Inspection on 05/07/05 for Prince Edward Duke of Kent Court

This inspection was carried out on 5th July 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Prince Edward Duke of Kent Court 26/06/08

Prince Edward Duke of Kent Court 06/07/07

Prince Edward Duke of Kent Court 15/08/06

Prince Edward Duke of Kent Court 31/01/06

Prince Edward Duke of Kent Court 07/12/04

Prince Edward Duke of Kent Court 13/07/04

Prince Edward Duke of Kent Court 17/02/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Prince Edward Duke of Kent Court Stisted Hall Kings Lane Stisted CM7 8AG Lead Inspector Kathryn Moss Unannounced 5th July 2005 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 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. Prince Edward Duke of Kent Court I56-I05 s17912 Prince Edward v237426 050705 stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Prince Edward Duke of Kent Court Address Stisted Hall, Kings Lane, Stisted, Braintree, Essex, CM7 8AG Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01376 345534 01376 353545 Royal Masonic Benevolent Institution Mrs Deborah Stevenson Care Home 47 Category(ies) of Old age, not falling within any other category 35 registration, with number Both of places Dementia - over 65 years of age 13 Both Prince Edward Duke of Kent Court I56-I05 s17912 Prince Edward v237426 050705 stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, aged 65 years and over, only falling within the category of old age (not to exceed 35 persons) 2. Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 13 persons) 3. The total number of service users accommodated must not exceed 47 persons Date of last inspection 7th December 2004 Brief Description of the Service: Prince Edward Duke of Kent Court is a large period house set in extensive grounds adjacent to a golf course. Although the home is in a semi rural location with limited access by public transport, Braintree town is just a short drive away and the Home has its own transport. The home has several lounges, a library and a conservatory, and also extensive grounds and an enclosed courtyard. The home provides 24 hour personal care and support, and has a through-floor lift and other equipment (e.g. mobile hoist, hand rails, etc.) to assist residents with limited mobility. It is registered to provide care to a maximum of 47 service users, and its conditions of registration allow the home to care for up to 35 older people and up to 13 people with dementia. All service users are accommodated in single rooms, and these are located on three floors of the main house, and on two floors of the annex, a converted stable block that accommodates 18 service users, including up to 13 service users with dementia (referred to in thie report as the EMF (Elderly Mentally Frail) unit). Prince Edward Duke of Kent Court I56-I05 s17912 Prince Edward v237426 050705 stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on the 5/7/05, lasting nine hours. The inspection process included: discussions with the manager, five staff, and six residents (one of whom was also the relative of another resident); the viewing of communal areas; and inspection of a sample of records. Previous recommendations were not specifically reviewed. 16 standards were covered, and 4 requirements and 6 recommendations have been made. The home was operating at full occupancy on the day of the inspection. During the inspection, staff spoken to showed a good awareness of residents’ needs and individual likes and dislikes, were caring and patient with residents’, and demonstrated a positive and open attitude and approach. Residents spoken to expressed satisfaction with their lives at Prince Edward Duke of Kent Court, and were seen to relate well to staff and to join in activities. What the service does well: What has improved since the last inspection? Over the last year the home has made considerable progress in developing activities within the home. This is particularly due to the appointment of a dedicated activities person, who has implemented a good programme of activities and events, and residents spoken to were enthusiastic about these. Prince Edward Duke of Kent Court I56-I05 s17912 Prince Edward v237426 050705 stage 4.doc Version 1.40 Page 6 Since the last inspection there had been good progress with training in the home. Individual training records were now in place, and a number of training courses had been provided; the home was also in the process of training several of the senior staff to be able to deliver various aspects of training within the home. Although not yet sufficient, progress had also been made towards providing particular training needs identified at the last inspection (dementia care, and protection of vulnerable adults). What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Prince Edward Duke of Kent Court I56-I05 s17912 Prince Edward v237426 050705 stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Prince Edward Duke of Kent Court I56-I05 s17912 Prince Edward v237426 050705 stage 4.doc Version 1.40 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 standard(s) 1, 4 and 5. Standard 6 is not applicable at Prince Edward Duke of Kent Court. Prospective residents are given information about the home, to enable them to make a decision about living there. Prospective residents and/or their representatives have opportunity to visit the home prior to admission, to assess its suitability. The home has the facilities and skills to meet the needs of the people that it aims (and is registered) to accommodate. EVIDENCE: The manager confirmed that the statement of purpose had been revised following previous feedback given by the CSCI after the last inspection, and was currently being printed (a copy is to be sent to the CSCI). She also confirmed that the ‘service user guide’ now includes the home’s complaints