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Inspection on 29/11/05 for Edgeview Nursing Home

Also see our care home review for Edgeview Nursing Home for more information

This inspection was carried out on 29th November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

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 Home is well organised, with a committed care management team. Emphasis goes into involving the residents and their families in the process of care, ensuring a highly personal approach to meeting individual needs. Nursing care is of a high standard with named nurses and key workers actively deployed. The emphasis is on the team spirit and family feel to create an environment conducive to good nursing care practice. Assessment procedures and care planning is of an excellent standard, offering detailed information on each resident`s progress in the meeting of objectives. The housekeeping and support services all contribute to the team approach, and are recognised by the management for their efforts. Maintenance of satisfactory staffing levels, staff training and supervision are well established in safeguarding the interests of residents. Overall the attitude in meeting clinical and organisational demands is highly commendable, with forward thinking, planning and application contributing to an excellent service.

What has improved since the last inspection?

There has been extensive work done on improving the quality of bathrooms and some bedrooms identified in the last inspection. There has been a successful enterprise of practical common sense, good planning and professional approach to resolving problems. Fire lecture organisation has been improved with each member of staff receiving two training sessions a year. Some work has gone in to establishing the snoezlan room, which is hoped to be up and running by April 2006.

What the care home could do better:

To maintain the very high standards achieved, constant vigilance is needed. Residents risk assessment need reinforcement. Ongoing attention to furbishment remains constant. The heating system arrangements are in need of review.

CARE HOME ADULTS 18-65 Edgeview Nursing Home The Compa Comber Road Kinver Nr Stourbridge Staffordshire DY7 6HT Lead Inspector Unannounced Inspection 29th November 2005 09:00 Edgeview Nursing Home DS0000022324.V271436.R02.S.doc Version 5.0 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 Edgeview Nursing Home DS0000022324.V271436.R02.S.doc Version 5.0 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 Adults 18-65. 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. Edgeview Nursing Home DS0000022324.V271436.R02.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Edgeview Nursing Home Address 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) The Compa Comber Road Kinver Nr Stourbridge Staffordshire DY7 6HT 01384 872804 01384 878980 edgeviewhomes@AOL.com Edgeview Homes Ltd Mrs Julia Ann Jasper Care Home 24 Category(ies) of Learning disability (24), Learning disability over registration, with number 65 years of age (1), Mental disorder, excluding of places learning disability or dementia (24) Edgeview Nursing Home DS0000022324.V271436.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th May 2005 Brief Description of the Service: Edgeview caters for twenty-four adults (18 – 65 yrs) with learning disabilities, including those with challenging behaviours and persons of a similar age range suffering mental ill health, which require twenty-four hour nursing care. It does not admit persons detained under the provisions of mental health legislation. There are sixteen service users in the main house; three more independent service users in the bungalow and five service users in the newly refurbished stable block annex. Edgeview aims to provide a home environment that will afford service users greater security, choice, independence and a good quality of life. This is achieved by maintaining a relaxed, friendly atmosphere with staff who appreciate that they are there to cater for their individual needs in a home environment, while maximising the services that the Home can offer to the service users. Edgeview is located in a residential area of Kinver, approximately one mile from the village centre in an area of outstanding natural beauty. Road links to nearby Stourbridge and Wolverhampton are good, with regular services. Edgeview Nursing Home DS0000022324.V271436.R02.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was conducted by two inspectors, with the provider, operations manager and senior nursing and care staff. The last inspection report was discussed, and it was noted that recommendations made all had been attended to. The tour of the home was carried out in a relaxed, courteous and professional manner; everyone concerned expressed confidence in the atmosphere. All the service users approached were highly complimentary of the care, service and attention they received from a willing, attentive care team. There were 23 residents on the day of inspection, 4 categorised with high dependency needs on a one-to-one basis. Four service users were case tracked, confirming the establishment of a well run home, comfortable and ‘homely’. Everyone appeared comfortable and at ease with their surroundings A sample review of the administration