Inspection on 14/01/08 for St Edith`s Court

This inspection was carried out on 14th January 2008.

CSCI found this care home to be providing an Adequate service.

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 Edith`s Court 18/12/08

St Edith`s Court 16/02/07

St Edith`s Court 03/03/06

St Edith`s Court 05/12/05

St Edith`s Court 16/12/04

St Edith`s Court 17/05/04

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 St Edith`s Court 18 Hillside Crescent Leigh On Sea Essex SS9 1EN Lead Inspector Michelle Love Unannounced Inspection 09:00 14 January 2008 th 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 Edith`s Court DS0000015468.V353940.R01.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 Edith`s Court DS0000015468.V353940.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Edith`s Court Address 18 Hillside Crescent Leigh On Sea Essex SS9 1EN 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) 01702 480688 01702 471894 www.anchor.org.uk Anchor Trust Mrs Patricia Ann Welch Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39) of places St Edith`s Court DS0000015468.V353940.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th February 2007 Brief Description of the Service: St.Edith’s Court is part of the Anchor Trust who provides residential care in the region. The home is situated in a quiet residential area of Leigh-on-Sea and is situated close to local amenities. The home provides single accommodation for 39 older people over the age of 65. Residents’ flats are situated on two floors and offer en-suite and kitchen facilities, as well as a range of comfortable communal areas throughout the home. A passenger lift is available to the first floor as well as conventional stairs. Outside of the home is a well-designed garden that is stocked with shrubs and plants. Access to the garden is suitable for wheelchair users and sufficient seating areas exist. There are adequate parking facilities to the side of the home in a designated car park belonging to the home. The weekly fee as detailed within the service users guide is £570.00. In addition to this, residents are charged for private telephone calls/telephone bills for those who have their own telephone in their room, chiropody, hairdressing, holistic therapy, transport to healthcare appointments where the NHS trust does not provide transport, staff escort for private events and for some social events/community activities. St Edith`s Court DS0000015468.V353940.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Quality Rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced key inspection. The visit took place over a 10-hour period and all but one of the key standards and the manager’s progress against previous requirements from the last inspection were inspected. Prior to this inspection, the registered provider had submitted an Annual Quality Assurance Assessment, detailing what they do well, what could be done better and what needs improving. As part of the process a number of records relating to residents, care staff and the general running of the home were examined. Additionally a partial tour of the premises was undertaken, residents and members of staff were spoken with and their comments are used throughout the main text of the report. Following the inspection, relatives were contacted so as to seek their views about the services provided and surveys were returned to the Commission for Social Care Inspection by staff. The manager, deputy manager and other members of the staff team assisted the inspector. Feedback on the inspection findings were given throughout the day and summarised at the end of the day. The opportunity for discussion and/or clarification was given. The management of medication for residents remains poor and as a result of concerns, an immediate requirement notice was issued at this inspection. It is disappointing to note that this issue was raised at the previous key inspection to the home and necessitated an additional inspection by a specialist pharmacist inspector. Should shortfalls as identified within the main text of this report continue, the Commission for Social Care Inspection may consider taking legal action. What the service does well: The home environment is well maintained and decorated to a high standard and enables residents to maintain a level of independence and self worth. Residents are enabled to exercise choice and control over their lives. Residents are supported to maintain contact with family and friends. Visitors to the home are made to feel welcome and staff were observed to have a good relationship with resident’s relatives/friends. Rapport between staff and residents is good and staff were knowledgeable about individual residents care needs. St Edith`s Court DS0000015468.V353940.R01.S.doc Version 5.2 Page 6 Residents feel able and comfortable to raise concerns or queries with staff and feel confident that they will be listened to. Staff training in core areas remains good. 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 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. St Edith`s Court DS0000015468.V353940.R01.S.doc Version 5.2 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 Edith`s Court DS0000015468.V353940.