Inspection on 18/01/06 for Edgeworth House Nursing Home

This inspection was carried out on 18th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Edgeworth House Nursing Home 04/06/08

Edgeworth House Nursing Home 05/04/07

Edgeworth House Nursing Home 13/10/06

Edgeworth House Nursing Home 29/07/05

Edgeworth House Nursing Home 15/10/04

Edgeworth House Nursing Home 14/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Edgeworth House Nursing Home Church Road Bebington Wirral CH63 3DZ Lead Inspector Julie King & John McCabe Unannounced Inspection 18th January 2006 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 Edgeworth House Nursing Home DS0000020945.V277838.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. Edgeworth House Nursing Home DS0000020945.V277838.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Edgeworth House Nursing Home Address Church Road Bebington Wirral CH63 3DZ 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) 0151 643 1271 0151 643 1352 Ashbourne Homes Limited Mrs Margaret Lynne Walter Care Home 103 Category(ies) of Old age, not falling within any other category registration, with number (103) of places Edgeworth House Nursing Home DS0000020945.V277838.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 103 beds nursing care / 14 beds personal care in an overall total of 103 Two named adults under 65 years of age The person registered must ensure that appropriate aids and equipment are provided and the care plan of the named service user (variation application dated 24.2.04) should be regularly reviewed, the outcome of which must be forwarded to the Commission for Social Care Inspection monthly. One named service user under 65 years of age with Physical Disability To vary the conditions of registration to allow two named service users under the age of 65 years to have respite at Edgeworth House for a set two week period from 17 August 2005 29th July 2005 4. 5. Date of last inspection Brief Description of the Service: Edgeworth House is registered to provide nursing care to 103 older people, 14 of which may require personal care only. The home is a three storey purpose built home and offers the majority of service users, single, en-suite accommodation with baths or showers. The bathrooms are conveniently situated and provide bathing aids. Each floor has two lounges and offers a choice of a non-smoking or smoking lounge. The dining room is situated on the ground floor. All floors are served by a passenger lift. There are large gardens that are fully accessible to service users and a patio area. There is car parking to the front and rear of the home. The home is situated in Bebington and is close to local shops and public transport services. Edgeworth House Nursing Home DS0000020945.V277838.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over half a day, and was completed by CSCI Inspectors Julie King and John McCabe. During the inspection time was spent in the office examining records, policies and procedures, and talking to the manager and care manager. Numerous residents, staff and some visitors were also spoken to during this inspection. A full tour of the home was undertaken, both inside and the external and premises. Staff were seen interacting with residents, and a good rapport was observed. What the service does well: What has improved since the last inspection? What they could do better: Communication records in service user’s care plans could contain more detailed and concise information. Edgeworth House Nursing Home DS0000020945.V277838.R01.S.doc Version 5.1 Page 6 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. Edgeworth House Nursing Home DS0000020945.V277838.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 Edgeworth House Nursing Home DS0000020945.V277838.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): 1, 2, 3, 4, & 5. New service users are fully assessed before they are admitted to the home in order to ensure their needs are met. EVIDENCE: The records demonstrated that service users are appropriately assessed before they come to live at the home. The general manager or care manager assess each prospective service user using an assessment framework that meets the National Minimum Standards. There was evidence of multidisciplinary healthcare professionals and family being involved in the pre-admission assessments. A discussion with the care manager indicated that prospective service users and their relatives are able to visit the home on as many occasions as they wish before making a decision as to whether to move to the home. Service users can move in on a trial basis for 4 weeks before a final decision as to whether to stay at the home is made. This is reflected in the terms and conditions provided to service users. Edgeworth House Nursing Home DS0000020945.V277838.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, 11. The needs of service users are well supported by the care planning processes in place at the home. The home’s policies and procedures for managing medicines does not safeguard service users. EVIDENCE: A sample of service user ‘s care plans were seen. These contained sufficient information to enable staff to meet the health, personal and social needs of the service users. The care plans seen had been reviewed monthly. The records at the home and a discussion with the manager and deputy manager indicated that referrals are made to health professionals in accordance with the needs of service users. A record is made of visits by health professionals and the outcome is documented. A sample of accident records were examined and were appropriately maintained. The manager undertakes an audit of the number of accidents at the home and provides this information to the regional manager on a monthly basis. Edgeworth House Nursing Home DS0000020945.V277838.R01.S.doc Version 5.1 Page 10 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. Residents have choice and flexibility how they spend their day in the home, and pursue leisure activities according to their choice and preferences this allows independence and individuality for each resident. Residents receive a varied nutritious diet that is in accordance with their preferences. EVIDENCE: Residents in the home are asked on admission about their lifestyle, choice of foods, and choices and preferences of the social activities they would like to participate in. On admission to the home the resident with help from a family member completes “Getting to know you” questionnaire, which is a “Work life History” of the resident, and includes schooling, work, hobbies, food likes and dislikes etc. This information is used to facilitate organised activities for the resident. The home employs a full time activities coordinator for the resident’s activities. The coordinator is aware of the National Association of Patient Activities (NAPA), which is a national organisation, which promotes, activities for residents in all health care facilities. Edgeworth House Nursing Home DS0000020945.V277838.R01.S.doc Version 5.1 Page 11 The inspectors spoke with the activities coordinator, especially about how she recorded and documented the activities for the resident, and how they participated in them. The inspectors was surprised to hear that she made a written recording on the day of the activity and then at the end of the week the night staff transcribed her original notes in to the personal health file of the residents. How residents join in the activity (or refuse) is part of the holistic care approach for the resident, this