confirmed solid practice and effective management. A feedback session was offered at the end of the inspection with open discussion involving the senior management. What the service does well: The Home is well organised, with a committed care management team. Emphasis goes into involving the residents and their families in the process of care, ensuring a highly personal approach to meeting individual needs. Nursing care is of a high standard with named nurses and key workers actively deployed. The emphasis is on the team spirit and family feel to create an environment conducive to good nursing care practice. Assessment procedures and care planning is of an excellent standard, offering detailed information on each resident’s progress in the meeting of objectives. The housekeeping and support services all contribute to the team approach, and are recognised by the management for their efforts. Maintenance of satisfactory staffing levels, staff training and supervision are well established in safeguarding the interests of residents. Overall the attitude in meeting clinical and organisational demands is highly commendable, with forward thinking, planning and application contributing to an excellent service. Edgeview Nursing Home DS0000022324.V271436.R02.S.doc Version 5.0 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. Edgeview Nursing Home DS0000022324.V271436.R02.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Edgeview Nursing Home DS0000022324.V271436.R02.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5 It is recognised that the Statement of Purpose represents the foundation on which the home operates upon, offering service users and their relatives the opportunity to make an informed choice about where to live. Following an assessment the senior nurse assessor determines the suitability of the application in view of the facilities available, and at the capacity of the home, to manage the individual and any special needs. The Home has demonstrated their commitment to promote a partnership of care, to meet the objectives of providing a home to meet individual needs. EVIDENCE: The recently reviewed Statement of Purpose presents an excellent explanation in to the aims and objectives, management and staffing, facilities and services that Edgeview can offer. This gives residents and their relatives the opportunity to make an informed choice about where to live. Service users are admitted to Edgeview following a comprehensive preadmission needs assessment, carried out by the provider or Operations Manager accompanied by the homes Registered Manager and Primary Nurse. This assessment initiates the process of care, each individual having a plan of care. Case tracking showed a detailed care assessment, offering substantial information to prospective service users on the services and facilities that Edgeview can provide to meet their individual and special needs. This was confirmed by speaking to staff and residents. Edgeview Nursing Home DS0000022324.V271436.R02.S.doc Version 5.0 Page 9 The management style is highly personable and inclusive, generating a warmth and comfortable environment. Relatives are welcome to view the facilities and participate in the planning and assessment of care. Edgeview Nursing Home DS0000022324.V271436.R02.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 and 10 Residents spoken to were keen to show the extent of independence and the degree of involvement in their care, a ‘partnership of care’ approach. This focused on positive behaviour, ability and willingness of the individual, showing that service users freely make decisions about their life in the home. Residents were also seen to be supported by their key workers and the management to take risks as part of an independent lifestyle in the home. The arrangements for socialisation are extremely conducive to the ethos of independent living. EVIDENCE: Assessments, care plans and risk assessments were examined and found to offer an excellent record of daily living, which were comprehensive, and included a provider assessment; a person centred plan, a health and safety assessment, and a planned intervention, rehabilitation and therapeutic programme. Evidence of health care professional visits showed an attentive awareness to service user’s needs. It was noted that each day had a different schedule of events encouraging therapeutic and social activities geared to meeting service users sense of belonging. Residents who smoke continue to pose problems of risk-assessed independence, which require the staff to reinforce the ongoing accommodation of high-risk activities. Edgeview Nursing Home DS0000022324.V271436.R02.S.doc Version 5.0 Page 11 Four residents were case tracked with a full examination of care records, health records including general practitioners and consultant visits, risk assessments, dependency charts, records of reviews and action plans. Records inspected showed that residents freely make decisions about their life in the home. Altogether the communication ‘package’ offers a comprehensive appraisal of resident’s needs and aspirations. Risk assessments were carried out on an individual basis and reviewed. Included in the care records were applications of established monitoring systems following a process of goals, care and evaluation models. The activity centre continues to provide facilities for independent expression and facilitating life skills for individuality. During the inspection the inspectors were impressed with the lively environment and cheerful banter, with a team led by the activities co-ordinator. It was most encouraging to see how much work had gone into promoting personal awareness and a sense of belonging. Edgeview Nursing Home DS0000022324.V271436.R02.