procedure, and a draft contract (this was not viewed on this occasion). A recent quality assurance survey had highlighted that not all relatives seemed aware of the complaints procedure, and the manager was considering ways of ensuring this is more available to residents and their visitors. Prince Edward Duke of Kent Court I56-I05 s17912 Prince Edward v237426 050705 stage 4.doc Version 1.40 Page 9 A new resident was spoken to: although they had been unable to visit the home before admission due to health reasons, their relative had knowledge of the home and had previously visited. The resident felt that they had been welcomed into the home, and had had the routines and facilities explained to them. All new residents have a trial period. Staff spoken to on the EMF unit showed a good understanding of the residents, and of the needs that the unit aimed to meet. They explained that they took an individual approach to dealing with each resident’s particular mental health needs, based on what worked best for that individual; they were able to discuss different approaches and were clear that it was important for all staff to follow a consistent approach with each person. Staff were seen to deal caringly and appropriately with a confused resident. Staff spoken to in the main house were also knowledgeable and informed about their residents, and showed good understanding of the physical care needs the home aimed to meet. They were observed to be responding professionally and appropriately to changing health needs, and to promptly arrange medical intervention when required. Some dementia training had been provided to staff in the main house since the last inspection, in response to issues raised at previous inspections about the changing needs of some residents in the main house (see Staffing section). It was noted that a recently admitted resident in the main house appeared to have needs which fell outside of those that the main house aims to meet; staff spoken to in the main house expressed some concern about this person. The manager said that the information had been checked prior to admission, and that there was no formal diagnosis of any condition that was contrary to the home’s registration. However, the information provided to the home prior to admission suggested that this person’s needs may fall outside of the frail elderly registration category of the main house. Prince Edward Duke of Kent Court I56-I05 s17912 Prince Edward v237426 050705 stage 4.doc Version 1.40 Page 10 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 standard(s) 7, 8 and 10 Health and personal care needs were well met within the home. Residents’ needs were set out in individual plans of care; however, care plans for mental health needs lacked sufficient detail of the support required to meet these needs. Staff treated residents with dignity and respect. EVIDENCE: All six residents spoken to were extremely positive about the care provided to them at Prince Edward Duke of Kent Court. They appeared well cared for, and all reported that the staff were kind and competent, and the spouse of one resident said they were very happy with the care their partner received. Personal and health care needs were being well met, and observation of a shift handover demonstrated good communication processes, and prompt attention to any health issues noted by staff. Only two residents’ care plans were viewed on this occasion, and therefore general progress with care plans cannot be commented on. The care plans for a resident in the main house covered appropriate needs, although there was no care plan to describe the action staff should take to deal with challenging behaviour; a care plan for short term memory loss referred to encouraging the person in activities and social events, but did not detail any specific action to Prince Edward Duke of Kent Court I56-I05 s17912 Prince Edward v237426 050705 stage 4.doc Version 1.40 Page 11 deal with issues or behaviours arising from the memory loss. There was an appropriate care plan relating to the support the person needed with smoking (although no corresponding risk assessment). A resident in the EMF unit had care plans to address short-term memory loss, and also agitation. Although these contained some relevant observations and actions, in talking to staff it was clear that they had a better understanding of this person, and strategies for dealing with their agitation, than was reflected in the care plans. In both files the care plans had been regularly reviewed. No residents had a pressure area at the time of the inspection, and therefore a previous requirement relating to care plans could not be assessed. One person had just been identified at risk of their skin breaking down, and staff had already implemented appropriate action (i.e. requested a District Nurse visit, and started a regime of afternoon bed-rest). Continence was not discussed on this visit, but it was noted that one shift leader has responsibility for liaison with the continence advisor. Daily notes were seen to be clear and factual, providing useful information. Records of daily food choices were being maintained to reflect nutrition; a record of visits by health professionals was maintained. Staff reported that the home is well supported by District Nurses, and the manager said that they have also recently received good support from a Care Home liaison nurse appointed by the PCT, who is providing help with hospital discharges, advice and support, and training. Staff appeared to have the skills and knowledge to meet the general needs of residents; it was felt that staff in the main house would benefit from more training in understanding the needs of people with a cognitive impairment or mental health needs, and how to support and assist them (see Staffing section). Staff were seen to treat residents with respect