CARE HOMES FOR OLDER PEOPLE
Edmore House 20 Oakham Road Oakham Dudley West Midlands DY2 7TB Lead Inspector
Mrs Jean Edwards Key Unannounced Inspection 11th October 2007 08:00 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 Edmore House DS0000024953.V345494.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. Edmore House DS0000024953.V345494.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Edmore House Address 20 Oakham Road Oakham Dudley West Midlands DY2 7TB 01384 255149 01384 255149 annnewton@aol.com 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) Mr Charanjit Singh Atwal Mrs Ann Newton Care Home 18 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (1), Physical disability over 65 years of places of age (17) Edmore House DS0000024953.V345494.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 12/09/06 Brief Description of the Service: Edmore House is a privately owned care home and is registered to provide accommodation for 18 elderly persons. It is a converted property consisting of three floors. The first and lower ground floors can be accessed via the lift or stairs. All bedrooms are tastefully decorated and service users are encouraged to bring small items of furniture with them if they wish. There are three lounges on the ground floor and a dining area. At the rear of the property is a patio with garden furniture, potted plants and a large garden. Car parking is available at the front of the house and visitors may visit at any time. Care staff are available 24 hours a day to meet the needs of the service users and ancillary staff are employed during the day. A statement of purpose and service user guide is available to inform residents of their entitlements. Information regarding fee levels has not been provided to the Commission for Social Care Inspection. Edmore House DS0000024953.V345494.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This is the key inspection visit for 2007 - 8, undertaken by an inspector from the Commission for Social Care Inspection (CSCI). The inspector has spent ten hours on a weekday at the home. All Key National Minimum Standards have been assessed at this visit. The range of inspection methods to obtain evidence and make judgements includes: discussions with the proprietor, registered manager and staff on duty during the visit, discussions with residents and examination of a number of records. Other information was gathered before this inspection visit from the AQAA (Annual Quality Assurance Assessment, notification of incidents, accidents and events submitted from the home. Service user surveys, relatives and healthcare professional surveys were sent to the home by the CSCI. An analysis of the 9 survey forms from service users, 9 from relatives and 5 GP responses is contained throughout this report. Responses are very positive. There are currently 17 residents living at the home. During the visit the inspector spoke to the majority of residents. Longer discussions have taken place with the residents whose care was looked at in depth. The inspection has included a tour of the premises, including the grounds, communal areas of the home, the bathrooms, toilets, laundry, kitchen areas, and residents’ bedrooms, with their permission. What the service does well:
The home provides comprehensive information for prospective residents and their representatives, assisting people to make decisions, which are right for them. The residents are very complimentary about the care and support they receive with comment such as: all questions readily answered, and always somebody there to help. All responses from relatives surveys state they have sufficient information, including the comment, Edmore house was carefully chosen because my husband and I felt the caring atmosphere and natural warmth when we first visited on our assessment trail of residential homes The home has a key worker system, which means that there is a closer relationship between staff and individual residents, whose preferences and needs receive more detailed attention. All 9 resident surveys responded that there are always sufficient staff and include comments such as, I feel that everyone cares, and Im very happy to be living here, staff and everyone make you feel good, excellent Edmore House DS0000024953.V345494.R01.S.doc Version 5.2 Page 6 Staff are aware of each persons dietary needs and food intake is recorded as required with residents weight monitored and action taken as needed. There are excellent relationships between the home and health care professionals. Comments from GPs about what the home does well include, Sensible staff, are pro-active in looking out for patients needs, have always sought clarification of care & second opinion, if not sure, individual care, needs of patient put first, people well looked after, social aspects & interaction encouraged and Treat them as individuals, call GPs appropriately. Relatives comments include, I am always informed if my mother is unwell, and what action is being taken e.g. calling in GP. There is a wide range of organised and spontaneous activities and outings for residents advertised on a notice board in the communal areas. The home has a supply of outsized games, puzzles and quizzes, which are enjoyed by residents. Residents’ are supported to go out regularly on trips and outings for example to church, Merry Hill and Walsall Lights. There are also people who come to the home to provide crafts, exercises and entertainments. Residents spiritual needs are met with visits from church groups to the home, with services, and arrangements are made to take any resident who wishes to go to church. All residents and relatives surveys state that there are always activities available, including comments, we keep very busy with activities provided by the management and prefer sometimes to join in. The relatives survey responses include, encourages social activity and provides a homely atmosphere. The home is clean, comfortable and homely, comments from residents and relatives include, very clean & tidy, cleanliness comes high on the agenda, and I have never walked in and noticed nasty niffs. The staff are caring, knowledgeable about the residents needs and they are welcoming and friendly. Comments from the relatives survey about what the home does well are, I always feel that the staff are available to answer any queries as they arise and extra effort is often made to motivate and keep my mother mobile as she has difficulty walking and standing There is lots of conversation and informal activity between residents who move freely around the home to chat to their friends in other parts of the home. The residents are caring towards each other, even visiting people in their rooms when they are too unwell to be in the communal areas of the home. The management of this home show a strong commitment to training and developing staff, which means that the residents benefit from their skills and knowledge. Comments include wish all homes are as nice as this one and management excellent. The registered person, manager, and senior care team, have put in place quality and monitoring systems, which actively involve residents, relatives and staff across a number of areas of the home, including how care is provided, Edmore House DS0000024953.V345494.R01.S.doc Version 5.2 Page 7 menus, activities, and the environment. A resident says the food is very good, another describes food as smashing. This inspection was conducted with full co-operation of the proprietor, registered manager, staff and residents. The atmosphere through out the inspection was relaxed and friendly. The Inspector would like to thank staff, and residents for their hospitality during this inspection visit. What has improved since the last inspection?
