Inspection on 12/09/06 for Edmore House

This inspection was carried out on 12th September 2006.

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

Edmore House 19/11/08

Edmore House 11/10/07

Edmore House 31/01/06

Edmore House 06/09/05

Edmore House 01/12/04

Edmore House 11/06/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Edmore House 20 Oakham Road Oakham Dudley West Midlands DY2 2TB Lead Inspector Mrs Jean Edwards Unannounced Inspection 12th September 2006 08:40 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.V307277.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.V307277.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Edmore House Address 20 Oakham Road Oakham Dudley West Midlands DY2 2TB 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.V307277.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31/01/2006 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. The fees to stay at Edmore House range from £328 to £375. Edmore House DS0000024953.V307277.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first unannounced key inspection visit for 2006 - 7, undertaken by an inspector from the Commission for Social Care Inspection (CSCI), starting at 8:40 am and finishing at 7:40pm. All Key National Minimum Standards have been assessed at this visit. The range of inspection methods to make judgements and obtain evidence includes: discussions with the proprietor / deputy manager and staff on duty during the visit, examination of records and documents and discussions with residents, and relatives. Other information was gathered before this inspection visit from the pre inspection questionnaire submitted, notification of incidents, accidents and events, and an action plan submitted by the home following the unannounced inspection on 31 January 2006. Eighteen service user surveys were sent to the home by the CSCI and an analysis of the nine survey forms returned is contained throughout this report. Comments have been generally positive, particularly about the environment and staff. There are currently 17 people at the home, including one resident who is in hospital. During the visit the inspector has spoken to the majority of residents. Longer discussions have taken place with the residents whose care was looked at in depth. Relatives and other visitors have been asked for their views. Comments indicate that staff are friendly, helpful and welcoming. There has been 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: Relatives, residents and staff continue to express high levels of satisfaction with the service provided. There is comprehensive information available about the home, which helps people to make decisions about where to live. In answer to the questions on the CSCI service user survey forms all nine responses indicate that have received satisfactory information to help them make decisions and that they have a contract / terms and conditions of residency from the home. A comment states, I was given full information about the care available, and was shown bedrooms (unoccupied, otherwise permission to look at rooms has to be given by the residents) lounges, kitchen and bathroom/toilet facilities. Residents are very complimentary about the care and support from the proprietor, manager and staff. In response to the survey question: do you always receive the care and support you need? 8 people state - Always and 1 Edmore House DS0000024953.V307277.R01.S.doc Version 5.2 Page 6 person states Usually, with the comments, All care staff are very helpful and supportive and mom has been looked after with kindness and consideration, especially during bouts of ill-health, and a surprising amount of attention is given to each individual, and it is apparent, in conversation, that staff get to know each residents likes, needs, etc. for really well. Visitors are warmly welcomed to the home and are offered refreshments, support and appropriate information, for example a daughter states, I was told the timetable is flexible for going to bed and visiting, and visiting is always welcome except at mealtimes, when most staff are occupied, though I have stayed and helped feed my mother when she was unwell. There is a proactive approach towards any concerns or complaints, and efforts are made to listen and improve the service. A comment from the CSCI service users surveys states, Staff always listen to any concerns and have acted accordingly, and if there is something going wrong mom tells me, and I pass on the information to management. We have never had cause to make a formal complaint as matters are dealt with in a friendly discussion. The Proprietor is proud of the homely environment provided at Edmore House and responds to suggestions and requirements for improvements. Examples are: the completely refitted, attractive ground floor bathroom and residents bedrooms, which are redecorated at request. Comment from the CSCI service users surveys state, I have found the home to be fresh and clean on all visits, and hygiene is good, especially kitchen and bathrooms. Nasty niffs are always minimal and are dealt with promptly. This inspection was conducted with full co-operation of the Registered Proprietor, staff and residents. The atmosphere through out the inspection was relaxed and friendly. The Inspector would like to thank the proprietor, staff, and residents for their hospitality during this inspection visit. What has improved since the last inspection? The way the home plans each persons care has improved with the gradual introduction of new assessment processes, care plan and risk assessment formats for new residents. The written information is more detailed and specific and provides staff with clearer