CARE HOMES FOR OLDER PEOPLE
St Edburgs House Old Place Yard Church Lane Bicester Oxfordshire OX26 6AS Lead Inspector
Carole Moore Announced Inspection 6th October 2005 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.V252493.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. St Edburgs House DS0000036415.V252493.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service St Edburgs House Address Old Place Yard Church Lane Bicester Oxfordshire OX26 6AS 01869 252343 01869 252343 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.V252493.R01.S.doc Version 5.0 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. The continued registration of this service past April 2007 is dependent upon the physical environment meeting standards. As vacancies arise the PD/E category will be removed. Date of last inspection 3rd March 2005 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. 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. St Edburgs House DS0000036415.V252493.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an announced inspection and took place on Thursday, 6th October 2005. The inspector was made to feel very welcome by both staff and residents and was appreciative of the full co-operation of all the staff that were on duty that day. The inspector toured the building looking at most of the communal areas, the laundry, the kitchen and some bedrooms, accompanied by the resident. A majority of time was spent talking to residents and individual time was spent talking with staff who were on duty that day - the activities co-ordinator, the chef, two senior care leaders, several carers, laundry assistant, housekeepers and the manager. Three residents’ records of care and three staff records were looked at in detail, as well as paperwork relating to the health and safety of the home. The senior care leader was observed carrying out the lunchtime medication round and the inspector joined the residents for lunch. Positive comments have been received from the GPs who visit St Edburgs and very favourable comments have been received from relatives and friends. For example, ”Mum receives first class care from all the staff”, “Extremely satisfied”, “Staff show genuine care“. What the service does well:
. There is a very homely environment and generally happy atmosphere, and residents spoken to were pleased with their overall care and had nothing but praise for the staff. Feedback from a relative confirmed, ”The staff create a happy atmosphere”. The home is bright and clean and the communal areas have recently been redecorated. The home has a new activities co-ordinator and she is working hard to organise activities related to the wishes and abilities of all the residents. Those residents spoken to were pleased with the amount of activities that were currently on offer. On the day of the inspection there were art and craft classes in the morning and a word game in the afternoon. The inspector observed many residents enjoying the stimulating activity of word search. The staff group are committed to providing the best quality care to the residents, and residents confirmed that staff were “really helpful and caring”.
St Edburgs House DS0000036415.V252493.R01.S.doc Version 5.0 Page 6 Care records and the handover meeting seen on the day of the inspection demonstrated that staff were looking at the residents’ emotional needs as well as their physical needs. Many of the residents are self-caring and staff ensure that their independence is maintained for as long as possible. This was evidenced in the residents’ care records. Residents are treated as individuals with their likes and dislikes catered for in a calm and tranquil setting. One resident was busy sweeping the path when the inspector arrived and another was busy tending the gardens and greenhouse. The building is old and does not meet the spatial standards required. However, every effort is currently being made to keep the building well decorated and clean. What has improved since the last inspection? What they could do better:
St Edburgs House DS0000036415.V252493.R01.S.doc Version 5.0 Page 7 Care records have been greatly improved and care staff are writing clearly in the communication daily records. It would be helpful if the care leaders could monitor the recording in order to ensure consistency in the quality of the recordings. Feedback from relatives and friends indicated that some were unaware of the complaints procedure. Although the procedure is displayed on notice boards and is clearly recorded in information given to prospective residents, it might be useful to reinforce this with families. The procedure for recruiting staff is robust in most areas. However, care needs to be taken when looking at the work history of applicants. Any gaps in employment must be identified and explained and recorded on the employee’s file. 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.V252493.R01.S.doc Version 5.0 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.V252493.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&5 All prospective residents have an assessment of their care needs so that the home, the prospective resident and their family are clear that the overall needs can be met. EVIDENCE: Residents and their families are encouraged to visit the home for a day’s assessment and this is carried out by the care leaders. This ensures that the home is able to meet the needs of the prospective resident and it is an opportunity for the resident and their families to meet staff and help to make the transfer into St Edburgs more pleasant and personal for them. Evidence of these pre-admission assessments were seen in residents’ records of care and they were comprehensive and complete. Every effort is made to have a holistic profile of the older person. Wherever possible emergency admissions are avoided.