The registered persons have met 27 of the previous 28 requirements and the remaining requirement is partly met. In addition 6 of the 7 previous good practice recommendations have been met. Each person or their representative now receives written confirmation that the home is able to meet all of their needs. Everyone is offered the opportunity to make introductory visits, with outcomes and decisions about visits fully recorded on residents individual case files. This demonstrates that people have good information and opportunities, to make decisions about where they will live. The way the home plans each persons care has improved with very detailed and specific written information providing staff with clear guidance about each persons needs and preferences. At this visit additional areas needing fuller detail have been discussed. Health care assessments are good, with detailed measures in place to minimise risks of falls and risks involved in moving and handling people. There are also records on each persons file, showing that there is good access to specialist medical, chiropody and dental care. The results from all three GP surveys are very positive about the way this home meets residents healthcare needs, which indicates the good relationships between the staff and health care professionals. The homes system for the management and administration of residents medication has been improved in a number of areas, though as a result of this visit there are additional minor improvements needed, so that residents are safeguarded as far as possible. The registered manager has taken action to explore the comments made by some residents and relatives in the homes own quality assurance surveys and residents meetings, relating to meals and spiritual needs. The registered manager and staff have created an environment, where comments and concerns are welcomed as an opportunity for the home to improve and a comments from a relative state, these matters are only ever of a minor nature, issues that my mother would not mention herself, and we deal with whatever comes up in a friendly and co-operative way and all questions are fully answered with appropriate details and time given.
Edmore House DS0000024953.V345494.R01.S.doc Version 5.2 Page 8 The proprietor has taken advantage of a Government grant for funds and plans to build a freestanding conservatory / summerhouse in the very attractive, well-tended gardens. The home has a maintenance, redecoration and renewal programme, and new dining room furniture has been provided, with a new dinning room carpet on order. There are new sets of matching bed linen and hand towels and communal areas of the ground floor have been repainted, in addition to the redecoration programme for residents bedrooms. There are also new pictures, mirrors, ornaments, plants and fresh flowers in communal areas. The staffing levels are now more stable and the recruitment processes and staff personnel records have improved, which provides good safeguards for the residents. The registered persons have put in place a robust quality assurance system to measure and monitor the homes performance, using questionnaires and other means to seek the views of residents, relatives and other professionals in the wider community. The results of the homes surveys are very positive and these are reflected in the responses to surveys sent out from the CSCI. These are a sample of comments from relatives surveys, this is a very well run, homely, friendly residential home. I cannot thank them enough for the care they have given to my mother. The food is excellent she has gained two stones, the TLC provided, and support given to the family has always been second to none, we are so pleased that such a care home exists, every person in this particular care home cares, from our family observations everyone is an individual and is treated with kindness, the care and attention shown to M is outstanding in every way, in view of her special needs, and Edmore house provides a warm, stable, caring atmosphere where everyone is treated as an individual who still has a place in the daily life of a community and whose contentment and happiness is important. What they could do better:
The homes Annual Quality Assurance Assessments (AQAA) submitted to the CSCI should contain fuller information and better detail of the supporting evidence of what the home does well and how the improvements have been made. Minor improvements are needed to make the homes system of medication administration as safe as possible and health care screening records should accurately reflect the current needs of residents, and be updated when the residents needs change. The registered persons and manager should make additional improvements to the homes staff training programme, for example to include equality and diversity training. Please contact the provider for advice of actions taken in response to this