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is an appropriate system in place to ensure that residents are assessed prior to admission, however shortfalls were evident which could affect the safety and welfare of residents as a result of care staff not having sufficient information. EVIDENCE: Two files were examined for those people recently admitted to St Edith’s Court. Records showed that a pre admission assessment had been completed prior to admission for only one person and when discussed with the manager, they advised that an assessment had been completed for the most recent admission, however were unable to locate the document. This is disappointing as this was highlighted at the previous key inspection to the home and the management team at the time were advised that this should be easily available to key care staff. This was again reiterated at this inspection. St Edith`s Court DS0000015468.V353940.R01.S.doc Version 5.2 Page 9 Records showed that the pre admission assessment document is detailed and comprehensive and covers all of the required areas and if completed, can provide some very useful information to staff detailing the individual resident’s care needs. Under the heading of `what we do well` the Annual Quality Assurance Assessment details, “The management team in the home carry out the assessment of residents needs. All residents admitted into the home have their needs assessed prior to admission….” The manager must ensure that pre admission assessments are completed for all prospective residents and that records are kept secure and are readily available to evidence this process as having been undertaken. No information was available to indicate that the management team at the home had confirmed in writing to the resident and/or representative that they could meet the individual person’s care needs or that the care home was appropriate. No information was available detailing that the resident and/or their representative had been offered the opportunity to visit the care home prior to admission. The manager advised the inspector that relatives and prospective residents are encouraged to visit St Edith’s Court. Following the inspection, two relatives, at random, were contacted to seek their views pertaining to the admission process at the care home. Both relatives confirmed that they had visited the care home prior to their member of family’s admission, and were given sufficient information detailing the services and facilities at St Edith’s Court. Following the inspection the manager also advised that as part of the admission process, information relating to individual residents are recorded onto the home’s computer. St Edith`s Court DS0000015468.V353940.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although residents are happy with the care provided, significant shortfalls in care planning and medication practices were highlighted, which could have an adverse affect on outcomes for residents and their wellbeing. EVIDENCE: Since the last key inspection, a new care planning format has been introduced and implemented within the care home. This was seen to be comprehensive and included formal assessments relating to manual handling, nutrition, pressure sores and falls. The inspector was advised that the majority of individuals care plans have now been transferred from the previous format to the new document. Records relating to a recent staff meeting indicated that team leaders are to complete the transfer of information within the next two weeks. St Edith`s Court DS0000015468.V353940.R01.S.doc Version 5.2 Page 11 As part of this inspection a random sample of care files were examined. It was of concern, that of those care files examined no care plan had been devised for two people. In the case of one person the only information recorded within their care plan documentation included the pre admission assessment and their manual handling assessment. The care file for one person indicated that not all information from their previous care plan had been transferred or accurately reflected the resident’s current care needs. The deputy manager confirmed to the inspector regarding the latter that staff, were using both care plan documents until such time that the new care plan had been completed. The deputy manager was advised that this could be confusing for some members of staff and could lead to inconsistencies of care being inadvertently delivered to the resident. The Annual Quality Assurance Assessment details “New service user plans currently being introduced will confirm that we have the necessary information to provide care that will achieve the best possible outcome for the resident and provide evidence that residents are receiving care appropriate to their needs”. This statement did not concur with the inspector’s findings in some cases. There was some evidence to indicate that in some cases not all elements of individual care plans had been reviewed regularly and/or updated. Additionally some care plans evidenced little proactive action being undertaken to monitor and provide appropriate interventions pertaining to refusal of medication and weight loss. An example of this is in relation to one care file randomly sampled. This evidenced that over a 6-7 week period the resident had lost approximately 5KG. No formal nutritional assessment had been completed, and no care plan/risk assessment for nutrition had been devised and implemented. Medication Administration Records (MAR) for several people indicated that they refuse some of their medication regularly. This was not highlighted within their care plan and there was no evidence that this was being monitored or that appropriate advice had been sought from a healthcare professional. This is disappointing, as the organisation’s medication policy states that should this occur, this should be discussed with a GP. The deputy manager advised the