and dignity, relating well to them, and assisting discretely. All resident had single rooms, and they were able to have telephones installed in their rooms if they wished. The six residents spoken to were unanimous in their praise of staff, and were happy with the way staff treated them. Prince Edward Duke of Kent Court I56-I05 s17912 Prince Edward v237426 050705 stage 4.doc Version 1.40 Page 12 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 standard(s) 12, 13 and 15 The home provides a flexible lifestyle and a range of activities to meet residents’ social interests and needs. Contact with families and the local community is encouraged and supported. The home provides a good, balanced and varied diet, served in pleasant surroundings, and is flexible to individual needs. EVIDENCE: Daily routines in the home were flexible: residents could get up or go to bed when they wanted, and could exercise choice in how and where they spent their day. One resident said they could use a small upstairs kitchen area to make their own drinks. Care files contained a section to record ‘summary of past life’, but it was noted that for a person in the EMF unit this section recorded ‘does not wish to divulge’. Whilst individuals’ wishes should be respected, this was discussed with staff in relation to residents who may lack the capacity to make this decision. For residents who have dementia, a knowledge of their past history and interests can help staff to understand and support current needs and behaviours, and this is therefore important information to find out and record. The home has made considerable progress in the development of activities over the last year, and should be commended for this. An activities coordinator has been in post over this time, and all residents spoken to were Prince Edward Duke of Kent Court I56-I05 s17912 Prince Edward v237426 050705 stage 4.doc Version 1.40 Page 13 unanimous in their appreciation of the increased range of activities available. There is a monthly calendar of events, with activities including arm chair yoga, bingo, quizzes, a monthly ‘pub hour’ before lunch (seen on the day of the inspection, and enjoyed by all those participating), entertainment and social events, plus regular trips out (e.g. outing to Felixstowe, a monthly tea dance, pub lunches, shopping trips, etc.). Activities are advertised on posters, and ‘flyers’ on the dining room tables. Special meals are arranged for particular events (e.g. Father’s Day, Easter Sunday, etc.), with ‘restaurant style’ menus produced, which have interesting information about the event on the back (e.g. a brief history of Father’s Day). The activities organiser stated that they make the meals a special occasion, with nice napkins, table decorations, and meals including a starter and desert, glass of wine, coffee and mints, etc. The activities organiser maintains records of the activities taking place, including who has participated, and also transfers this information onto individual care records. It was recommended that, particularly for those with dementia, records also reflect the outcome for each individual (i.e. how they responded to the activity, whether they benefited from it, etc.). This would assist in the review of their social/emotional and mental health care plans, and help to monitor and identify whether certain types of activities are more beneficial to certain residents. The Manager stated that they are looking at ways of encouraging care staff in the main house to become more involved in activities, and this should be pursued. Residents can receive visitors at any time, and the home has a visitors’ room where visitors can stay overnight. The home has social events that visitors are invited to, and an Association of Friends who are actively involved in the home. Residents were positive about their involvement in the home (e.g. arranging quizzes, providing volunteer transport, etc.). A monthly communion service is held in the home. All six residents spoken to were very positive about the meals served at the home, and felt that the range and quality of meals was very good. One resident felt that there had been recent improvements to the meals. The kitchen staff seek feedback from residents after every meal, and the chef also attends the quarterly residents’ meetings to discuss meals with them. The dinner and tea seen on the inspection looked appetising and well presented, and included fresh homemade items (e.g. quiche, soup, cakes, etc.). There was a good choice of meals available, and also flexibility to meet individual requests: for example, one resident had asked for stilton cheese and salad for tea, and this had been provided; another resident spoken to said that they were cooked an individual omelette for breakfast, because they did not want the bacon and egg being served. The chef spoke knowledgably about catering for diabetics; sandwiches were prepared for supper-time snacks. Prince Edward Duke of Kent Court I56-I05 s17912 Prince Edward v237426 050705 stage 4.doc Version 1.40 Page 14 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 standard(s) 18 Staff have not received sufficient training to ensure that they have current knowledge of the issues and procedures relating to the protection of vulnerable adults from abuse. EVIDENCE: Only issues arising from the last inspection were inspected on this occasion, and this related to providing staff with training in the protection of vulnerable adults. Since the last inspection, eight staff had attended a workshop on the protection of vulnerable adults, and a further eight staff were booked on training in November. However, out of a staff team of over 50 care and auxiliary staff this is not a sufficient level of training, and requires further action. Prince Edward Duke of Kent Court I56-I05 s17912 Prince Edward v237426 050705 stage 