Edmore House DS0000024953.V345494.R01.S.doc Version 5.2 Page 9 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. Edmore House DS0000024953.V345494.R01.S.doc Version 5.2 Page 10 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 Edmore House DS0000024953.V345494.R01.S.doc Version 5.2 Page 11 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): 1, 2, 3, 4, 5 Quality in this outcome area is good. The home has an up-to-date statement of purpose and service user guide. This has the effect that residents and their advocates have good information regarding their rights and entitlements, any agreed restrictions and how care will be provided. The home uses comprehensive assessment tools, which means that residents’ needs are thoroughly assessed to ensure that care needs will be met. The home actively encourages introductory visits and there is evidence to demonstrate that people have been given the opportunity and time to make decisions, which are right for them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has an updated statement of purpose and service user guide, providing good clear information about the home, produced in a large print format. The service user guide has been expanded to include a copy of the
Edmore House DS0000024953.V345494.R01.S.doc Version 5.2 Page 12 contract/terms and conditions of residence and the summary the most recent inspection report. However the service user guide does not contain actual details of the level of fees charged, which would be good practice. Copies of the statement of purpose and service user guide, the complaints procedure and recent CSCI inspection Reports, together with information about visiting times and advocacy services are located in the reception area. Examination of residents case files and discussions with residents and relatives confirm that they have been given a welcome pack with copies of the homes statement of purpose, service user guide and complaints procedure. There are also signatures on residents files to indicate receipt of these documents, demonstrating good practice. There is evidence from the CSCI service user and relatives surveys and from a sample of case files that each resident is provided with a contract / statement of terms and conditions. These documents have been revised to incorporate good practice guidance issued by The Office of Fair Trading. From discussions and observations there is evidence that all prospective residents and families have an invitation to visit before coming to live at the home. Records are available to demonstrate decisions and outcomes of visits, or reasons why a visit has been declined or was not able to take place. One relative spoken to says this was the first home she visited for her mother, and she came back and chose it because of the managers approach. She feels the proprietor is delightful and the manager is very professional, knows all about the residents and the care is excellent, can always see staff about and they are friendly and helpful. There are currently 17 residents accommodated, 15 people at the home, 1 person in hospital and 1 person discharged from hospital to a step-down bed in a nursing home. Discussions with registered manager and proprietor / deputy manager and assessment of the pre inspection information supplied by the home, indicates an awareness that if and when residents deteriorate and they may need care, which the home is not able and not registered to provide, they are supported to access a more appropriate placement. The examination of a sample of residents records and discussions with relatives and staff confirm that the assessment is conducted professionally and sensitively and has involved the family or representative of the resident. Individual preferences are recorded such as rising, retiring, likes and dislikes, preferred gender of staff to give assistance with personal care. Each resident and / or their family has written confirmation from the registered manager to confirm the persons admission to the home, and the correspondence has been expanded since the last inspection visit, to confirm that the home can meet all assessed needs. Edmore House DS0000024953.V345494.R01.S.doc Version 5.2 Page 13 The staff show that they are aware of residents needs, and there are improved records of each residents preferences such as rising, retiring, likes and dislikes, which reduces risks posed by reliance on verbal communication between staff. Edmore House DS0000024953.V345494.R01.S.doc Version 5.2 Page 14 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, 10, Quality in this outcome area is good. The improved care planning, risk assessments and monitoring provides staff with the information they need to satisfactorily meet residents needs. There is good multi disciplinary working taking place on a regular basis, which results in the health needs of residents being well met. The home has made good progress to improve the arrangements for administration of medication, which safeguards residents health and well being. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager has introduced improved care plans. Each resident has a comprehensive plan for their care needs, with evidence of the involvement of the person and their family where appropriate, in the development and review of the plan, which demonstrates good practice. There are now fuller details of foot, oral care, nutrition, and medication regimes. Residents and relatives confirm their involvement in developing the plan and receive feedback on decisions made during reviews.