inspector, that alert sheets (care plan progress/evaluation sheets) are not completed daily and are only recorded as and when “something happens”. Of those daily care records seen, inconsistencies were noted with some information being detailed and informative, whilst others gave very little evidence of actual care provided by staff. For example the records relating to one person’s personal care recorded only 5 entries over a 12 day period and in some cases made no reference to their personal care being provided by staff e.g. “happy mood, breakfast in their room”. This is seen as not good practice as daily care records can provide a good source of information, provide evidence detailing staff’s interventions/actual care provided and assist the management of the home to audit care provision. St Edith`s Court DS0000015468.V353940.R01.S.doc Version 5.2 Page 12 Risk assessments were not devised for all areas of assessed risk. This needs to be improved in order to ensure the welfare of residents. Following discussions with staff during the day, it was clear that staff had a good understanding and knowledge of individual resident’s care needs. Of those relatives spoken with following the inspection, it was positive to note that all were complimentary regarding the care provided at St Edith’s Court for their member of family. Comments such as, “the service is excellent”, “the relationship between care staff and resident’s is very good”, “it is wonderful” and “I am delighted with the care my relative receives” were expressed. Records relating to the healthcare needs of individuals, was generally well maintained, however both the manager and deputy manager were advised to ensure that records clearly demonstrate resident involvement, consultation with staff where appropriate and outcomes. Following the last key inspection and concerns raised in relation to medication administration and record keeping an additional inspection was conducted at the care home by a specialist pharmacist inspector in May 2007. At this inspection the majority of medication is managed through a monitored dosage system (blister pack). It was positive to note that quite a few of the residents self medicate and on inspection of a random sample of care files, all were noted to have a completed self administration agreement, self administration assessment confirming that the person was deemed competent to administer their medication, care plan, risk assessment and monitoring form. However, shortfalls were identified in relation to the Medication Administration Record (MAR) record for one person detailing that some of their medication was not administered, as they were asleep. The handwritten MAR sheets were not always double signed by staff to evidence information recorded was accurate and the date medication was received. Additionally there was no record of some medicines having been given to the resident when they were due, as the entries on the MAR chart had been left blank. Records also recorded for some people that medication could not be found and that they had not received their prescribed medication. It was also noted that one staff member administered medication to residents in the dining room and did not check that this had been actually taken by the individual residents concerned. During the morning, medication was observed to have been completed on the first floor at 10.30 a.m., however the lunchtime medication was administered at the usual time and completed by 1.15 p.m. The time span between the morning and lunchtime medication was observed to be short and could result in some residents receiving their medication too soon. Both the manager and deputy manager were advised that appropriate measures must be undertaken to monitor and improve current medication St Edith`s Court DS0000015468.V353940.R01.S.doc Version 5.2 Page 13 administration and recording practices, so as to ensure residents safety and wellbeing. Records from a recent staff meeting detailed that team leaders are to check each others MAR records at handover for missing signatures. As a result of the above concerns, an immediate requirement form was left with the manager. Under the heading of “what we do well”, the Annual Quality Assurance Assessment stated, “we have robust medication policies and procedures in place” and “we have reviewed all our medication procedures in the home”. This does not concur with the findings on the day of inspection and it is clear that the manager has not dealt effectively with previous identified shortfalls and these remain outstanding and are once again highlighted at this inspection. On inspection of staff training records it was evident that the majority of staff had up to date medication training, however the records for two people indicated that one person’s training was last undertaken in 2006 and for one person there was no evidence to indicate when they last received this training. St Edith`s Court DS0000015468.V353940.R01.S.doc Version 5.2 Page 14 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): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activities programme at the home meets the social care needs of those people living at the care home. Residents receive a good diet. EVIDENCE: The manager advised the inspector that there is no planned activity programme, however there is a notice board adjacent to the dining room where activities of the day and/or future events are displayed. Residents spoken with confirmed that they were aware of activities available within the home and are given the choice whether