information should be documented in the residents’ daily health record sheet, so as a full picture of the residents day is recorded. All the medication rooms and related documentation and records were examined in each of the three units – at the time of this inspection all were found to be managed in accordance with current good practice guidelines. The home is large and spacious and has well-furnished and decorated communal lounges. Corporate management of home should consider allocating one of the lounges solely for the purpose of organised activities. This would be useful for wheelchair users and other less mobile residents to come together and join in-group activities according to their choice and preferences. Residents told the inspectors that the enjoyed meals served in the home, which they could eat in the dining room or in their own bedroom. Residents spoken with on the day of the inspection told the inspectors that the staff was kind and very helpful Edgeworth House Nursing Home DS0000020945.V277838.R01.S.doc Version 5.1 Page 12 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, 17, 18. The home has a satisfactory complaints system with evidence that the views of service users and their representatives are listened to and acted upon. There are procedures at the home to help ensure service users are protected from abuse. EVIDENCE: There is a complaints procedure available that clearly explains how to make a complaint and is easy to understand. A record is made of complaints and they are sent to divisional office. The records kept in relation to complaints are clear and well maintained and show that complaints are investigated and action taken to address any issues identified. Since the last inspection complaints have been made to the CSCI about the standards of care provided at the home. As a result requirements and recommendations were made by the CSCI. The registered persons have supplied an action plan outlining how these recommendations and requirements are to be met. The home has an adult protection procedure, including whistle blowing. The home also has access to a copy of Wirral Borough Council’s adult protection procedures. Staff receive training around the adult protection procedures. Edgeworth House Nursing Home DS0000020945.V277838.R01.S.doc Version 5.1 Page 13 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, 20, 21, 22, 23, 24, 25, 26. The overall fabric of the building is of a good standard, with most resident’s rooms being highly personalized. EVIDENCE: A full tour of the home was undertaken, during which a sample bedrooms were inspected, all food preparation areas and communal areas. In general the home is satisfactorily maintained with evidence of decorative and maintenance work taking place. The sample of furnishings seen were of a good quality, and numerous items of furniture had been replaced since the previous inspection. The majority of the bedrooms and communal areas inspected were clean, and numerous areas have been re-carpeted since the previous inspection. Decorators were seen in process of painting one of the units, and service users are given the opportunity to choose colour schemes as they wish for their own Edgeworth House Nursing Home DS0000020945.V277838.R01.S.doc Version 5.1 Page 14 rooms. Safety records were up to date regarding hot water temperatures, bedrails, and appropriate risk assessments. Edgeworth House Nursing Home DS0000020945.V277838.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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): 27,28,29,30. There are sufficient numbers of staff with complementary skills to meet the needs of service users. EVIDENCE: The rota and a discussion with the staff and the manager indicated that there are sufficient numbers of staff to meet the needs of the service users. There is a mix of trained and experienced care staff employed that meets the staffing requirements for the home. The rota and a discussion with the manager indicated that nursing and care staff are appropriately deployed to meet the needs of service users. The home uses it’s own bank staff to cover staff shortages. Agency staff are utilised at the home to cover staffing shortfalls. The manager reported that agency staff are always deployed to work alongside a regular member of staff who knows the home well to ensure continuity of care. The numbers of ancillary staff employed at the home who have responsibility for catering, domestic, administrative tasks and maintenance are sufficient to meet the needs of the service users. Training records were examined as part of the check on staff personnel files. They evidenced mandatory and specialist training, with most staff having already achieved, or in process of NVQ training. Housekeeping staff are included into this NVQ training programme, and a senior healthcare assistant has now completed her NVQ4 in care, enabling her to act as a mentor for more junior members of staff. Edgeworth House Nursing Home DS0000020945.V277838.R01.S.doc Version 5.1 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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): 31,32,33,34,35,36,37,38. The service users benefit from a manager who is qualified and competent to discharge their duties and who ensures the health and safety of service users is promoted. EVIDENCE: The manager was been in post for 6 years. The manager has completed an NVQ Level 4 qualification in management, and has achieved her Registered Manager’s Award. The manager reported that both herself and the care manager have attended training to keep their knowledge and skills up to date. An examination of the induction and follow on training schedule indicated that staff are provided with sufficient training to ensure that all senior staff are familiar with the conditions/diseases associated with old age. The records of fire safety checks, electricity and gas were in order. Training records showed that staff are given appropriate training in safe working practices. Edgeworth House Nursing Home DS0000020945.V277838.R01.S.doc Version 5.1 Page 17 There are policies and procedures in place to promote the health and safety of service users and staff. Service contracts and required safety certificates were in date and valid. Service users finances are managed competently by a qualified administrator, who was able to demonstrate clarity and precision regarding record keeping and safeguarding accounts. Edgeworth House Nursing Home DS0000020945.V277838.R01.S.doc Version 5.1 Page 18 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 3 3 3 3 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 3 3 3 3 3 3 3 Edgeworth House Nursing Home DS0000020945.V277838.R01.S.doc Version 5.1 Page 19 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. Standard Regulation Requirement Timescale for action 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 Refer to Standard 12 Good Practice Recommendations It is recommended that when residents participate in organised activities, how they participated in the activity is documented in the person file of the resident by the activities coordinator It is recommended that the corporate management of the home consider allocating one of the communal lounges for the purpose of organised activities. 2 12 Edgeworth House Nursing Home DS0000020945.V277838.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Liverpool Local Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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. 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