00hrs and this has improved continuity of care and staff handover at a busy time. Registered nurses now have supernumerary shifts and this has helped to improve care planning and staff training at the home, which is very positive in relation to improving care standards and providing a qualified and experienced team to care for residents. One resident spoken to said ‘there are more nurses here now than there have ever been’. Edensor Nursing and Residential Home DS0000015322.V342876.R01.S.doc Version 5.2 Page 20 Since the last inspection the staff team at the home have worked hard in relation to NVQ. They have maintained their 50 standard and more staff have now achieved an NVQ level 3. More staff are also in the process of undertaking NVQ level 2. Staff recruitment systems were checked and found to be in good order with all the required checks and documentation in place. The manager is aware that the application form is limited and she plans to review and update this in the near future. Good interview records are also maintained. The home does employ quite a few staff from Europe. Both relatives and residents commented on some of the staff abilities with regard to speaking English. The manager is aware of this and tries to ensure that staff are able to converse with residents and relatives but perhaps needs to review this in light of comments received. The manager has a training programme in place. As the staff supervision system develops these systems should link together. Records show very good compliance levels with regard to training on manual handling, fire safety, food hygiene and health and safety. It is disappointing to note that despite the registration of the home, only a limited number of staff have training on dementia related subjects and none in relation to mental health. Records show that the manager plans to provide 12 further places for dementia training and possibly training on challenging behaviour but none in relation to mental health. This should be reviewed in light of the registration categories of the home. Training is also planned in relation to end of life care. New care staff to the home are undertaking the Skills for Care induction and records were available to evidence this. Edensor Nursing and Residential Home DS0000015322.V342876.R01.S.doc Version 5.2 Page 21 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 adequate. This judgement has been made using available evidence including a visit to this service. Management at the home is stable and they are steadily developing services and systems to improve outcomes for residents. The manager has a proactive approach to developing the home but still has some work to do to improve standards further. EVIDENCE: The manager is well qualified and experienced to run the home. Management at the home is stable and residents, relatives and staff speak positively about the manager. Residents and relatives feel that the manager is approachable and that she is available around the home. Staff turnover is low and there is Edensor Nursing and Residential Home DS0000015322.V342876.R01.S.doc Version 5.2 Page 22 no agency use at the current time. Records show that the manager holds meetings with her staff team and the residents, covering a wide range of subjects and staff and residents are both able to raise any issues for discussion. On discussion with the manager, she is keen to develop the home and improve outcomes for residents. Her current planning records show that she is looking at a wide range of subjects including quality audits, staff supervision and development, care plans, residents contracts, staff induction and specific care development for individual residents. Records show that the manager is addressing a wide range of development work in the home that will improve standards in the home and affect outcomes positively for residents. Since the last inspection the manager has been developing the quality assurance programme for the home but has yet to implement this fully. The manager holds residents meetings as she states that residents are either unable or reluctant to fill in forms. This was discussed with the manager, as she needs to develop other ways to obtain feedback from her residents. Customer feedback forms are available in the main corridor but this system, whilst giving good information, is ad hoc and a more structured approach may be needed in order to get a full picture of peoples views. The manager has developed some internal audits systems to monitor standards in the home and develop services but she has yet to use these. On discussion, the manager is aware that this is an area that she needs to work on. The home had appropriate procedures in place for the safe storage of residents’ monies. Receipts are held for expenditure and records were confirmed by signature. The procedures were well adhered to and amounts held were confirmed as correct. Some residents are able to manage their own money and the management of the home help them to do this. The home has a health and safety policy in place. In the past safe working practice risks assessments have been completed but these now need review. This is of importance due to the poor working practices within the homes laundry department as discussed in section 4 – Environment. The manager is in the process of developing a staff handbook, which will include aspects of safe working practice and health and safety in general. Accident records were reviewed and found to be completed well and showed follow up where required. Records show that the manager audits accident records and looks at the incidence of falls and skin tears and the time of accidents, in relation to the deployment of staff. This has improved since the last inspection and is a good quality assurance system, which can improve outcomes for residents. Records show that the majority of staff at the home have received training this year in health and safety and food hygiene. Further training is also planned. Edensor Nursing and Residential Home DS0000015322.V342876.R01.S.doc Version 5.2 Page 23 Random inspection of maintenance and safety certificate for the equipment and fixtures in the home show that these are maintained in good order. Edensor Nursing and Residential Home DS0000015322.V342876.R01.S.doc Version 5.2 Page 24 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 N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 X X 1 Edensor Nursing and Residential Home DS0000015322.V342876.R01.S.doc Version 5.2 Page 25 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 Requirement Timescale for action 31/07/07 2. OP7 15 3. OP12 16 4. OP18 13 All new residents admitted to the home must have care plans and risk assessments in place as their assessed needs specify, to ensure that their needs are being fully met. Work must continue to develop 14/08/07 the care planning system to ensure consistent positive outcomes for residents. This relates to person centred care planning, social care plans, family and social histories and the involvement of residents and relative in the care planning process. The activity programme needs to 31/07/07 develop in order to meet residents’ individual needs. Care staff should have a greater appreciation of residents social care needs. More staff training in adult 14/07/07 protection issues and procedures should be provided to ensure staff are well informed so that the risk to residents is reduced. Edensor Nursing and Residential Home DS0000015322.V342876.R01.S.doc Version 5.2 Page 26 5. OP19 13 6. OP30 18 7. OP33 21/24 The laundry room must be made 30/06/07 safe with regard to resident access to equipment and COSHH items. Staff working in the laundry must understand the potential risks to residents. This is a repeat requirement and the manager was advised on the day of the inspection. Further training must be 14/08/07 provided to staff that relate to the specialist needs of residents in the home, to help ensure that their needs will be met. This relates to dementia and mental health. The quality assurance 14/08/07 programme in the home needs to be developed further and ways to obtain resident feedback given more consideration, so that the development of the home and services provided takes their feelings into account. 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. 2. 3. 4. Refer to Standard OP15 OP26 OP26 OP29 Good Practice Recommendations Table settings at mealtimes should be reviewed in order to ensure that some residents are not being treated differently where it is not required. Consideration should be given to providing further infection control training to increase staff awareness and reduce risks to residents and staff. The fire safety risk assessment for the home should be reviewed to ensure that all fire safety issue are up to date and so that any risks can be reduce where possible. Work should be done with staff from European countries to ensure that their abilities with regard to the English language improve so that residents and relatives can DS0000015322.V342876.R01.S.doc Version 5.2 Page 27 Edensor Nursing and Residential Home 5. OP38 communicate easily with them. Safe working practice risk assessments should be reviewed to ensure they are up to date and staff are well informed of risks and how to reduce them. Edensor Nursing and Residential Home DS0000015322.V342876.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Edensor Nursing and Residential Home DS0000015322.V342876.R01.S.doc Version 5.2 Page 29 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!