or not they participate. On the day of inspection several residents were observed to take part in gentle exercises and throughout the day several residents were observed to go out independently. One resident confirmed that after lunch they were due to attend their weekly church club, which they looked forward to. Other residents confirmed that other activities include the mobile library (3 weekly), cards, coffee mornings, manicures, crosswords/puzzles, film afternoon, knitting class etc and that leading up to Christmas, there had been a Christmas party, coffee morning with mince pies and sherry, Christmas bingo and a visiting church choir. Forthcoming events were also displayed and this indicated that an St Edith`s Court DS0000015468.V353940.R01.S.doc Version 5.2 Page 15 external entertainer was booked for the end of the week and a St George’s Day Party planned for the end of March 08. Of those residents spoken with, all were happy with the range of activities provided at St Edith’s Court. The Annual Quality Assurance Assessment details that an activity co-ordinator has been newly employed. This was confirmed from discussion with the manager and from evidence of the staff roster. This document also details that within the next 12 months it is hoped for a relatives/friends of St Edith’s group to be newly created. Visiting at the home is open and many visitors were observed to come and go throughout the day. Staff, were observed to have a good relationship and rapport with visitors. It was evident on the day of inspection that residents are enabled to maintain contact with their friends and family. Residents spoken with confirmed that they are able/encouraged to exercise choice and control pertaining to their daily routines. The inspector was advised that they are able to get up/retire to bed at the time of their choice, they can choose where to have their meals e.g. own room or in the main dining room, residents are issued with a key to their private space and are actively encouraged to bring their personal possessions when they move into the home. Information relating to local advocacy services were readily available and displayed. The management team operate a four-week menu. The menu was observed to be displayed outside the dining room and many residents were observed to look at this to check the choices available. This was observed to offer residents a varied diet and included two options of main meal at lunchtime. At teatime there is always a hot option available and this includes alternatives such as a salad, omelette or choice of sandwiches. It was positive to note that residents are shown the options available for lunch on the day and that staff, in the afternoon ask residents what they would like for tea and that this is not done in advance e.g. the previous day. This is seen as good practice and enables residents to make an informed choice. Dining tables were seen to be attractively laid, with jugs of juice and condiments readily available for residents. It is positive to note that in order to enable residents to maintain independence and a sense of self worth, serving dishes of vegetables are placed on individual tables at lunchtime so that residents can help themselves and have second helpings if they so choose. At the end of the meal residents were observed to be offered, a choice of tea or coffee. Of those residents spoken with, all were positive about the quality and quantity of food provided and comments such as “it’s lovely”, “ it’s always good” and “it is much improved” were noted. Relatives spoken with also confirmed that food provided is of a good quality and the only criticism made was in relation to portions of food on occasions being too big and maybe to overwhelming for some people. St Edith`s Court DS0000015468.V353940.R01.S.doc Version 5.2 Page 16 The lunchtime experience for residents was observed to be calm and relaxed, with appropriate care provided to those people who require assistance to eat their meal. St Edith`s Court DS0000015468.V353940.R01.S.doc Version 5.2 Page 17 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): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate systems are in place to ensure that residents are safeguarded and that any concerns raised are dealt with proactively. EVIDENCE: St Edith’s Court has a clear complaints policy and procedure in place and this was observed to be displayed for all interested parties in the main entrance hall and within the service users guide. The management team’s complaint file showed that since the last key inspection there have been 7 complaints, of which 3 related to meals/food, 1 related to one member of staff’s poor attitude, 2 related to issues relating to the home environment and 1 related to an alleged theft. Records were well maintained, and included evidence of the specific nature of the complaint, investigation and action taken. Of those residents spoken with, all confirmed that should they have any concerns, they would be comfortable to discuss this with the manager, deputy manager or other members of staff. Relatives spoken with confirmed that they were aware of the procedures in place and should any issue arise, they felt confident that they could raise this with the management team of the home and that concerns would be listened to and dealt with effectively. Policies and procedures relating to safeguarding were readily available. Since the last key inspection to the home, no safeguarding issues have been St Edith`s Court DS0000015468.V353940.R01.S.doc Version 5.2 Page 18 highlighted. