Inspection on 16/02/06 for St Edburgs House

This inspection was carried out on 16th February 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

St Edburgs House 12/12/06

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 Andy McGuckin Unannounced Inspection 16th February 2006 09:30 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.V284042.R01.S.doc Version 5.1 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.V284042.R01.S.doc Version 5.1 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 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) The Orders Of St John Care Trust 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.V284042.R01.S.doc Version 5.1 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. 6th October 2005 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. St Edburgs House DS0000036415.V284042.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on a weekday morning and was unannounced, which meant that the home was not given prior warning of the inspection. The inspector was welcomed into the home and it was explained that the manager was on fire training. The inspector was assisted in the inspection process by two senior staff members, and the inspector would like to thank them for stepping in at such short notice. The inspector toured the building and spoke informally to staff and residents, inspected key documentation and observed staff interacting with service users. Improvements have been made to the building since the last inspection and the management and staff should be commended for making the home as comfortable as possible, given the overall age and layout of the building. What the service does well: What has improved since the last inspection? What they could do better: All health and safety issues directly affecting the health and welfare of service users and staff must be addressed immediately. Delays must not happen due to the process for identifying finance. St Edburgs House DS0000036415.V284042.R01.S.doc Version 5.1 Page 6 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. St Edburgs House DS0000036415.V284042.R01.S.doc Version 5.1 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 St Edburgs House DS0000036415.V284042.R01.S.doc Version 5.1 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): 1, 2, 3, 4, 5, 6 The organisation provides prospective service users with sufficient information presented in a clear and concise format on which an informed decision can be made. EVIDENCE: The home makes available documentation and information on which prospective residents can make decisions as to the suitability of the home. The organisation should be commended for the standard and quality of this information. This documentation is presented in clear and concise language and sets out the terms and conditions of the home’s contract. Residents or their representatives sign the contract and retain a copy. Prospective residents are assessed by the home in collaboration with other interested professional agencies. Where possible, prospective residents are invited to spend some time at the home prior to taking up a vacancy. Prospective residents are invited for a meal or overnight stay. A trial period is agreed to allow either party to assess the suitability of the home to meet the needs of the individual. St Edburgs House DS0000036415.V284042.R01.S.doc Version 5.1 Page 9 The placement and care plan are reviewed regularly. The inspector viewed a random selection of care plans and residents’ files which were presented in a clear and easily understandable format. Current information is presented in a cardex system with a second file for background, historical information and correspondence. Comprehensive information is also held on residents attending for respite care. Standard 6 is not applicable, as the home does not offer an intermediate care facility. St Edburgs House DS0000036415.V284042.R01.S.doc Version 5.1 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 the following standard(s): 7, 8, 9, 10, 11 The health , social and emotional well-being of the home’s service users is being met. EVIDENCE: The inspector spoke informally to three residents, all of whom expressed satisfaction with the home and the level of care it provides. Six residents’ files were examined which provided evidence that resident’s individual health, personal and social care needs are being met. The home has appropriate policies and procedures to manage the storage, recording and distribution of medication. A random selection of residents’ medication administration sheets was inspected and found to be satisfactory. Personal care plans are drawn up to identify the individual needs and wishes of residents. Where possible, residents are fully involved in this process. Residents are encouraged to be fully involved in all aspects of the home if they are willing or able. Where residents do not want to participate in activities, this is respected. St Edburgs House DS0000036415.V284042.R01.S.doc Version 5.1 Page 11 Some residents are responsible for the management and administration of their own medication. This is encouraged by the home. Information is kept on file as to the wishes of residents following serious illness or death. St Edburgs House DS0000036415.V284042.R01.S.doc Version 5.1 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 the following standard(s): 12, 13, 14, 15 The home provides activities, both planned and ad-hoc, in order to meet the needs of its residents. An activities co-ordinator has been appointed. EVIDENCE: The home has employed a full time activities co-ordinator who has not been in post very long. The inspector formally interviewed the post holder and was impressed with the ideas and plans for the future. The main priority for the home at present is to consolidate what is already good and build on this. The home is in the process of buying new equipment. The home has contacts with the local Round Table who funds activities from time to time. Some of the home’s residents are still fully active in the local community and manage their own affairs with little input from the home. Residents’ meetings are held regularly and are well attended. Residents are encouraged to maintain as much control over their lives as they are able or willing to do. On the day of the inspection the inspector met with the chef and toured the kitchen. All equipment was found to be clean and in good working order. St Edburgs House DS0000036415.V284042.R01.S.doc Version 5.1 Page 13 There is a daily menu, which is rotated on a regular basis, and residents are asked to choose individually on a daily basis their preference. Alternatives to the main menu are made available. Salad and vegetarian options are provided and fruit is available in residents’ rooms. Special dietary requirements can be met if required. St Edburgs House DS0000036415.V284042.R01.S.doc Version 5.1 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 the following standard(s): 16, 17, 18 The home has a formal complaints procedure. EVIDENCE: The home’s complaints/concerns are, where possible, dealt with at source and usually with a satisfactory outcome. Formal processes are in place if complaints cannot be resolved in this manner. One recent complaint was viewed by the inspector, and was found to have been dealt with in a timely and satisfactory manner. The home has a procedure in place to identify and deal with potential issues of abuse in line with the Oxfordshire adult protection policy. St Edburgs House DS0000036415.V284042.R01.S.doc Version 5.1 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 the following standard(s): 19, 20, 21, 22, 23, 25, 26 The home does not meet many of the standards required under this regulation. The home is to be relocated to a new site in 2008/9. The building is, however, fit for purpose. EVIDENCE: As previously mentioned in this report, 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. T he 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 facilities. Many bedrooms had lino-type floor coverings and metal framed beds. Some rooms are shared and have a curtain as a separator. St Edburgs House DS0000036415.V284042.R01.S.doc Version 5.1 Page 16 At present when a room is vacated it is redecorated. The inspector was shown evidence of this. Previous requirements regarding water temperatures have been addressed since the last inspection to a satisfactory standard. On the day of the inspection the home was found to be clean and smelt fresh. St Edburgs House DS0000036415.V284042.R01.S.doc Version 5.1 Page 17 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 home is staffed to an acceptable standard. EVIDENCE: On the day of the inspection there was sufficient staff to meet the needs of the current service user group. The manager is both experienced and qualified, holding the Care Managers Award and NVQ Level 4. Five staff files were inspected and these evidenced that staff are being recruited appropriately and that regular training is taking place. Future training has been identified for all staff. Staff are being supervised on a regular basis and issues identified at supervision are dealt with appropriately. Evidence of staff meetings taking place was found and minutes reflected that subjects covered were relevant to the care of the residents. St Edburgs House DS0000036415.V284042.R01.S.doc Version 5.1 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 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): 30, 31, 32, 33, 34, 35 ,36, 37, 38 The home is professionally run and managed. EVIDENCE: The registered manager is experienced and trained to manage the care provision offered by the home. The registered manager is supported to do this by a staff group of sufficient numbers and experience in the care of the elderly. The home is part of the larger organisation of The Orders of St John Care Trust and, as such, has the full backing of the organisation. The home was found to be managed in a professional manner. Accounts are available for inspection if required. Accounts were not required as part of this inspection. St Edburgs House DS0000036415.V284042.R01.S.doc Version 5.1 Page 19 The health, safety and welfare of residents is, in the main, being promoted and protected. The inspector concludes that the home is professionally run and managed. St Edburgs House DS0000036415.V284042.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 3 18 3 3 3 1 3 3 3 3 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 3 3 3 3 3 3 3 St Edburgs House DS0000036415.V284042.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP21 Regulation 23 Requirement The manager must consult with the environmental health officer in relation to the hot water taps which are not effectively thermostatically regulated due to problems with the boiler, and provide written feedback to the CSCI. The inspector has since been given evidence that this standard has now been met. Timescale for action 01/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Edburgs House DS0000036415.V284042.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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 St Edburgs House DS0000036415.V284042.R01.S.doc Version 5.1 Page 23 - 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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