guidance. All care plans now include all medication details and are generally updated regularly to reflect any changes. There are also improved records on each persons file, showing that there is good access to specialist medical, chiropody and dental care. Each persons dietary needs are looked at and their weight is monitored, with advice requested from GPs and dieticians as needed. A comment from the CSCI service users surveys states, GP visits are always arranged if Mom is poorly, and hospital emergencies are dealt with efficiently. If I am not available a Edmore House DS0000024953.V307277.R01.S.doc Version 5.2 Page 7 member of staff has accompanied Mom to hospital in an emergency and stays with her as long as was needed. The home is improving the level of activities on offer for residents, with outings advertised on a notice board in the reception area. Comments from the CSCI service users surveys states, There have been a selection of activities of late, which the residents seem to enjoy, and Mom has very limited mobility, so physical activities are exhausting. She enjoys group games such as giant snakes and ladders, and the exercise lady who comes every other week, even though she cant do very much of the exercise. Visits from the entertainers are usually well received (with a sing-a-long). The home holds small amounts of residents monies in temporary safekeeping for everyday incidentals and has improved the system, making it more secure and accountable. There are a number of areas of record keeping and compliance with health and safety, which have improved. For example the manager is undertaking a regular recorded analysis of accidents, which highlights any trends and now there can be improved measures put in place to minimise risks for residents. What they could do better: The registered person must make sure that all residents have an revised and up-to-date contract/or terms and conditions of residence, containing full details including fees, which has been agreed and signed by them or their representative. Each person or their representative must receive written confirmation that the home is able to meet all of their needs and offers and decisions about introductory visits must be fully recorded on residents individual case files. This will demonstrate that people have good information and opportunities, to make decisions about where they will live. The development of new care plans and fuller health care screening and assessments must be put in place to make sure that residents needs are not missed or overlooked. The homes system for the management and administration needs improvement in a number of areas so that it is a safe as possible. Examples are that staff receive more comprehensive training from an accredited trainer, that medication storage and records are reviewed and revised in accordance with advice. The improvements relating to provision of more activities and outings must be built on and all residents must be asked about their preferred individual activities. The information collected must then be used to devise, advertise and offer a regular programme of a variety of group and individual activities, Edmore House DS0000024953.V307277.R01.S.doc Version 5.2 Page 8 with each persons participation or refusal noted. To the question on the service user survey, are there activities arranged by the home that you can take part in? Answers are - Always - 3; Usually - 2; Sometimes - 3; Never - 1. Whilst comments about food during the visit have been positive and the meals look appetising, the responses from the service user survey to the question: Do you like the meals at the home? Are as follows: Always - 4, Usually - 2, Sometimes - 3. The home needs to explore these results with the residents. Although the recruitment processes and staff personnel records show improvements, there are a few additional areas, which need further improvement, such as fuller employment histories on application forms to make sure there are no unaccounted for gaps in employment. The registered persons must 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. There are a number of records and areas of health and safety, which must be improved to safeguard the residents. For example the risks of Legionella and Asbestos in the home must be assessed and advice must be sought from Dudley MBC Environmental Services regarding acceptable standards of food safety training for staff preparing food. 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. Edmore House DS0000024953.V307277.R01.S.doc Version 5.2 Page 9 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.V307277.R01.S.doc Version 5.2 Page 10 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 The overall outcome for this group of standards is judged to be good. The home has an up-to-date statement of purpose and service user guide and all residents have a contract / terms and conditions of occupancy. 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 generally 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 verbal evidence to demonstrate that people have been given the opportunity and time to make decisions, which are right for them. EVIDENCE: The home has a statement of purpose, which clearly sets out the objectives and philosophy of Edmore House and this is supported with a service user guide, providing good clear information about the home. Minor amendments have required, such as the date of the next review of the documents. The Edmore House DS0000024953.V307277.R01.S.doc Version 5.2 Page 11 service user guide needs to include a copy of the contract/terms and conditions of residence and a reference to the most recent inspection reports. Discussions with residents and examination of residence case files confirm that are given a welcome pack with copies of the homes statement of purpose, service user guide and complaints procedure. There are signatures on residents files to indicate receipt of these documents. 