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 and 17 Throughout the inspection residents were seen to be enjoying a high degree of encouragement to express themselves in positive and meaningful ways. Bedrooms were seen to demonstrate that individuality, each different to match personal outcomes. A fully flexible open visiting policy was seen to be in operation with some visitors present throughout the inspection, reflecting the importance placed upon family or friends’ regular contact. The residents and staff were seen to be enjoying a well-presented lunch. EVIDENCE: The Statement of Purpose and Guide indicate a flexible routine, established to meet the preferences of service users. The policy was evidenced in admission assessment, care plans examined, and talking to service users and relatives, a policy much appreciated and freely expressed. Routine is seen as flexible to acknowledge individuality, yet maintain a focal point for service users to latch on to without dictating events. Staff were observed to hold a friendly, Edgeview Nursing Home DS0000022324.V271436.R02.S.doc Version 5.0 Page 13 sympathetic and confident interaction with service users and family, in lounge areas and at lunchtime in helping those who required assistance. Service users’ life-styles and interests are recorded in their care plans, discussed with their relatives prior to admission, and documented as far as possible to enhance a position of supported independence. The recording of social activities was seen to be a valuable part of care reporting and planning. The management demonstrated the strength of protecting service user’s rights, which was secured through the robustness of the procedures in place. This was confirmed on examination of records. The tour of the Home demonstrated a high degree of expressed individuality in each of the bedrooms inspected. A varied menu is available for service users on a four-week cycle and represent a wholesome, appealing and varied balanced diet. It was noted that at short notice a member of the care staff had stood in for a sick cook, and produced a very good lunch, and demonstrated a high level of food, and general hygiene. The dining areas in the main building, Stables and Bungalow were very pleasant, offering conducive ambience for a social meal. The kitchen was seen to be clean, well organised and with modern equipment. An effective cleaning schedule was seen to be in operation. Fridges/freezers and food temperature records were seen to be up to date and accurate. It was most encouraging to see the continuing high standards made in social and occupational therapy initiatives. The activity centre continues to act as a centre providing a range of life skills training events led by an enthusiastic full time activity co-ordinator and assistant with an arts therapist. There was a very strong influence of creativity, not only in the centre, but also throughout the Home. The Home continues to develop a ‘snoezelan’ room, a multi sensory room where individuals can watch light displays, listen to music for therapeutic relaxation sessions. The care manager and activities co-ordinator has initiated training for staff, to present an expanding facility adjacent to the games/leisure room. Plans for Christmas festivities are well advanced. Resident’s life-styles and interests are recorded in their care plans, discussed with their relatives prior to admission, and documented as far as possible to enhance a position of supported independence. Routine is seen as flexible to acknowledge individuality, yet maintain a focal point for service users to latch on to without dictating events. The overall emphasis on the importance of nurturing a solid foundation of trust and respect with the local and wider community is impressive and merits particular recognition. A recent altercation with a neighbour has not deflected the overall confidence in relations. Edgeview Nursing Home DS0000022324.V271436.R02.S.doc Version 5.0 Page 14 The Home’s policy on sexuality is dealt with in a sensitive and professional manner acknowledging that residents are able to develop and maintain intimate relationships in a discrete and sensitive fashion. Sexuality was seen to be an important element of care planning and assessment. Service users living in the independent living bungalow are able to prepare and cook their own meals, in well-equipped kitchenettes, observed by their key worker. There is a need for continuing vigilance in maintaining a good standard of cleanliness monitoring and repair. Edgeview Nursing Home DS0000022324.V271436.R02.S.doc Version 5.0 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 and 21 The pre-admission assessment is recognised as the foundation for a comprehensive care planning process. A profile of the service user’s social, physical and psychological status offers an individual plan of care to be implemented and reviewed. Service users