Edmore House DS0000024953.V345494.R01.S.doc Version 5.2 Page 15 The sample of three care plans examined during the inspection include all essential information necessary to plan the individuals care and there are a range of risk assessments in place. All care plans include beliefs, contact with relatives, physical abilities, healthcare & personal care needs, mental health and communication. All plans examined contain photographs of the person and good information about their preferred daily routines. The care plans include information about how care needs will be met for example, level of assistance, prompts, and monitoring required. There is generally satisfactory evidence that information and changing actions appear on care plans. The registered manager has introduced plans for short term care needs, for example one person has recently had a chest infection and has needed more care in bed and in her own room, with a course of antibiotics and the need for extra fluids, all of which is well documented. The short-term care plans are recorded on colour-coded records (green), which are archived to the back of the case file, when no longer needed. The daily notes completed by staff are detailed and give good information and relate to the recorded care needs. However the monthly checklists of personal care provided have some gaps, for example there is no indication of what care was given to a resident who was unwell in September on 1, 5 and 7 of the month. Another residents personal care checklist has large numbers of gaps, which the manager explained could be because this person sometimes undertakes their own personal care, which should be recorded as such. All three care plans sampled contain evidence that they are audited monthly, signed & dated by the persons key worker. However notes are brief and basic, such as no problems and been fine, the manager has indicated that there are other additional records as supporting evidence. The residents files have good written evidence of a range of risk assessments, dependency levels, for moving and handling, Waterlow tissue viability and nutritional assessment. The home is not currently undertaking a documented falls risk assessment for all residents, which should be a base line record, though there is a falls log on file for each resident and there is evidence of involvement of the Dudley Falls Team, where relevant, which is very positive. One new resident has not been weighed on admission but her weight has been monitored subsequently. The manager and staff are proactive in seeking professional advice on health care issues, always acting upon it and generally able to access the aids and equipment recommended. The comments from the GP surveys and from visiting district nurses are very positive about relationships with staff at this home. There is documentary evidence that all residents have appropriate access to dentists, opticians, chiropodists and other community services. One resident chooses to make his own appointments with his private chiropodist. Edmore House DS0000024953.V345494.R01.S.doc Version 5.2 Page 16 One GP survey contains the very positive comment, residents at Edmore House are very well looked after. Edmore House is the only residential home & probably care home that I would send a relative to in this area One resident who is deteriorating and is being cared for in her bedroom, with full involvement of GP, district nurses and family has a comprehensive care plan in place and evidence of the aids needed such as a pressure reliving mattress and cushion. However the health care assessments have not been updated as yet, for example the moving & handling assessment does not reflect that she is no longer able to walk and the score of medium dependency needs to be reviewed. These have been discussed with the registered manager who agrees that they will be reviewed and updated to more accurately reflect the residents needs and the level of care and support, which is being provided. The relatives say very happy with the care and feel involved every step of the way, staff ring and keep in touch, the staff are great, they really care and are very sensitive and welcoming in the approach to the residents elder brother, who feels Edmore House is home from home. Mother has never eat well but staff have persevered to encourage her to eat soft foods and are very patient sitting with her to encourage her to drink. This relative also states that the home has pleasant and friendly residents, who care about each other and have asked if they can visit her mother in her room, and they do knock on the door and go in to visit. The home has a comprehensive medication policy, accessible for staff guidance. Staff involved in medication administration have received accredited medication training from Wolverhampton College and demonstrate a good awareness of the use and effects of medications in the home. Medication records are generally up to date for each resident and medicines received, administered and disposed of are recorded. The home has introduced the use of red tabards, which read Do Not Disturb Administering Medication, for the senior carers undertaking this task, which demonstrates good practice. Any residents who wish to administer some or all of their own medication are supported to do so, with systems in place so that this can happen safely, including risk assessments. Where medication systems are in need of improvement action, there is confidence that the registered person is working to achieve the improvements. The home still has systems where the senior carer takes and checks the medication from a locked cupboard in its secure location to the resident, wherever they may be in the home, returning to repeat the process for the next persons medication, which has been discussed with the pharmacy provider and is still under review. Minor improvements are required as a result of this inspection, for example, as previously indicated records of medication administered need to be fully recorded on MAR sheets, whether it has been given or not with a code to denote the reason and as directed dosages still need to be clarified in a small number of records. Edmore House DS0000024953.V345494.R01.S.doc Version 5.2 Page 17 From observations and discussions there is evidence that staff are aware of the need to treat residents with respect and they consider personal dignity when delivering personal care. The home arranges for residents to enjoy the privacy of their own rooms any time they wish. The residents say that are happy with the way that the staff deliver their care and show them respect. Comments from the relatives survey include, always very professional and caring in their approach. If anything occurs they cant deal with they always contact the appropriate agencies e.g. doctors, district nurses and They always strive to keep my mothers dignity and privacy. The registered manager and some of the staff group have undertaken accredited dementia training, Yesterday Today and Tomorrow, provided by the Alzheimer Society. She states that this has been beneficial although it has been personally challenging for some people. It is very positive that she has arranged group sessions to help and support staff with their individual learning, which will give them improved knowledge and skills to meet the needs of residents with dementia. Edmore House DS0000024953.V345494.R01.S.doc Version 5.2 Page 18 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): 12,13,14,15 Quality in this outcome area is good. There are planned and spontaneous activities available on a which give residents opportunities to take advantage of and stimulating activities. Residents cultural and spiritual needs majority of residents are able to maintain good contact with regular basis, develop socially are well met. The family and friends. Dietary needs of residents are well catered for with a balanced and varied selection of food that meets residents tastes and choices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is evidence that the residents and relatives are able to discuss what makes them happy and make comments if they feel improvements can be made. Evidence from the CSCI residents and relatives survey forms and from discussions during the inspection visit indicates that staff listen and make genuine efforts to enable residents to enjoy a good quality of life. There are residents meetings with the proprietor every 2-3 months, with notes to show that a range of topics is discussed and ideas shared.