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. There is evidence from the CSCI service user survey and from a sample of case files that in each resident is provided with a contract or statement of terms and conditions. Advice has been given about the recent revisions and additions to the Care Homes Regulation 5, and good practice guidance issued by The Office of Fair Trading, which needs to be incorporated into the next review. Evidence from examination of residents records and discussions 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. There is written confirmation from the registered manager to confirm the persons admission to the home, however the correspondence needs to be expanded to confirm that the home can meet all assessed needs. From discussions it is evident that the home of offers introductory visits, however there is no documentary evidence to show decisions and outcomes of visits or reasons why visits have not been able to take place. A comment from the CSCI service user survey states, Three visits were arranged before the final decision was made. We were always warmly welcomed. Discussions have been held about the possibility of requesting a variation to the homes registration categories. Information has been given about the centralisation of the registration processes and contact details of the CSCI Regional Registration Team. Edmore House DS0000024953.V307277.R01.S.doc Version 5.2 Page 12 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 The overall outcome for this group of standards is judged to be adequate. The improved care planning and monitoring provides staff with the information they need to adequately meet residents needs. There is good multi disciplinary working taking place on a regular basis, which results in the health needs of residents being generally well met. The home is committed to make progress to improve the arrangements for administration of medication, which reduces potential risks to residents. EVIDENCE: Each resident has a care plan, though there are currently two formats because the registered manager is introducing a new format, the Standex care planning system. Assessment of a sample of new and existing plans show that there are positive points to both systems. The transfer of information from the old to the new system must be monitored carefully to avoid the loss of important information. Assessment of two new care plan formats for two residents admitted recently show evidence of the good practice of involving residents and their relatives in the development and review of the plans, with signatures in place. Edmore House DS0000024953.V307277.R01.S.doc Version 5.2 Page 13 The plan in most cases includes essential basic information necessary to plan the individuals care and includes a risk assessment element. It is noted in the care plan of a new resident that she likes routine but needs only minimal assistance, gets very anxious and likes to stay in her room. She likes TV and has her own TV set in her bedroom. Her medication regime is recorded and it is noted that she needs small meals and came to the home. The food supplement prescribed prior to admission has been discontinued, as her appetite has increased since admission to the home. Her daughter is pleased with the care and attention provided and the improvement in her mothers general well being. However from examination of the sample of residents case files, some care plans have small omissions. Examples are missing areas from care plans where residents have been prescribed antibiotics for chest or urinary tract infections and there are no short-term care plans in place. There are also residents with occasional behaviours, which are described as outbursts of aggression and there are no documented risk assessments or risk management strategies to guide staff as to how to deal with these situations. In one incident a member of staff had completed an accident record for scratches sustained. Similarly there is no documented risk assessment or management strategy and guidance for staff relating to the resident who is deteriorating and continually wanders and displays agitation. All residents have good access to health care services to meet their assessed needs both within the home and in the local community. Some residents are able to choose their own GP within the limits of geographical borders and there is documentary evidence that all have access to dentists, opticians, chiropodists and other community services. There is evidence from records and discussions that each resident’s health is monitored with appropriate action taken. However there is insufficient documentary evidence in the care plans examined of health care assessments, screening, treatment and intervention, such as use of nutritional tools and tissue viability and falls assessments. The home seeks professional advice on health care issues, acts upon it and generally is able to access the aids and equipment recommended. Observations and discussions show that pressure relieving equipment is in place or is under review with district nurse but this is not currently recorded. There are records of regular weight monitoring and though there are two residents requiring regular food supplements all current residents are maintaining or gaining weight. The home has a medication policy which is accessible to staff, medication records are generally up to date for each resident and medicines received, administered and