CARE HOMES FOR OLDER PEOPLE
Edward House Albion Row Cambridge CB3 0BH Lead Inspector
Lesley Richardson Unannounced Inspection 5th December 2005 10:00 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 Edward House DS0000015267.V261028.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Edward House DS0000015267.V261028.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Edward House Address Albion Row Cambridge CB3 0BH 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) 01223 316776 01223 368613 Edward Storey Foundation Joy Wood Care Home 16 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (16) of places Edward House DS0000015267.V261028.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. No service users with Dementia to be admitted to the home. DE(E) to cover service users whose needs have changed. 7th August 2005 Date of last inspection Brief Description of the Service: Edward House is a care home proving personal care and accommodation for sixteen older people and up to four people already in the home with dementia. It is run by The Edward Storey Foundation, a registered almshouse charity, and only provides services to women. One of the registered beds is only used for short-term respite care. The home is purpose-built building, on two floors, accessible by stairs or a passenger lift. The home is physically linked to Storey’s House, which provides sheltered accommodation. A number of people living at Storey’s House visit the home for meals and support during the day; however the home is self-contained and has a separate entrance. The home is within walking distance of Cambridge city centre and local amenities. Despite being on a busy one-way road system the home is peaceful and has access to a patio area and the gardens of Storey’s House. All service user bedrooms are for single occupancy and all but one have en-suite facilities. Edward House DS0000015267.V261028.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over 4½ hours and was carried out as an unannounced inspection on 5th December 2005 and completed on 9th January 2006. It was the second inspection of this home for the 2005-2006 year. Two and a half hours were spent examining records and documents and two hours were spent with service users and staff. A tour of the building was also undertaken during this time. The manager was present during the inspection. Three people who were living at the home and three of the staff on duty were spoken to during the inspection. What the service does well: What has improved since the last inspection? What they could do better: Edward House DS0000015267.V261028.R01.S.doc Version 5.0 Page 6 Care plans must be written about everything a person needs help with, or is not able to achieve without help. These must be looked at and changed if a person’s needs have changed. They should be looked at every month, although some plans had not been looked at for several months. The views of people living at the home are obtained, but this information is not available for them to read. A copy of any report from a survey of the people who live at the home must be made available. There are two good practice recommendations for the home. Although administration records for medication are properly kept, controlled drugs are not recorded separately. Good practice would be for the home to record this is a designated register, as this protects staff members who have the responsibility for administering medication. The other area that is recommended is that records that are kept for health and safety checks should be available to show the checks are completed. 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. Edward House DS0000015267.V261028.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Edward House DS0000015267.V261028.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of these standards were assessed on this occasion. Edward House DS0000015267.V261028.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 and 10 Some improvement must be made to care recording to ensure that all the personal and health care needs of service users are identified and met. EVIDENCE: Individual care plans and risk assessments are available to ensure personal and health care needs are identified and planned for. Care plans are reviewed, although not always on a monthly basis, and there were periods of up to four months between reviews in one person’s care plan. Most care plans were rewritten when care needs change; ensuring changes were recorded. However, one plan for mobility had not been reviewed or updated to show any changes following a fall suffered by that person. Medication is administered by care staff to people who live at the home who are unable to or do not wish to administer their own medication. All staff members with the responsibility for medication administration are given training from a qualified source external to the home. Medication held in the home is stored correctly and administration records (MAR) are maintained with recording for medications given and not given. However, the administration of controlled drugs is not recorded separately. Although this is not required by
Edward House DS0000015267.V261028.R01.S.doc Version 5.0 Page 10 law, good practice would be for these drugs to be recorded in a bound book or register, a balance maintained, and for the drug administration to be checked by another carer. People at the home who spoke to the inspector said they thought the home is wonderful, that the care staff are “lovely” and they could not fault it. Edward House DS0000015267.V261028.R01.S.doc Version 5.0 Page 11 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 Social activities provide stimulation and interest for people living in the home, but as service users are not consulted about their interests, individual preferences may not be catered for. EVIDENCE: The home has an activities co-ordinator who arranges group and individual activities both at the home and as outside excursions. A plan of each week’s events is placed on notice boards around the home, and records are kept of events that take place and who attends. The activities co-ordinator tries to arrange a number of voluntary or free events, which included a piano recital by a music student on the day of inspection. This ensures people who live at the home have a range of events to satisfy all tastes. However, although staff demonstrated knowledge of the lives of people who live at the home, for example one person has close contact with her family who are regular visitors and often invite her out to family events, there is not documented evidence of this. Social interests are not explored and plans to show how social needs are to be met are standard for all people living at the home, rather than individual to each person. Edward House DS0000015267.V261028.R01.S.doc Version 5.0 Page 12 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None of these standards were assessed on this occasion. Edward House DS0000015267.V261028.R01.S.doc Version 5.0 Page 13 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 The standard of the environment within this home is good, providing service users with a attractive and homely place to live. EVIDENCE: The home is purpose built and accessible to all service users. It is comfortable and well maintained, with a good standard of décor. There were no offensive smells in the home on the day of inspection. Edward House DS0000015267.V261028.R01.S.doc Version 5.0 Page 14 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 Staffing numbers were sufficient to meet the needs of service users. EVIDENCE: Staffing levels on the day of inspection were adequate. Sick leave is covered by the staff working at the home working extra shifts or by agency staff. Although the manager said a shift would also be covered by the on call manager to ensure people who live at the home have at least one person working who is familiar with their care. Edward House DS0000015267.V261028.R01.S.doc Version 5.0 Page 15 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): 33, 35, 37 and 38 The home has systems in place that ensure money kept on behalf of service users is safe. EVIDENCE: A quality assurance survey was conducted in September 2005 amongst people who live there, their relatives and visitors to the home. The findings are collated and a report and flowchart generated from the results of the survey. Feedback is given to staff members during meetings. However, the report is not made available in the home for interested parties to read. Service users money held by the home for safekeeping purposes is kept in a locked box within a locked cupboard. Each service user’s funds are kept separately and receipts and withdrawals documented with a double book keeping system. The Charity’s accountant checks the ledger on a monthly basis and an independent auditor reconciles the accountant’s figures yearly.
Edward House DS0000015267.V261028.R01.S.doc Version 5.0 Page 16 Checks are completed to ensure the health and safety of service users and the results of these are recorded. The fire safety policy and procedure is comprehensive and contains information on fire drills, fire prevention, escape routes, equipment testing and what to do in the event of a fire. Records were seen for fire safety and hot water boiler temperatures. These were all recorded as acceptable. However, records for hot water temperatures from taps were not available, although the manager said they are routinely completed. This information has been requested from the manager. Edward House DS0000015267.V261028.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 3 X 2 3 Edward House DS0000015267.V261028.R01.S.doc Version 5.0 Page 18 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 OP7 Regulation 15(2)(b), (c) 24(2) Requirement The registered person must keep the service user’s plan under review and where appropriate revise the service user’s plan. The registered person must make a copy of the (quality assurance) report available to service users. Timescale for action 31/01/06 2 OP33 28/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP9 OP12 OP37 Good Practice Recommendations Controlled drugs should be recorded in a bound register, a balance maintained, with two carers signing administration, receipt and disposal. Service users social interests should be recorded to ensure all care staff have knowledge of the same information. Records of health and safety checks should be available. Edward House DS0000015267.V261028.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Cambridgeshire & Peterborough Area Office CPC1 Capital Park Fulbourn Cambridge CB1 5XE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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