Edmore House DS0000024953.V345494.R01.S.doc Version 5.2 Page 19 The home has a key worker system, which enables closer relationships between residents and staff, where likes, dislikes and needs are understood. There is improved evidence that Key workers use information to plan activities, which residents will enjoy. There is a good level of activities, especially relating to residents with dementia or sensory difficulties. The activities and events are well advertised with imaginative pictorial images. A number of residents enjoy outings, including visits with members of their families. The proprietor / deputy manager states that residents are supported to go shopping at Merry Hill for Christmas presents, the dates are arranged for 12 & 13 December 2007 and a trip is also booked to go to see the Walsall Illuminations. There are activities arranged at the home, such as someone who comes to do crafts and attractive handmade cards are on display. One resident has made a very imaginative hand made card to send to her great-grandson in New Zealand. The residents also enjoy exercise sessions with a training therapist and a singer who is regularly booked to provide entertainment at the home. During this inspection visit there has been lots of interaction between residents, moving about to sit and chat to each other. Some residents are also talented knitters, producing eye-catching garments for themselves. The home has a number of new activity aids around the home, such as the giant four in a row game and white board, which are used to encourage residents to join in. There are residents who are active members of St Peters church in Netherton and receive visits from other church members, including the choir who come to the home regularly to provide a service of hymns. The home also has visits from the local Salvation Army, which the residents enjoy. During discussions some people say that they prefer to spend their time on their own in their own bedrooms, with individual interests. The staff team are well aware of individual residents decisions, which are respected and supported. There is evidence that family and friends of the residents feel welcome and know they can visit the home at any time. The visiting policy and visitors book is located in the reception area. All visitors are greeted and requested to sign in and out of the home for safety and security reasons. It has been indicated that staff always make time to talk to visitors and share information with the agreement of the resident. There have been a large number of visitors to the home during this visit. Those spoken to have spoken very positively about the care and attention provided by the home, stating nothing is too much trouble and the management and staff are always friendly and ready to listen and help. Edmore House DS0000024953.V345494.R01.S.doc Version 5.2 Page 20 During the tour of the premises it is evident that residents are able to have personal possessions in their room, though there may be some restrictions, for example larger items of furniture, which may be due to space restrictions or health and safety considerations relating to the residents bedroom. There are inventories of residents personal possessions on the sample of files examined, which are now completed by families, which is a very good practice, however one inventory examined has not been signed by a member of staff. The home has a programme of menus offering meal choices, and residents are asked daily which food they want for each meal. Breakfast generally comprises: porridge, assorted cereals, toast, marmalade or jam, and one resident prefers jam sandwiches. On the day of this inspection visit lunch comprises: meat pie or cheese and potato pie, with a selection of roast or creamed potatoes and vegetables, followed by vanilla and bread-and-butter pudding or Madeira sponge with cream or custard. At teatime there is a choice of sandwiches with assorted fillings such as, tuna, ham, corned beef, cheese, or bananas, served with salad garnish and pickles. An alternative is salmon and broccoli quiche and three residents have chosen to have soup. For dessert there is a choice of ice cream, chocolate, assorted cakes, and yoghurt. Suppertime choices are prepared on an individual basis according to what the resident wants. The cook is experienced, consults with residents and tries to meet the preferences and suggested dishes when preparing the menu. Resident surveys conducted by the home in March 2007 indicate that all residents say they are happy with the food provided and this is confirmed in discussions during this inspection visit. A resident has commented, the food is beautiful, we are really well looked after. Residents are able to enjoy the flexibility of meal arrangements and can eat in their own room, or at a small table in one of the sitting rooms, if they wish. One resident chooses to have a late breakfast in the dinning room at around 10:30 am, she says, you can get up when you want here. There are plentiful supplies of cool drinks, with easy access for residents, around the communal areas of the home and it can be seen that staff willingly make drinks for residents at any time. The food is good quality, well presented and meets the dietary needs of residents. The staff are sensitive in their approach to help those residents who need help when eating. The home now has records of daily food and fluid intake for residents assessed as being nutritionally at risk. However as with the turn charts the food record charts appear to commence mid-week, which can be confusing, and the registered manager has agreed to review and revise these documents. Edmore