Inspection on 12/12/06 for St Edburgs House

This inspection was carried out on 12th December 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

St Edburgs House 16/02/06

St Edburgs House 06/10/05

St Edburgs House 03/03/05

St Edburgs House 12/05/04

Similar services:

St Vincents

Hamilton House

The Cotswold Home

Newbeech House

Newbeech House

Winton House

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

CARE HOMES FOR OLDER PEOPLE St Edburgs House Old Place Yard Church Lane Bicester Oxfordshire OX26 6AS Lead Inspector Nichola Cahill Unannounced Inspection 12th December 2006 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 St Edburgs House DS0000036415.V317416.R02.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. St Edburgs House DS0000036415.V317416.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Edburgs House Address Old Place Yard Church Lane Bicester Oxfordshire OX26 6AS 01869 252343 01869 250403 manager.stedburgs@osjctoxon.co.uk www.oxfordshire.gov.uk The Orders Of St John Care Trust 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) Andrea Woods Care Home 40 Category(ies) of Dementia - over 65 years of age (18), Old age, registration, with number not falling within any other category (40), of places Physical disability over 65 years of age (1) St Edburgs House DS0000036415.V317416.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The total number of persons that may be accommodated at any one time must not exceed 40. As vacancies arise the PD/E category will be removed. The continued registration of this service past April 2007 is dependent upon the physical environment meeting standards. 16th February 2006 Date of last inspection Brief Description of the Service: . St Edburgs is a care home for older people who do not require nursing and is situated in the centre of Bicester. The home itself was built some time ago and, as such, the design was dictated by the principles of that time. As a result the building appears dated with small rooms, double rooms and a lack of en-suite facilities being notable. However, the managers and staff make the best of the environment and endeavour to make it as homely and comfortable as possible. The home is owned and managed by The Orders Of St John Care Trust, which is a large charitable organisation. As the home no longer meets the current spatial standards as set out in the Care Homes Regulations, a new home is to be built in another part of the town to address these issues. It is anticipated that the move to new premises will take place sometime in 2007. A building plot has now been identified and work has started on the site. Information regarding the services offered is available from the home on request. The fees for nursing and care provision are from £491.00 - £620.00 per week. Items not covered by fees include, chiropody, hairdressing, visits from the beautician and newspapers. St Edburgs House DS0000036415.V317416.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the summary of the unannounced Key inspection visit carried out by Nicky Cahill (inspector) on 12th December 2006. The inspection took place over a period of 10 hours, this included the pre-inspection planning. The inspection consisted of the case tracking of three service users currently living in the home, service user and staff discussions, observations, a tour of the building, viewing of documents and meeting with the manager. An assessment was also carried out of any information received by the Commission since the previous inspection visit. Service users, relatives and representatives and other stakeholders were invited to submit comment cards prior to the inspection visit. The Commission received feedback from 6 service users, 9 relatives / representatives, 3 health care professionals and 3 GP’s. All comments were positive. An assessment was made against all key standards. A small number of recommendations have been made as a result of inspection findings. From the evidence seen and comments received, it is considered that this service meets the individual cultural, religious and diverse needs of all service users. What the service does well: Service users are appropriately assessed prior to admission. Service users are assured that the home can meet their needs. Service users are treated with dignity and their right to privacy is upheld. The home has an activity programme in place to ensure that service users’ social and recreational interest and needs are catered for. Service users are supported to exercise choice and control over their lives. Visitors are welcome to visit at any time this ensures that service users maintain contact with their families and friends. Service users receive a varied and appealing diet and are supported in their choice of meals in accordance with their assessed needs. A complaints policy is in place and service users are empowered in airing their Concerns and complaints. No complainant has contacted the St Edburgs House DS0000036415.V317416.R02.S.doc Version 5.2 Page 6 Commission with information concerning a complaint made to the service since the last inspection. Robust policies and procedures are in place to ensure that service users are protected from abuse. Care staff receive appropriate training in order to meet ensure the safety of service users. Staffing allocation is adequate to continue to fully meet the needs of the service users. The home is well managed and run in the best interests of the service users. Service users are able to live in a home that provides a quality service throughout. Service users are protected from financial abuse by the homes policies and procedures in place. Health and safety systems are in place to ensure that service users are protected from harm. What has improved since the last inspection? 