spoken to were particularly pleased in the way their privacy and dignity was respected, not only by the care staff, but everyone connected to the running of the home. The Home operates an environment conducive in support of individual physical and emotional needs. The routines involving medication was inclusive whenever possible, yet safe, secure and efficiently administered. Discussion concerning an aging population with associated care needs is a recognised feature for long-term planning. EVIDENCE: It was pleasing to see that the administration of medicines continues to adhere to procedures to maximise protection to service users. The storage was secure with satisfactory added security for controlled drugs. A controlled drug register was examined and found to be in order. A trained member of staff completed Edgeview Nursing Home DS0000022324.V271436.R02.S.doc Version 5.0 Page 16 MAR sheets accurately, with accountability recorded throughout the process. The philosophy of promoting individuality and self-determination, as laid out in the Statement of Purpose, continues to be seen to be exercised in many aspects of care. The general atmosphere throughout the home was one of family, confidence, warmth and contentment. Staff were observed in addressing service users in a respectful and dignified way. The service user’s spiritual needs are attended to with respect. Relatives are involved and have free access at all times as desired by the service user. The staff ensure that the service user has the appropriate care and prescribed pain relief. Palliative care and bereavement training has been identified as an area for increasing attention due to an aging population of resident, and the wishes to maintain the family partnership of care. The Inspector agreed to make overtures to the necessary clinical nurse specialist for advice. It was noted that an appraisal of any special preferences or observances is recorded on admission, and is regarded as integral in the assessment process. Edgeview Nursing Home DS0000022324.V271436.R02.S.doc Version 5.0 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The home had a meaningful complaints policy, clearly identifying the CSCI as a resource to approach with a complaint or grievance. On discussions it was evident that any small matters were handled immediately, discretely and to the satisfaction of all concerned. Service users’ legal rights are protected by the systems in place in the home to safeguard them, including their contract, the continual assessment of care planning and policies in place. EVIDENCE: The complaints policy was seen and records examined. There were few complaints, none recent, to assess. On discussions it was evident that any small matters were handled immediately, discretely and to the satisfaction of all concerned. Case tracking confirmed the effectiveness of a care manager and staff sensitive to service users needs and readiness to test the robustness of their information and report structures. As part of the process of encouraging self-determination a policy exists to be able to offer advocacy services should they be required. Family involvement has been the usual means of representation in the past. Service users’ legal rights are protected by the systems in place in the home to safeguard them, including their contract, the continual assessment of care planning and policies in place i.e. the complaints procedure. This process was evidenced on examination, and case tracking as previously reported upon. Edgeview Nursing Home DS0000022324.V271436.R02.S.doc Version 5.0 Page 18 The management showed satisfactory evidence of a protocol and response to anyone reporting any form of abuse, to ensure effective handling of such an incident. Staff induction and in-house training programmes clarified the responsibilities of all staff in their daily contact with service users, especially their privileged position in protecting service users from abuse, of all natures. Edgeview Nursing Home DS0000022324.V271436.R02.S.doc Version 5.0 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29 and 30 The home has succeeded in meeting the needs of service users in providing a safe and comfortable environment. Bedrooms were generally well maintained to meet service user’s personal preferences; the outcome is a comfortable and familiar private domain that reflects the service user’s preferences. There is evidence of an awareness of health and safety issues being high on training and supervision priorities. Individual rooms are presented as highly personalised and inviting individual residence. The Home continues to present a clean and pleasant, odour-free atmosphere, much to the credit of staff. EVIDENCE: Edgeview is well appointed to meet the needs of service users with learning difficulties, in providing a safe, inviting and comfortable environment. External access is satisfactory for service users access and visitors parking, fire escapes were kept free of obstruction and well maintained. There was however, some debris blocking the walkway from the activity room to the Stables. Edgeview Nursing Home DS0000022324.V271436.R02.S.doc Version 5.0 Page 20 Service users take advantage of attractive gardens and grounds and it was pleasing to see that the activity co-ordinator has introduced a resident’s garden, which he