House DS0000024953.V345494.R01.S.doc Version 5.2 Page 21 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, 18 Quality in this outcome area is good. Complaints are listened to and action is taken to look into them, and there are systems to record investigations and outcomes. Arrangements for protecting residents are generally satisfactory. Policies, procedures, guidance and staff training are being implemented, which safeguard residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has complaints procedure displayed in the reception area and contained in the service user guide. The complaints procedure has been produced in large print, with pictures making it easy to read. Information supplied as part of the homes Annual Quality Assurance Assessment (AQAA) indicates that the home has not received any complaints since the last inspection in August 2006. From the results of the service users survey, all respondents indicated that they are aware of how to raise concerns and use the homes complaints procedure. The manager and proprietor indicate that they use residents meetings and individual reviews to discuss the homes complaints procedure. Edmore House DS0000024953.V345494.R01.S.doc Version 5.2 Page 22 The home has not received any allegations relating to abuse of vulnerable residents. There is a copy of the multi-agency procedures to safeguard adults, Safeguard and Protect at the home. There is a signature list to show that all staff, including two new staff have signed to show they are aware of the up to date version of Safeguard & Protect. The homes policies and procedures regarding protection of residents are generally satisfactory they have been reviewed and updated to be generally in line with regulations and other external guidance. Progress has been made to provide all staff with appropriate training to respond to the need to safeguard residents at the home and staff spoken to are able to discuss what action to take in the event of any allegation or disclosure. Edmore House DS0000024953.V345494.R01.S.doc Version 5.2 Page 23 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): 19,21,24,25,26 Quality in this outcome area is good. The significant and positive changes to the décor and furnishings are continuing. The incremental improvements contribute to creating a pleasing and pleasant environment for residents to live in. The grounds are very well maintained to provide a safe, pleasant and stimulating outdoor environment for residents to enjoy. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Edmore House has a bright and cheerful interior and is homely and domestic in style. There are attractive gardens and garden furniture for the residents comfort and enjoyment. There is a maintenance programme, which provides assurance that there are plans to maintain the high standards for the environment.
Edmore House DS0000024953.V345494.R01.S.doc Version 5.2 Page 24 The gardens are generally well laid out and are well maintained, with trees, shrubs and plants. The proprietor has successfully applied for government funding for a garden project to provide a stand-alone conservatory in the rear garden, so that the residents can enjoy the feeling of the outdoors all year. The tour of the building identified that a number of further improvements have been made and a programme of redecoration and refurbishment is continuing. The ground floor corridor has been redecorated in a lighter colour, which gives the area a more spacious feel. During discussion residents indicate that they are comfortable, the home is clean, warm, well ventilated, and well lit. There are two spacious communal rooms and a dining room and residents are able to generally sit where they wish. There are new dining tables and adapted chairs to offer support, where needed and a new carpet has been ordered. There are numerous attractive new pictures, mirrors and ornaments throughout the communal areas of the home and the fresh flowers and plants in the lounges add to the pleasing ambience. Residents bedrooms, some with en-suite facilities, are well maintained and individually decorated providing pleasant personal living space. The home has appropriate communal bathing facilities, which provide pleasant environments for residents to enjoy their baths or showers, according to their preference. The towels and linen are good quality and the proprietor has recently ordered 80 new hand towels and purchased 40 complete sets of beautiful matching bed linen, so that every resident can have new bed linen at the same time. It is noted that the laundry and kitchen areas are well organised, clean and tidy. Though the laundry is small, it is well organised and it is sited on the lower ground floor away from food serving or preparation areas. There are hand-washing facilities, sluicing functions within industrial washing machines and guidelines for effective infection control. Although there are no infectious conditions at the home at present, it is recommended that a supply of disolvo sacks is available on site to effectively contain any outbreak or other acquired infection. The proprietor, with help from his family has introduced very striking, pictorial signs, with colourful, floral borders, for the bathing and toilet facilities, to help residents with their orientation around the home. There are also pictorial fire signs, including the instructions not to use the lift in the event of fire. The passenger lift also has Braille symbols. Several residents have small amounts of medication in their bedrooms; mainly creams and these are not currently stored securely and may pose risks, especially to residents with impaired capabilities. Edmore House DS0000024953.V345494.R01.S.doc Version 5.2 Page 25 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, 30 Quality in this outcome area is good. Staff morale and confidence is good. There are sufficient care staff and ancillary staff ensuring that residents have care, support and need for stimulation met. The staff recruitment processes are satisfactory, which provide residents with safeguards. The registered persons demonstrate strong commitment to staff training, support and development. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There are currently 17 residents accommodated, with a variety of dependency levels and diverse needs. As assessment of staffing rotas show satisfactory staffing levels are being maintained, in terms of numbers and stability. The registered manager and the proprietor / deputy manager regularly take action to identify residents dependencies and occupancy levels and regularly review staffing levels, making appropriate adjustments, with the use staff if someone needs extra care. Assessment of the AQAA submitted, staff files and staffing rotas during the visit show that seven staff have left the homes employ since the last inspection visit in August 2006 and six new staff have been recruited. The home currently has one staff vacancy, which is in the process of being filled.
Edmore House DS0000024953.V345494.R01.S.doc Version 5.2 Page 26 There are considerable improvements to the documentation and management of staff personnel files, with indexes, dividers and checklists, improving file organisation. Examination of new staff files show that robust recruitment processes are in place and the only minor improvement needed as a result of this visit is to ensure all staff files contain a recent photograph. The AQAA information indicates that 12 of the 18 care staff have achieved an NVQ level 2 care award. The registered manager states that there are an additional 3 staff undertaking NVQ 2 and 3 senior staff undertaking NVQ 3. This means that the home is now able to demonstrate that it exceeds the ratio of 50 of care staff with an NVQ 2 (or equivalent) award. The proprietor / deputy manager and registered manager continue to demonstrate strong commitment to staff training and development. They participate in training initiatives and provide support measures such as structured supervision and staff appraisals. The home has a training needs analysis and training plan and individual staff training profiles in place. The manager has discussed the need for nutritional training and the inspector has provided the home with the contact details of the Community Dieticians, based in Amblecote who may provide staff training at the home. During discussions it is evident that staff are knowledgeable about what residents needs are and how to meet them and there is a warm rapport with both residents and visitors. Staff spoken to generally feel that morale is good, that they are valued and that they are know what their responsibilities are, and what is expected of them. Edmore House DS0000024953.V345494.R01.S.doc Version 5.2 Page 27 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, 36, 37, 38 Quality in this outcome area is good. The home has effective management systems providing good leadership and direction, which ensures continuity and consistency. There are systems for resident consultation at Edmore House, and there is evidence that efforts are made to ensure that residents’ views are continually sought and acted upon. The improvement in the standards of record keeping and health and safety compliance at this home provide protection for residents from risks of harm. This judgement has been made using available evidence including a visit to this service. Edmore House DS0000024953.V345494.R01.S.doc Version 5.2 Page 28 EVIDENCE: The registered manager Ann Newton has worked at Edmore House for a number of years and she has many years of managerial and practical experience caring for older people. She has achieved the NVQ level 4 care and management award and the Registered Managers Award (RMA). The registered proprietor, Mr C Atwal, who also works at the home as the deputy manager and has also, achieved the NVQ level 4 care and management award and the Registered Managers Award (RMA). Both people have been present, helpful and knowledgeable throughout this inspection. There is evidence that although the proprietor takes a subordinate role, as deputy manager, there is mutual respect and clear understanding each persons role, responsibility and accountability. It is evident that the arrangement is working well and people work well with each other. The home has a quality assurance-monitoring package, which includes tools for obtaining feedback about the homes performance from residents, families and other stakeholders in the wider community, which is being successfully implemented. The home has a documented annual development plan and continues to hold the Investors in People Award. The home has collated responses from all surveys undertaken in March 2007, with results, which are very positive available. There is evidence that that staff and residents meetings take place regularly, with minutes available. These show a record of views and decisions reached, an example is what people want as spiritual support, such as visits from church groups to the home. There are planned schedules for meetings, with resident and relatives meetings planned for the coming year. The registered manager and proprietor / deputy manager undertake staff supervision meetings with staff every 8 weeks, in addition staff have annual appraisals. The supervision process has