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 St Edburgs House DS0000036415.V317416.R02.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Edburgs House DS0000036415.V317416.R02.S.doc Version 5.2 Page 8 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 St Edburgs House DS0000036415.V317416.R02.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive an appropriate assessment prior to admission to the home. EVIDENCE: The pre-admission assessments were viewed for two service users. One assessment had been completed prior to the service user being admitted to the home and detailed documentation was in place. It was noted that a small amount of information collated at the time of the assessment had not been transferred onto the care plan. This omitted information could have an impact on the outcomes for the service user. A recommendation has been made for improvement in this area. The second assessment was being completed at the time of the inspection visit for a service user who had been admitted from another of the organisations St Edburgs House DS0000036415.V317416.R02.S.doc Version 5.2 Page 10 homes as an emergency. In this instance the service users notes had been received and were being utilised to develop a care plan. At the time of the inspection the home were trialling a new system of assessment. An extra member of staff would be rotered to spend a day with a service user within the home to complete a thorough assessment. This is considered as good practice. St Edburgs House DS0000036415.V317416.R02.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have an appropriate plan of care, health care needs and wishes and preferences are noted. From the information recorded and systems in place the home are able to fully meet the needs of the current service user group. Service users privacy and dignity is respected and confidentiality is protected at all times. EVIDENCE: Three service user care plans were viewed and case tracking was carried out to ensure positive outcomes, this included, service user discussions, observations and discussions with care staff. Care plans were found to be informative and included a short profile of the service users back ground, health and personal care needs, risk assessments, St Edburgs House DS0000036415.V317416.R02.S.doc Version 5.2 Page 12 regular reviews and other information which would enable staff to fully meet the service users needs. During the feedback session a recommendation was made for further improvements in one area of care planning, this would include the use preassessment information. Health care needs were recorded appropriately and included details regarding specialist equipment supplied, visits by GP’s, district nurses and the podiatrist. The medication systems and storage were assessed. Medication administration records (MAR) were viewed and were completed correctly. Medication storage systems were adequate and would ensure the ongoing safety of service users. An external company had recently audited the medication systems in place. Observations were made throughout the day of excellent practices regarding the protection of service users privacy and dignity. Service users also reported that staff were, ‘Very respectful’. St Edburgs House DS0000036415.V317416.R02.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an activity programme in place to ensure that service users’ social and recreational interest and needs are catered for. Visitors are welcome to visit at any time this ensures that service users maintain contact with their families and friends. Healthy and nutritious meals are supplied. Service users are support to exercise control over their lives and choices made. EVIDENCE: Daily life and social activities were assessed through discussions with service users and staff, through documentation viewed and from observations made during the inspection visit. The home has an activities co-ordinator, who showed a great understanding of the complex and diverse needs of the service users currently residing in the home. Service user spoke highly of the activities offered and the opportunities to be involved both on a one to one basis, as a small group or as part of the wider community. St Edburgs House DS0000036415.V317416.R02.S.doc Version 5.2 Page 14 Service users confirmed that they were able to fulfil their spiritual and cultural needs whilst living in the home. This was also evident from documentation viewed and discussions with relatives The inspection visit was during a busy period were personal care was taking up most of the care staffs time. However, care staff engaged in appropriate conversations whilst carrying out other duties and it was pleasant to hear service users singing and socialising in small groups around the home. It was confirmed that visitors are always welcomed. A choice of menu was available and displayed around the home. Service users were able to eat meals within a pleasantly decorated dining area or within the privacy of their own bedrooms. Service users requiring help with meals were assisted with dignity and respect. All service users reported an enjoyment of all meals served. St Edburgs House DS0000036415.V317416.R02.