hopes will develop along therapeutic lines in the Spring. Each room offers single accommodation with adequate and safe radiators, windows, each with smoke alarms and light dimmer switches. Some bedrooms are beginning to show a need for redecoration. It was recognised that there is a programme to provide most bedrooms with divan beds. In one room there was a bed in disrepair, presenting a health and safety hazard. Each resident is encouraged to bring their own personal possessions and furniture if they so wish. It was felt in one room that the resident’s smoking habit had not been thoroughly risk assessed, in the way that smoking debris had build up in his bedroom, and the lack of attention to overall cleanliness in his room. Nevertheless the intended aim is seen to be successful in achieving a sense of identity, a place of comfort and privacy. The Stables and annex have had some recent remedial repairs made to décor and fabric, but continue to need attention, especially in the Bungalow kitchen. However the kitchenette areas in the annexes were generally well presented, adequately stocked and equipped with domestic appliances, although some areas were poorly cleaned. There was no evidence that the daily cleaning and fridge/freezer records had been attended to in the Stables. One freezer handle had been broken off, presenting a hazard. The home’s policies and procedures complied with the fire service requirements in general. A recent fire officer’s report has been complied with. It was noted that the heating control of the building needed attention, with some bedrooms with no heating during the day, whilst some corridors were uncomfortably hot. In the Stables there was a freestanding heater in use, with a very high temperature to touch. It was agreed to withdraw the appliance immediately. One radiator in the Bungalow was unguarded and too hot. Controls were applied with advice that a long-term solution to the heating arrangements be attended to. Adequate attention has been given to ensure maximum privacy within riskassessed boundaries. Upgrading of bathrooms is almost complete, providing much improved facilities. The continuing work in providing a snoezlan facility is slowly showing some emergence, and is hoped to be in general use in the New Year. The laundry area was clean and very well organised, with new washing machines in evidence. Procedures were in place for coping with soiled/infected linen with the provision of alginate bags to minimise handling and crossinfection. Chemical cleaners were used appropriately throughout the home, were seen to be secure and under COSHH recommended practices. Edgeview Nursing Home DS0000022324.V271436.R02.S.doc Version 5.0 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35 and 36 Staffing had maintained consistent levels to ensure equilibrium between numbers, skills and qualifications, with a strong presence of long serving experienced staff. The provider has established a high profile in the management process, offering a detailed knowledgeable and helpful contribution. The Operations manager informed the inspector of routine staff induction programmes, well established and well designed on which formed the base upon which in-service supervision and training are planned and achieved. Formal staff clinical supervision has been established, and extended to encompass general working standards as part of the cascaded package involving all the staff. EVIDENCE: The numbers and skill mix of the staff adhere to, and exceed the Notice of Staffing. Three weeks of off-duty were examined, providing evidence that the home is suitably staffed in numbers, skills and qualifications to ensure the needs of the service users are met Edgeview Nursing Home DS0000022324.V271436.R02.S.doc Version 5.0 Page 22 On the day of inspection the staffing levels were: 0745 – 1415 1415 – 2045 2045 – 0745 – 2 trained 9 carers - 1 trained 8 carers - 1 trained 3 carers The provider and operations manager continue to present a high profile in the management and organisational process, working closely with a highly committed care manager. This team offers a consistent, detailed, knowledgeable presence, essential to the efficient running of a demanding service need. There had been recent difficulties with laundry and catering coverage, which have been tackled. In the interim care staff have covered. The arrangements for laundry coverage were unsatisfactory with an hour-on, hour-off approach. The manager agreed that the coverage would be for a shift basis until satisfactory replacements commence. Four staff files were examined and found to protect equal opportunities, and provide satisfactory evidence that promoted protection of vulnerable service users. The process of appointing new staff were well organised, consistent and safeguarded the interests of residents. NVQ programmes continue with a commitment of internal assessors and the contribution of Dudley and Kidderminster colleges. It is pleasing to see the commitment to care education sustained and enhanced. The supervision programme is firmly establised, which involved establishing a shared aspect of responsibility between staff and trainer, with the involvement of cascaded mentor trained staff. Edgeview Nursing Home DS0000022324.V271436.R02.S.doc Version 5.0 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,41,42 and 43 The care manager offers a sound resource of experience and skills, which are reflected in the high standing in which Edgeview is held by residents, their relatives and the community alike. Edgeview has in place a highly effective and motivated management team, sensitive to the needs of each resident, organisational demands and the professional standing of services to people with learning disabilities. Personnel are well trained and appreciated for their professionalism. Policies are meaningful, supported with up to date procedures and skilled application of good practice. Each presents a safe and secure environment in protection of rights, interests, health and safety of the residents. EVIDENCE: The care management have demonstrated competence in running Edgeview in establishing a solid Statement of Purpose and policy portfolio that has been implemented, to achieve a high standard of set aims and objectives. Edgeview Nursing Home DS0000022324.V271436.R02.S.doc Version 5.0 Page 24 Staff meetings are held frequently in which staff are encouraged to participate fully in the management and direction within the home. The inspector observed at first hand the confident interrelationship that exist not only between management and staff, but also between staff and residents. The care manager has reinforced the presence of quality assurance with a monthly audit of standards, and regular review of risk assessments. There was strong evidence of openness and honesty in speaking with service users, relatives and staff in which day to day events and episodes are freely discussed. Evidence was secured to confirm a quality monitoring system has been introduced, based upon audit of standards, care plans and feed back from service users and relatives. Standards are discussed at staff meetings, daily reports, direct observation and involvement and one to one staff meetings. The procedures manual was randomly examined and found to offer a very comprehensive reference, although these policies are in need of review to reflect changing circumstances and contemporary issues. A report from a fire prevention inspection had been completed and complied with Fire safety remains high priority for all staff evidenced in routine maintenance checks, regular fire drills and frequent staff training sessions were recognised. Suitable accounting and financial procedures were found to be satisfactory. The appropriate insurance cover was in place. Records were kept of all transactions entered into by the registered person and made available for inspection. Small amounts of service users’ pocket monies were accounted for, and kept secure, these were made available and seen to be accurate and up to date. Discussion with the care manager indicated that supervision sessions and individual training programmes are areas that with continuing improvements, will enhance the desired impact on quality of service. A sample of administrative, maintenance and care records were examined including water and fire alarm maintenance contracts, and found to offer an accurate reflection of a service committed to providing a safe and comfortable environment for learning difficulty service users. The Regulations, Standards and Schedules as provided in the Care Standards Act 2000 are recognised and implemented. Records were seen to be generally well maintained, accurate and up to date in accordance with the Data Protection Act 1998. Accidents were seen to be addressed, risk assessed, actioned and recorded in an effective way, with access to Riddor if needed. No serious accidents have been recently reported. The administration and management of the home is efficient, uncomplicated and sensitive to the needs of service users. Edgeview Nursing Home DS0000022324.V271436.R02.S.doc Version 5.0 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 4 4 4 4 4 Standard No 22 23 Score 4 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 4 4 4 2 4 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 4 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 4 13 4 14 3 15 4 16 4 17 Standard No 31 32 33 34 35 36 Score 3 4 3 4 3 3 CONDUCT AND MANAGEMENT OF THE HOME 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Edgeview Nursing Home Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 4 4 3 4 3 3 4 DS0000022324.V271436.R02.S.doc Version 5.0 Page 26 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 2 3 Standard YA24.6 YA24.6 YA24.10 Regulation 23(2)(p) 23(2)(p) 23(2)(c) Requirement That remedial work is carried out to the heating system That radiators be guarded at all times. Damaged bedstead be replaced Damaged freezer handle be replaced. Timescale for action 01/04/06 01/01/06 01/01/06 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 YA24.1 YA24.12 YA33.1 YA8.2 Good Practice Recommendations Attend to debris on pathways Upgrade general fabric, furnishings and décor That staff covering laundry duties do not practice care duties in the same shift. That residents who are high risk, i.e. smokers, are risk assessed thoroughly. Edgeview Nursing Home DS0000022324.V271436.R02.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Edgeview Nursing Home DS0000022324.V271436.R02.S.doc Version 5.0 Page 28 - 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. 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