disposed of are recorded. There are currently a small number of residents who wish to administer their own medication and risk assessments are in place to monitor that this practice is conducted in safety. Where medication systems are in need of action the registered person is Edmore House DS0000024953.V307277.R01.S.doc Version 5.2 Page 14 working towards improvement. The areas to be improved include accredited training for all staff involved in the administration of medication and a more efficient use of senior staff time when administering medicines. The current systems means that the senior has to take and check 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. This may mean as many as 17 or 18 trips around the home. An approved medication trolley would be safer and save staff time and effort. Observations of the actual administration practice shows that this is preformed diligently and well. From discussions it is evident that staff are aware of the need to treat residents with respect and to consider dignity when delivering personal care. The home arranges for residents to enjoy the privacy of their own rooms and provides screens in the shared rooms. Discussions with residents indicate that are happy with the way that the staff deliver their care and show respect for them. Edmore House DS0000024953.V307277.R01.S.doc Version 5.2 Page 15 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 The overall outcome for this group of standards is judged to be good. There is evidence of progress to make planned and spontaneous activities available on a regular basis, which give residents improved opportunities to take advantage of and develop socially stimulating activities. The majority of residents are able to maintain good contact with family and friends. Dietary needs of residents are generally catered for with a balanced and varied selection of food that meets residents tastes and choices. EVIDENCE: Residents at Edmore House have the confidence to discuss what makes them happy and to comment where improvements can be made. The proprietor /deputy manager takes residents feedback seriously and makes changes where possible. Evidence from the service user survey forms indicate that staff listen to residents and make considerable effort to provide a flexible service, which enables them to enjoy a better quality of life. The home has a key worker system, which enables closer resident and staff relationships, where likes, dislikes and needs are shared. Key workers can use the information to plan activities, which residents will enjoy. There is a good understanding for the need to increase the level of activities and access to Edmore House DS0000024953.V307277.R01.S.doc Version 5.2 Page 16 social stimulation. There is evidence that some people prefer to spend their time on their own in their own bedrooms, with individual interests. These decisions are well understood, respected and supported by staff at the home. The home needs to continue to develop a system for displaying information and bringing attention to community events and activities. A relative states that activities at the home have increased, with entertainment brought into the home and more planned outings. There are exercise sessions every other week and a singer has been booked to provide an evening of entertainment. It is stated that residents are supported in groups of two to go shopping at Merry Hill for Christmas presents and a trip is booked to go to see the Walsall Illuminations. A new resident is an active member of St Peters church in Netherton and received a visit from the vicar during this inspection. There are plans for the vicar to regularly visit her former parishioner and spouse, who also lives at Edmore House. The resident states she would like to continue to visit the church on Thursday mornings and the proprietor is happy to arrange for this to take place. The proprietor states that one or two residents have expressed an interest in visiting the newly built local Hindu temple and he is exploring the options to take them to see it. The Salvation Army has also visited the home. 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. Residents are able to have personal possessions in their room, but may be not always be able to bring large items of furniture 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, however these are not always signed and dated by the resident or their representative. Residents enjoy the flexibility of meal arrangements and are able to eat in their own room if they wish. Regular drinks are available and staff are always willing make drinks at any time. It has been observed that there are plentiful supplies of cool drinks, with easy access for residents, around the communal areas of the home. The food in the home is of good quality, well presented and generally meets the dietary needs of residents. The cook is experienced, consults with residents and tries to meet the preferences and suggested dishes when preparing the menu. Staff have training to help those residents who Edmore House DS0000024953.V307277.R01.S.doc Version 5.2 Page 17 need help when eating and are sensitive in their approach. Records of daily food intake are needed for residents assessed as being nutritionally at risk. Edmore House DS0000024953.V307277.R01.S.doc Version 5.2 Page 18 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The overall outcome for this group of standards is judged to be adequate. Complaints and concerns 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 not yet satisfactory. Policies, procedures, guidance and staff training have not been fully implemented in order to provide residents with safeguards from abuse. EVIDENCE: The home has complaints procedure displayed in the reception area and contained in the service user guide. Information supplied as part of the preinspection questionnaire indicates that the home has not received any complaints since the last inspection in January 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 proprietor indicates he plans to use residents meetings and individual reviews to discuss the homes complaints procedure. It is recommended that the complaints procedure be produced in alternative formats suitable for residents, such as large print. The home has not received any allegations relating to abuse of vulnerable residents. There is a copy of the multi-agency procedures for the protection of vulnerable adults, Safeguard and Protect at the home. The homes policies and procedures regarding protection of residents are generally satisfactory Edmore House DS0000024953.V307277.R01.S.doc Version 5.2 Page 19 they have been reviewed and updated to be generally in line with regulations and other external guidance. Currently there is no documentary evidence that all staff have been made aware and have been given time to read and understand procedures for the protection of vulnerable adults. Progress is being made to provide all staff with appropriate adult protection training. Edmore House DS0000024953.V307277.R01.S.doc Version 5.2 Page 20 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, 21, 24, 26 The overall outcome for this group of standards is judged to be good. There continues to be significant and positive changes to the décor and furnishings. The incremental improvements contribute to creating a pleasing and pleasant environment for residents to live in. The grounds are maintained to provide a safe and pleasant outdoor environment for residents. 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. The tour of the building identified that a number of improvements have been made and a programme of redecoration and refurbishment is in progress. Residents bedrooms are well maintained and individually decorated providing pleasant personal living space. A maintenance programme is newly in place, which provides assurance that there are plans to ensure high standards for the environment. The ground floor bathroom has been tastefully refurbished and all bathing facilities provide Edmore House DS0000024953.V307277.R01.S.doc Version 5.2 Page 21 pleasant environments for residents to enjoy their personal ablutions. It is noted that a jug and bar of used soap had been left in the ground floor bathroom and there is a risk that these items will be used communally, which compromises the homes infection control measures. 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, though some people are protective about their own personal space. 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. The ventilation in the kitchen needs to be monitored as at times it is excessively hot and there are no external windows, meaning that ventilation and temperature control are dependent on fans. Two opened bottles of red and brown sauce have been noted on the open shelves, without a date of opening and not refrigerated in accordance with manufacturers instructions. Edmore House DS0000024953.V307277.R01.S.doc Version 5.2 Page 22 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 The overall outcome for this group of standards is judged to be adequate. Staff morale and confidence is good, with better attendance, diligence and less reliance on staff working in excess of contracted hours, and there is improvement to staff recruitment processes, which has reduced the potential for residents to receive an inconsistent and unsatisfactory service. The proprietor and manager demonstrate a commitment to staff training, support and development. EVIDENCE: There are currently 17 residents accommodated, with a variety of dependency levels and diverse needs. Assessment of staffing rotas show an improvement in staffing levels, both in terms of numbers and stability. However the proprietor / deputy manager is not able to regularly identify residents dependencies and occupancy levels and regularly review staffing levels, making appropriate adjustments, with the use of a recognised staffing tool. It is also noted that the registered manager and deputy manager have recently provided care hours for a significant number of shifts. Assessment of the pre-inspection questionnaire submitted, staff files and staffing rotas during the visit show that three staff have left the homes employ since the last inspection visit in January 2006 and assessment of staff files identifies that a newly recruited care assistant has also resigned. At least one care assistant is noted on the rota as a senior carer, however her application form and contract of employment indicate that she is employed as a care Edmore House DS0000024953.V307277.R01.S.doc Version 5.2 Page 23 assistant. Employment records must accurately reflect staff roles and responsibilities. There are some improvements to the documentation and management of staff personnel files, though indexes and dividers would provide further improvements in file organisation. Generally robust recruitment processes are in place and there are only minor improvements needed as a result of this visit. The pre inspection information indicates that 9 of the 15 care staff have achieved an NVQ level 2 care award, with new candidates about to be registered for NVQ level 3. This means that the home is now able to demonstrate that it meets the ratio of 50 of care staff with an NVQ 2 (or equivalent) award. However there is no documentary evidence available on the file of a new member of staff for the NVQ level 2 qualification claimed on the application form. The proprietor / deputy and registered manager demonstrate strong commitment to staff training and development, together with support measures such as structured staff appraisals. The homes training needs analysis and training plan and individual staff training profiles are incomplete at this visit and the proprietor / deputy manager has agreed to send completed documentary evidence to the CSCI office, Halesowen. 