been developed to include topics such as policies, and training needs, with actions and timescales agreed. Discussions have taken place relating to the new Regulation 24, requiring the home to submit an annual AQAA on request by the CSCI and it is recommended that the registered manager proactively use this as an additional quality assurance tool. In addition the evidence to support statements made in the AQAA need to be more detailed, as the evidence will be tested and verified during future inspection visits. Residents have the opportunity to manage their own money if they wish, though most have families who manage financial affaires for them. Each persons financial arrangement is recorded as part of their care plan. Edmore House DS0000024953.V345494.R01.S.doc Version 5.2 Page 29 The Home has secure facilities for the small amounts of residents cash held in temporary safekeeping. A sample of balances and financial records examined is satisfactory. There are improvements to records keeping, which include comprehensive preadmission information, care plans, and daily records, though there are still records requiring minor improvement such as risk assessments, falls risk assessments, medication records and staff photographs. The random assessment of a sample of health and safety and service maintenance records examined shows that they are generally satisfactory. The home now has a Legionella and Asbestos risk assessment. There is evidence that mandatory training is being sourced and provided for all staff on an on-going basis. The registered persons have sought advice from Dudley MBC Environmental Services regarding acceptable standards of food safety training for staff preparing food and have received a written response indicating that training provided is acceptable. The home also has a copy of the recent guidance Safer food, Better Business. There have been 14 recorded accidents involving residents in the past 12 months. The registered manager has a system for auditing, analysing and evaluating accidents involving residents, this shows effective measures, such as the involvement of the Dudley Falls Team and recently a review of medication with the GP and a change of the time to administer Zoplicone from 10:00pm to 6:00pm to reduce the risk of falls when the person gets up. One resident now needs to use compressed oxygen and also uses an oxygen concentrator in her bedroom, which is appropriately stored. This has been included in the homes fire risk assessment and there is a letter advising the West Midland Fire Service. Edmore House DS0000024953.V345494.R01.S.doc Version 5.2 Page 30 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 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 3 3 X X 3 3 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 3 X 3 3 3 3 Edmore House DS0000024953.V345494.R01.S.doc Version 5.2 Page 31 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 OP9 Regulation 13(2) Requirement 1) To seek advice from the pharmacy provider about provision of an approved medication trolley, which must be secured to the wall, when not in use (Timescale of 01/11/06 is Partly Met) It is the home’s responsibility to notify the CSCI when this requirement is met. 2) To ensure that any handwritten entries on MAR sheets are dated, signed and witnessed by 2 appropriately trained staff (Timescale of 01/11/06 is Partly Met) It is the home’s responsibility to notify the CSCI when this requirement is met. 3) To clarify as directed dosages with the prescriber or pharmacist (Timescale of 01/11/06 is Partly Met)
Edmore House DS0000024953.V345494.R01.S.doc Version 5.2 Page 32 Timescale for action 01/12/07 It is the home’s responsibility to notify the CSCI when this requirement is met. 2. OP9 13(2) To ensure that any medication, including creams kept in residents bedrooms is stored securely al all times It is the home’s responsibility to notify the CSCI when this requirement is met. 3. OP29 17(2) Schedule 2&4 To ensure that all staff personnel files contain a recent photograph It is the home’s responsibility to notify the CSCI when this requirement is met. 01/12/07 01/12/07 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. Refer to Standard OP1 OP7 Good Practice Recommendations That clear information about the level of fees charged should be included in the homes statement of purpose That personal care checklists are fully completed and where residents undertake part of their own personal care this should also be indicated on the record to avoid unexplained gaps That all new residents should be weighed on admission to have a record of their baseline weight That all residents have a documented falls risk assessment in place. 3. 4. OP8 OP8 Edmore House DS0000024953.V345494.R01.S.doc Version 5.2 Page 33 5. 6. OP30 OP33 That all staff are provided with equality and diversity training, from a recognised training provider That the homes Annual Quality Assurance Assessments (AQAA) submitted to the CSCI should contain accurate, verified information and fuller details of the supporting evidence of what the home does well and the improvements made and to how needs for equality and diversity are met 1) That the home has an up to date copy of the DoH Infection Control Guidelines for Care Homes 2) That the home has a supply of disolvo sacks available in the laundry, examples: red for soiled linen, white for infected linen 7. OP38 Edmore House DS0000024953.V345494.R01.S.doc Version 5.2 Page 34 Commission for Social Care Inspection 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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
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