St Edburgs House DS0000036415.V252493.R01.S.doc Version 5.0 Page 10 Residents spoken to described how the home made them feel very welcome when they first visited St Edburgs, and how they were given all the relevant information to support their decision to choose the home that was right for them. St Edburgs House DS0000036415.V252493.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 &10 The home meets the overall needs of the residents and staff respect the privacy and dignity of residents. There is a safe system of medicine administration given by trained staff. EVIDENCE: A sample of three residents’ care notes were examined and all had the care needs clearly identified with actions on how they would be met. Regular reviews take place and are clearly documented. The inspector observed evidence of good practice in relation to good communication between the care assistants and the care leaders about the care of the residents. The care assistants were seen completing the communication sheets on the residents they had cared for that morning and feeding back any specific issues to pass on to the afternoon shift. The inspector observed the handover meeting and it was very informative, not only concentrating on the physical needs but also the emotional needs of residents. The first task for the new shift of carers was to check that all the residents were happy and safe.
St Edburgs House DS0000036415.V252493.R01.S.doc Version 5.0 Page 12 Residents spoken to felt that they received excellent care - ”Marvellous Staff”, “Everyone so helpful”. Residents also confirmed that the staff were respectful of their wishes and ensured their privacy and dignity. Staff interviewed also gave evidence of best practice in this area. The inspector accompanied the care leader for part of her medication round at lunchtime and all medicines were stored safely in a locked medication trolley. The medication records were examined and found to be accurate and all appropriately signed. There were no controlled drugs being administered at the time of the inspection but the controlled drugs book was examined and it is clear that staff are required to have two signatures. There is a new drugs fridge and the inspector examined its contents and all was in order. The trained care staff record temperatures of the fridge daily. There are only two residents who control their own medication and this is primarily inhalers. St Edburgs House DS0000036415.V252493.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, & 15 Residents are encouraged to join in social activities, to exercise control over their lives and to maintain contact with their family and friends. Residents enjoy a varied diet. EVIDENCE: The activities co-ordinator explained how residents are encouraged to join in activities and that members of the community also come into the home to talk to them or entertain them. Residents spoken to confirmed that they enjoyed being given the choice of daily activities and enjoyed the trips out into the community. On the day of the inspection the activities of the day were clearly displayed on a flipchart at the entrance to the dining room and the inspector observed many residents taking part in a variety of differing activities. Some residents enjoy taking more control of their daily activities and two gentlemen were busy around the grounds. One resident was sweeping the leaves from the pathways and one was busy in the garden and greenhouse.
St Edburgs House DS0000036415.V252493.R01.S.doc Version 5.0 Page 14 Other residents confirmed that they were sometimes accompanied into the town or to the library. There is a variety of visitors to the home and they confirmed that they are made to feel very welcome. This was also further confirmed in feedback from relatives and friends. The Age Concern advocate was present on the day of the inspection and she confirmed that she visited on a regular basis and found the home and staff to be very supportive of her visits, and gave positive feedback on the overall quality of care received by the residents. The residents were keen to say how good the food was and the inspector enjoyed the lunch that was served on that day. There was a choice of chicken in a sauce or beef pie followed by jam tart or ice cream. The inspector discussed the home’s food arrangements with the chef and she confirmed that residents were given alternatives should they not like the choice of the day. A selection of menus inspected showed a good range of fresh foods being used. The chef told the inspector about the current difficulties with some of the equipment in the kitchen but new equipment has been ordered as a matter of priority. St Edburgs House DS0000036415.V252493.