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 improving and that they are aware of their responsibilities, what is expected of them. Edmore House DS0000024953.V307277.R01.S.doc Version 5.2 Page 24 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): 31,32,33,35,36,37,38 The overall outcome for this group of standards is judged to be adequate. The proprietor / deputy manager and registered manager provide good leadership and direction, and there is good communication, which should ensure continuity and consistency of effective leadership and support. The systems for resident consultation at Edmore House are generally good with some evidence that indicates that efforts are made to ensure that residents’ views are both sought and acted upon. The improvement in the standards of record keeping and health and safety compliance at this home has generally continued, improving protection for residents from risks of harm. EVIDENCE: Edmore House DS0000024953.V307277.R01.S.doc Version 5.2 Page 25 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). Unfortunately she was not present at this Key Inspection due to illness. 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), has been present, helpful and knowledgeable throughout this inspection. It is positive that information and records at this home are generally well organised. Although there have been some revisions to the staffing structure since the last inspection there is still insufficient clarity of roles and lines of accountability. The previous requirement for the registered manager to be issued with a clear job description remains outstanding. It is noted that both the registered manager and deputy manager have recently had to provide cover to maintain adequate levels of care, which diminishes the management role and ability to fully monitor, oversee and develop the home as would be expected. Although the proprietor has purchased 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, this has not yet been implemented. The home does not yet have a documented annual development plan. However the home has achieved the Investors in People Award in the past year, which will be reviewed by the awarding body. It is positive that staff and residents meetings take place regularly, with minutes available. There are planned schedules for meetings, with seven resident and two family meetings planned for 2006. The proprietor / deputy manager undertakes staff appraisals with staff every 8 weeks. This process could be developed to encompass supervision topics such as training needs, actions and timescales agreed, which should be signed and dated by each party. Residents have the opportunity to manage their own money if they wish, though most have families who manage financial affaires for them. The Home has improved facilities for the safekeeping of small amounts of cash held in temporary safekeeping. There is a system is in place to record transactions and accounts for income and outgoings. A sample of balances and financial records examined are generally satisfactory. However not all transactions made on behalf of residents are consistently witnessed by two people. It is advised that one signatory may be the resident, where they have capacity to understand. Edmore House DS0000024953.V307277.R01.S.doc Version 5.2 Page 26 There are improvements to records keeping, which include comprehensive preadmission proformas, better care plans, and daily records, though there are still records requiring further improvement such as risk assessments, tissue viability assessments, falls risk assessments, nutritional assessments, medication records and staff records. The random assessment of a sample of health and safety and service maintenance records examined shows that they are generally satisfactory. The home does not currently have a Legionella or Asbestos risk assessment. The proprietor has agreed to forward these documents to the CSCI office, Halesowen. There is evidence that mandatory training is being sourced and provided for all staff on an on-going basis. However the previous requirement for the cooks and other staff preparing food to undertake intermediate food safety training remains outstanding. The registered persons have been advised to seek documented advice from Dudley MBC Environmental Services regarding acceptable standards of food safety training for staff preparing food. There have been 21 recorded accidents involving residents and 1 recorded accident involving staff since January 2006. The registered manager has a system for auditing, analysing and evaluating accidents involving residents, this must show effective measures, such as falls risk assessments have been implemented. Edmore House DS0000024953.V307277.R01.S.doc Version 5.2 Page 27 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 2 3 3 2 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X 3 X X 3 X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 2 2 2 Edmore House DS0000024953.V307277.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? 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 OP1 Regulation 4, 5 Requirement 1) To expand the admission procedure to reflect the range of needs the home is intended to meet and include review dates in the Statement of Purpose and Service User Guide. 