4.doc Version 1.40 Page 15 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 standard(s) None of these standards were inspected on this occasion. EVIDENCE: On the day of the inspection, areas of the home viewed were clean, tidy and free from any unpleasant odour. It was noted that some staff had attended infection control training recently, and that further training in this was planned. Prince Edward Duke of Kent Court I56-I05 s17912 Prince Edward v237426 050705 stage 4.doc Version 1.40 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30 Service users needs were generally being met by the number and skill mix of staff, and staff were trained and competent to do their jobs. Mental health needs arising in the main house were not yet being adequately addressed through staff training. Recruitment practices did not provide sufficient evidence that all the checks required to protect service users had been carried out for a new member of staff. EVIDENCE: Staff rotas were not specifically inspected on this occasion. Staffing levels previously agreed were ten staff throughout the day (allocated as four on the EMF unit and six in the main house). It was noted that afternoon staffing levels in the main house had been reduced to five (four carers and a shift leader) when occupancy numbers were low, but had not been increased again now the home was full. This was discussed with the manager, who was advised that previously agreed minimum staffing levels should be maintained. Staff in the EMF unit reported finding it difficult to manage early in the mornings, feeling that there were not enough staff in the unit to adequately assist residents to get up, serve breakfast and administer medication safely. The file of one staff member who had started work within the last year was viewed, and contained a completed application form detailing the employment history, a criminal declaration, and names of two referees. References had been obtained before the person started work, but there was no evidence of a CRB/POVA check being obtained by the home. Regarding agency staff, the manager stated that they have received a letter from the agency used by the Prince Edward Duke of Kent Court I56-I05 s17912 Prince Edward v237426 050705 stage 4.doc Version 1.40 Page 17 home confirming that all agency staff have CRB checks and references, and when an agency carer is used an individual form is signed by the agency for each carer confirming the CRB and the core training done. The manager was advised that this form should show whether the employer (the agency) has obtained all the information specified by Schedule 2 of the Care Homes Regulations 2001 (amended 2004) for that individual. Since the last inspection the home had implemented individual training records for staff, and those viewed showed several training sessions attended over the last year. Since the last inspection, 36 staff had attended a half-day DE workshop in March, which is to be commended. This had been highlighted as a training need on the last two inspections, particularly for staff in the main house where the changing needs of some residents was resulting in increased levels of confusion and some challenging behaviour. On this inspection, the needs of a new resident were also challenging the skills of staff. However, the manager stated that staff had not felt that this dementia training had provided them with the knowledge they needed to help them in their work, and this was reinforced by two staff spoken to in the main house. The manager stated that further training was therefore being looked into. Other training attended by some staff over the last year included: infection control/MRSA, fire safety, first aid, bowel and catheter care, osteo-awareness workshop, POVA training, dealing with aggression, medication, and appraisal skills. Training planned included: Parkinsons’ Disease, infection control/MRSA, bowel and catheter care, and POVA training (see Complaints and Protection section). The home is working towards training senior staff to deliver some training in-house, and towards this the deputy manager and three shift leaders had done a trainers course, all shift leaders had competed a manual handling trainer’s course, and three staff had done a fire safety trainer’s course. Induction training was not reviewed on this inspection. Prince Edward Duke of Kent Court I56-I05 s17912 Prince Edward v237426 050705 stage 4.doc Version 1.40 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32 and 33 The home’s manager has suitable experience, knowledge and skills to be able to discharge their responsibilities. The home has a clear management structure, and the ethos and practices in the home promote and enable residents’ involvement. The home aims to operate in the best interests of residents, and has systems in place for seeking feedback from residents and their relatives on the quality of the service. EVIDENCE: The manager of the home has completed her registration with the CSCI since the last inspection, and has appropriate skills and experience to manage a care home. She is currently progressing training to attain the NVQ level 4 in management and in care. The RMBI has a senior management structure that includes a regional manager who is available for advice and support, and who carries out monthly visits to the home (as required under Regulation 26 of the Care Homes Regulations 2001). A care co-ordinator appointed at the time of the last inspection was now operating as the deputy manager of the home. Prince Edward Duke of Kent Court I56-I05 s17912 Prince Edward v237426 050705 stage 4.doc Version 1.40 Page 19 Staff and residents reported that the manager is available and approachable, and all felt that they could speak to her. Systems were in place to seek staff and residents’ views about the daily running of the home, both informally (through day-to-day contact), and through staff and residents’ meetings. The residents’ meetings are held quarterly, and enable them to raise issues and provide feedback about the home. The manager reported the meetings are usually well attended: the minutes of the meetings showed a good range of relevant issues being raised by residents, and indicated where action had been agreed to address these; examples included issues around mealtimes being rushed, and trips out. The Chef attends the meetings to enable residents to make suggestions about meals. The manager had recently implemented a monthly newsletter for the home, providing residents with information on events planned and news about the home, with opportunities for staff and residents to contribute. This was well produced, and had been given to residents and was displayed on notice boards in the home. Some of the staff and residents spoken to during the inspection, whilst recognising the administrative responsibilities of the manager, said that they would like the manager to spend more time around the home with them. The manager felt that during her first year in the home her responsibilities had not allowed her to spend as much time around the home as she would have liked, and hoped that now she had the support of a deputy manager, and had made progress towards achieving some initial objectives, she could spend more time with staff and residents. As part of their quality monitoring processes, the RMBI carries out relatives and residents surveys each year. A recent relative survey had taken place, and the manager had received the responses and had produced a clear action plan to address the key issues arising. A report on the last years’ residents’ survey had previously been provided to the CSCI. Internal monitoring takes place in a variety of ways, including seeking feedback on food after each meal, monitoring of medication records, and monthly audit visits by the area manager (reports on which are provided to the CSCI). The home had a business plan, but this focused on business viability issues rather than service user outcomes. Although the manager and deputy manager had Personal Business Plan Objectives linked to this, there was no annual development plan for the home focusing on care related issues (e.g. specific training needs, improving care plans, activities, achieving supervision targets, etc.). The manager said that although they do have aims and objectives, these are progressed on a monthly basis through staff and management meetings and are not part of a written annual development plan. Prince Edward Duke of Kent Court I56-I05 s17912 Prince Edward v237426 050705 stage 4.doc Version 1.40 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x x 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 4 COMPLAINTS AND PROTECTION x x x x x x x x STAFFING Standard No Score 27 2 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 2 3 3 3 x x x x x Prince Edward Duke of Kent Court I56-I05 s17912 Prince Edward v237426 050705 stage 4.doc Version 1.40 Page 21 Yes 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 4 Regulation 14 Requirement The registered person must ensure that the home can meet the needs of any individuals admitted to the home, and that their needs fall within the homes conditions of registration. It is required that all staff attend training in the protection of vulnerable adults. This is a repeat requirement for the second time (previous timescale 31/3/05). The registered person must review the staffing levels throughout the day, to ensure that at all times there are sufficient care staff available to safely meet residents needs. It is required that the registered person ensure that all information required by regulation is obtained for new staff before they start work. This is particulary in regard to CRB/POVA checks. Timescale for action 29/7/05 2. 13 and 18 18 and 30 31/12/05 3. 18 27 31/8/05 4. 19, Schedule 2 29 29/7/05 Prince Edward Duke of Kent Court I56-I05 s17912 Prince Edward v237426 050705 stage 4.doc Version 1.40 Page 22 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 4 and 30 Good Practice Recommendations It is strongly recommended that the registered person ensure that staff in the main house receive adequate training in dementia care to be able to meet the needs of peoples who are confused or have challenging behaviour. The registered person should ensure that care plans are subject to ongoing development. This is particularly with regard to ensuring that needs arising from mental health problems (e.g. confusion, agitation, challenging behaviour) are addressed in care plans, with sufficient detail of the action required by staff to support the need. It is recommended that the home makes sure, wherever possible, that information about a residents past life and interests are recorded. It is recommended that records of activities participated in by residents who have dementia include an evaluation of the outcome of the activity for the person. It is strongly recommended that the registered person amend the form signed by agencies for each agency carer attending the home, to ensure that it reflects confirmation that they have obtained all the information required by Schedule 2 of the Care Homes Regulations. It is recommended that home has an annual development plan reflecting aims and outcomes for service users. 2. 7 3. 4. 5. 12 12 29 6. 33 Prince Edward Duke of Kent Court I56-I05 s17912 Prince Edward v237426 050705 stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Fairfax House Causton Road Colchester CO1 1RJ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Prince Edward Duke of Kent Court I56-I05 s17912 Prince Edward v237426 050705 stage 4.doc Version 1.40 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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