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 There is a clear complaints procedure, which does need more reinforcement with families. Residents are protected from abuse. EVIDENCE: The home has had one complaint since the last inspection and the inspector viewed the complaint log and corresponding paperwork. This was dealt with appropriately and resolved. The residents spoken to confirmed that they were more than able to voice any concerns and they were confident that any concerns would be listened to and acted upon. Feedback from relatives, however, confirmed that some were unaware of the complaints procedure. There are clear notices on the noticeboard and in the information given to prospective residents but, in discussion with the manager, it was felt that this information needs to be reinforced with relatives. There are also regular residents’ meetings where any areas of unhappiness can be discussed. St Edburgs House DS0000036415.V252493.R01.S.doc Version 5.0 Page 16 The manager and care services manager confirmed that staff receive initial induction training on the prevention of abuse but there needs to be more in-depth training to enable staff to have a thorough understanding of how to protect their residents from abuse. This training will be available to all staff on 17/18th October, 2005. St Edburgs House DS0000036415.V252493.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 St Edburgs does not meet the spatial environmental standards but it is safe, clean, homely, hygienic and well maintained. EVIDENCE: This home is old and this is reflected in some areas but every effort is being made to maintain the building and redecorate those areas that are in need. Cleaning was underway throughout the inspection and the housekeeping team work really hard to maintain the cleanliness of the building. Everywhere was clean tidy and fresh smelling. The only area identified by the inspector for repainting was the boxed-in pipe area behind the toilet in the bathroom in Silver Birch wing. The surrounding gardens are well maintained and a joy to residents. St Edburgs House DS0000036415.V252493.R01.S.doc Version 5.0 Page 18 There has been a problem with water temperatures and the handyman is regularly monitoring this. Also, new valves are to be installed to individual taps to further ensure the safety of residents. The inspector would like written confirmation when this work has been carried out. An environmental health officer visited on 23rd August 2005 and there were no contraventions or recommendations made. The inspector viewed the paperwork in relation to this visit. St Edburgs House DS0000036415.V252493.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 On the day of the inspection there were sufficient trained staff to meet and protect the overall needs of the residents. EVIDENCE: The staffing rota was examined and showed there was sufficient staff on duty that day. The home prides itself on not having to use agency staff as the staff team will fill in for any sickness, which is good for consistency of carers for the residents. The manger is currently encouraging staff to embark on the NVQ training programme and she is hoping to enrol all staff on NVQ 2. Currently St Edburgs falls below the expected 50 of staff needing to be registered on the programme by the end of 2005. Staff spoken to were clear on the training they have had and feel competent in their roles. The manager has a training matrix identifying all her staff training needs. Three staff records were examined and the home has a clear recruitment procedure. The only area of recommendation is in critically looking at the job history and identifying any gaps in employment. These gaps need to be checked and reasons for the gap documented on the files. All other areas of Schedule 2 of the regulations were met, thus ensuring the protection of the residents.
St Edburgs House DS0000036415.V252493.R01.S.doc Version 5.0 Page 20 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 36 & 38 The home is well managed and run in the best interests of the residents with their health and safety protected. EVIDENCE: There is a new manager currently in post and she is to go through the registration process with the Commission for Social Care Inspection. Formal supervision of staff takes place and this is recorded and kept on staff records. This ensures that all areas of practice are regularly monitored and staff supported through any difficulties. The inspector, through discussion and observation, concluded that there is a good staff team that support one another and there is good overall communication between staff and management.
St Edburgs House DS0000036415.V252493.R01.S.doc Version 5.0 Page 21 The central heating systems, lift, call systems, fire tests and lighting are all maintained under service contracts and the supporting documentation was examined and found to be up to date. St Edburgs House DS0000036415.V252493.R01.S.doc Version 5.0 Page 22 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 3 X 3 N/A 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 3 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 X X X 3 X 3 St Edburgs House DS0000036415.V252493.R01.S.doc Version 5.0 Page 23 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 OP16 OP29 Good Practice Recommendations It is recommended that the complaints procedure be reinforced with families. It is recommended that all employment history gaps are identified and checked in the process of recruitment. St Edburgs House DS0000036415.V252493.R01.S.doc Version 5.0 Page 24 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
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