2) To include a sample of the contract / terms & conditions and reference the recent Inspection Reports in the Service User Guide 2 OP2 5(1) To review the contract / terms and conditions taking account of the revisions to the Care Homes Regulation 5 and the publication from the Office of Fair Trading relating to Contracts and terms & conditions in Care Homes The written confirmation from the Registered Manager to the resident / representative must be expanded to include their identified assessed needs To provide documentary evidence on each persons case DS0000024953.V307277.R01.S.doc Timescale for action 01/12/06 01/12/06 3 OP4 14(1)(d) 01/11/06 4 OP5 14(1) 01/11/06 Edmore House Version 5.2 Page 29 file that trial visits have been offered prior to admission, recording outcomes. 5 OP7 13(3) 15(1) Care plans must include foot care, oral care and nutrition. (Timescale of 30/09/05 and 31/03/06 Not Fully Met) Care plans must include specific details of all medication prescribed as ‘as required’ including the name of the drug, the dosage, frequency of administration, maximum dose, the criteria for administration. (Timescale of 30/09/05 and 31/03/06 Not Fully Met) 1) To complete the process of transferring all information to new care planning formats, ensuring that valuable information is not lost between the two different formats 2) To complete care plans for short term care needs such as need for infections, antibiotics etc. 8 OP8 13(1) To ensure that the following are documented as part of each residents case file / care plan 1) Tissue viability assessment (such as a Waterlow Score) 2) Record of any pressure relieving equipment 3) Plan of any pressure relieving prevention, such as turns, change of position, mobilising 4) Nutritional screening assessment Edmore House DS0000024953.V307277.R01.S.doc Version 5.2 Page 30 01/11/06 6 OP7 13(2), 15 01/11/06 7 OP7 15(1) 01/10/06 01/11/06 9 OP9 13(2) 5) Falls risk assessment, and record of any referral to the Dudley Falls Service, with any preventative / protection measures in place 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 2) To provide all staff involved in medication administration with accredited medication training 3) To ensure that when the medication procedure is reviewed in September 2006, guidelines for repeated refusals are included 4) To ensure staff signatures are obtained to demonstrate awareness and compliance with medication policy and procedures 5) To ensure that the staff signature list is maintained to be up to date 6) To ensure that staff record variable dosages of medication administered on MAR sheets, for example one tablet or two 7) To ensure that any handwritten entries on MAR sheets are dated, signed and witnessed by 2 appropriately trained staff 8) To clarify as directed dosages with the prescriber or pharmacist 01/11/06 Edmore House DS0000024953.V307277.R01.S.doc Version 5.2 Page 31 9) To record carried forward balances of medication on MAR sheets 10) To undertake documented random audits of medication stocks, with any corrective measures identified 11) To ensure any specialist instructions for the administration of medicines is clearly documented as part of the medication regime in each persons care plan for example Allendronic Acid 70mg and Risedronate Sodium 35mg, which are given as a weekly dose 12) To store internal and external medication separately 13) To resume the documented handover of medication keys at shift changes 14) To ensure the pharmacist signs for receipt of returned medication, especially controlled drugs 15) To obtain a thermometer to record daily minimum and maximum temperatures for medication held the homes domestic fridge 10 OP12 16(2)(n) To complete the activities plan for each person and record all activities or refusals 1) To ensure the daily food / fluid intake recorded and monitored is recorded in sufficient detail to demonstrate a nutritious daily diet for any DS0000024953.V307277.R01.S.doc 01/11/06 11 OP15 14,15,16 01/11/06 Edmore House Version 5.2 Page 32 resident assessed as nutritionally at risk (Timescale of 30/09/05 and 31/03/06 Not Fully Met) 2) To ensure that recognised nutritional screening tools and assessments are carried out for all residents and provide nutrition /diet care plans for any residents identified to be at risk (Timescale of 30/09/05 and 10/02/06 Not Fully Met) 12 OP14 17(2) To ensure that residents 01/11/06 property inventories property are fully completed on admission and thereafter kept up to date, signed and dated by staff, resident and / or relative. To explore the comments made 01/11/06 by some residents on the service user survey forms, indicating not everyone is satisfied with the meals Behaviour care plans must be put in place to guide staff to understand behaviour triggers for individual service users and how to manage behaviour that challenges. (Timescale of 10/02/06 Not Met) 1) To ensure that there are no items in bathrooms, such as jugs or bars of soap, which may be used communally and compromise infection control 2) To ensure that high risk foods such as red and brown sauces etc. are labelled with dates of opening and use by dates and stored in accordance with the manufacturers instructions Edmore House DS0000024953.V307277.R01.S.doc Version 5.2 Page 33 13 OP15 16(2)(i) 14 OP18 15(1) 13(4)(6) 01/10/06 15 OP26 13(4) 01/10/06 16 OP27 18(1)(a) 1) To maintain the rota accurately at all times as a written record of who has worked. (Timescale of 10/02/06 Not Fully Met) 2) To calculate care staffing requirements using a recognised tool, such as the DoH Residential Forum staffing tool, providing documentary evidence of compliance 3) To ensure all rotas demonstrate