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are empowered in airing their Concerns and complaints and are protected from any abuse. EVIDENCE: Complaints and protection within the home was assessed through documentation, pre-inspection feedback and service users discussions. The home has received one complaint since the last inspection visit. Documentation viewed confirmed that this was dealt with appropriately and in accordance with the organisations polices and procedures. A copy of the complaints procedure was in place in the main entrance and other areas of the home. The Commission has not received any information about complaints or concerns regarding the home since the last inspection. The home has received many letters of thanks from friends and family for the quality service given to service users who have resided in the home in the past. St Edburgs House DS0000036415.V317416.R02.S.doc Version 5.2 Page 16 Adult protection polices and procedures are in place and staff confirmed that they would feel empowered in ‘whistle blowing’ should the need arise. The home has had one issue regarding the protection of vulnerable adults since the last inspection visit. Documentation viewed confirmed that this had been dealt with in an appropriate manner. It was confirmed that all staff have received up date training in this area. St Edburgs House DS0000036415.V317416.R02.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in a safe, comfortable and homely environment. However, the home is dated and does not ensure adequate private and communal space for the current service user group. EVIDENCE: The home is due to be relocated to a purpose-built site, which is in the early stages of the project. The home was built at a time when many of the standards expected today do not apply. The home’s managers and staff have done their best to ensure that the home is as homely and comfortable as possible. Bedrooms inspected were of a reasonable standard but many would not comply with today’s space standards and the requirement to provide en-suite St Edburgs House DS0000036415.V317416.R02.S.doc Version 5.2 Page 18 facilities. Many bedrooms had lino-type floor coverings and metal-framed beds. Some rooms are shared and have a curtain as a separator. On the day of the inspection the home was found to be clean, comfortable and free from offensive odours. St Edburgs House DS0000036415.V317416.R02.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home operates a robust recruitment procedure; staff are appropriately inducted and trained, protecting the safety of service users. Staffing allocation is adequate to continue to fully meet the needs of the service users. EVIDENCE: The assessment of staffing included sampling four personnel files, training and development files, staff rotas and brief discussions with staff and the manager. The home has robust recruitment procedures in place to ensure the safety of service users. The manager confirmed that all mandatory training was up to date. Training plans for individuals were available within files viewed. However, certificates were not all in place. A recommendation has been made for improvement in this area. Staffing numbers appeared to be sufficient throughout the inspection and service users confirmed that there was always someone available should they require assistance in any way, this was also reflected in observations made and staffing rotas viewed. St Edburgs House DS0000036415.V317416.R02.S.doc Version 5.2 Page 20 It was discussed during the inspection feedback that staffing levels would be re-assessed in more depth at the next inspection visit in preparation for the move to new premises. St Edburgs House DS0000036415.V317416.R02.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of the service users and health and safety is protected through policies and procedures in place. EVIDENCE: The manager of the home is Andrea Woods who has recently been registered with The Commission. Through discussions, observations and from documentation viewed it would appear that the home is run in the best interests of the service users. St Edburgs House DS0000036415.V317416.R02.S.doc Version 5.2 Page 22 The home has had a quality audit since the last inspection visit, however, it was confirmed that the service users views are presently being analyzed by the organisation. The results of this audit will be forwarded to The Commission on completion. It was confirmed that the home does not handle any service users finances. Health and safety around the home was assessed through observations and discussions. The pre-inspection questionnaire submitted by the manager confirms that health and safety practices are regularly reviewed. Accident and incidents were tracked through service users care plans. The home will notify the Commission of any accidents or incidents that affect the health and welfare of service users. St Edburgs House DS0000036415.V317416.R02.S.doc Version 5.2 Page 23 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 3 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 St Edburgs House DS0000036415.V317416.R02.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP2 OP30 Good Practice Recommendations It is recommended that the home ensure that all information is transferred from pre-admission assessments to ensure that service users needs are met at all times. It is recommended that training files hold a copy of all certificated training for individual staff. St Edburgs House DS0000036415.V317416.R02.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © 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 St Edburgs House DS0000036415.V317416.R02.S.doc Version 5.2 Page 26 - 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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