totals of actual hours worked by each person in each of their roles 01/10/06 17 OP29 19(1) 17(2) Sch 2&4 1) To ensure application forms are fully completed with details of qualifications claimed and full employment history 2) To ensure any gaps in employment history are fully explored and reasons documented and checked wherever possible 3) To check the authenticity of references, ensuring that there is a reference from the last care employer or documenting reason why not possible and request that referees print their name and use company paper or company stamp 4) To provide an accurate job description on each personnel file 5) To ensure the contract of employment / terms & conditions accurately reflects the post identified on the staff rota (e.g. carer being used as a senior 01/11/06 Edmore House DS0000024953.V307277.R01.S.doc Version 5.2 Page 34 carer) 6) To ensure that there is a copy of the hairdressers POVA/CRB clearance on file 7) To ensure that there are copies of the private Chiropodists or other therapists qualifications, public liability insurance and POVA/CRB clearances 18 OP30 18(1)(c) Staff must be provided with training in: 1) Nutrition - in progress 2) Mental Health Awareness Not Met 3) Behaviour that challenges the service - Not Met (Timescale of 31/03/06 Not Fully Met) 19 OP30 18(1)(c) All staff must receive a minimum of three paid days training per year. (may be added to training plan) (Timescale of 31/03/06 Not Met) 1) To provide all mandatory training, especially food hygiene, for the two new staff, as a priority 2) To complete the training needs analysis and annual training plan and send a copy to the CSCI office, Halesowen 3) To reconcile the training matrix with individual certificates of training received 01/12/06 01/12/06 20 OP30 18(1)(c) 17(1) 01/12/06 Edmore House DS0000024953.V307277.R01.S.doc Version 5.2 Page 35 4) To ensure copies of original NVQ certificates are obtained and retained on individual personnel files, these should be signed by the registered person to indicate originals have been seen 5) Documented inductions must be completed, signed and dated within 6 weeks 1) The Manager must be provided with a job description that fully outlines her responsibility and duties. (Timescale of 31/03/06 Not Met) 2) To ensure that there are sufficient supernumerary managerial hours to develop and monitor practices 22 OP33 24 To forward copies the following to the CSCI office, Halesowen 1) The annual development plan for the home 2) The collated results of the homes service user surveys 3) The collated results of the homes relatives surveys 4) The collated results of the homes stakeholder surveys 23 OP37 17(1) All service user records are to be updated in accordance with Schedule 3 (Regulation 17(1)(a). (Timescale of 30/09/05 and 31/03/06 Not Fully Met) To ensure that all records required in compliance with legislation are completed in ink (preferably black); correction DS0000024953.V307277.R01.S.doc 21 OP31 9 01/11/06 01/12/06 01/11/06 24 OP37 17(1) 01/10/06 Edmore House Version 5.2 Page 36 25 OP38 13(4) fluid (tippex) and pencil must not be used Staff must sign to acknowledge 01/11/06 understanding of all risk assessments undertaken. All signatures must be obtained for all risk assessments by date set. (Timescale of 30/09/05 and 31/03/06 Not Fully Met) 26 OP38 13(4) 18(1)(c) All staff are to undertake: Infection Control training, moving and handling refresher training, The manager is required to identify appropriate personnel to undertake Person Centred Planning training and to provide this training. (Timescale of 30/09/05 and 30/04/06 Not Fully Met) 01/12/06 27 OP38 13(4) 16(2) 1) The two cooks must undertake food hygiene training to Intermediate level. 2) At September 05 inspection agreed manager and proprietor would undertake this training. (Timescale of 30/09/05 and 30/04/06 Not Met) 3) To seek documented advice from Dudley MBC Environmental Services regarding acceptable standards of food safety training for staff preparing food 01/11/06 28 OP38 13(4) To forward to the CSCI office, Halesowen copies of the following 01/11/06 Edmore House DS0000024953.V307277.R01.S.doc Version 5.2 Page 37 1) Asbestos risk assessment 2) Legionella risk assessment 3) To undertake regular documented visual checks of Hoists & slings 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 OP12 Good Practice Recommendations That recorded discussions take place in residents meetings and individual reviews relating to any arrangements to worship or have spiritual support in accordance with personal preferences That the complaints procedure should be produced in alternative formats, such as large print, audio, video for residents who may not understand the written word That staff signatures are obtained to demonstrate that they have read and have an awareness of the homes and the multi-agency procedures for the protection of vulnerable adults Safeguard & Protect. The home should consider commissioning a private occupational therapist to assess the suitability of the premises and facilities. Residents should be informed of their right to access their records That a checklist matrix be used to record and monitor personal care provided That copies of the infection control guidance issued June 2006 by the DoH be obtained and used to expand the DS0000024953.V307277.R01.S.doc Version 5.2 Page 38 2 OP16 3 OP18 4 OP22 5 OP37 6 7 OP37 OP38 Edmore House laundry procedures and infection control guidance for staff Edmore House DS0000024953.V307277.R01.S.doc Version 5.2 Page 39 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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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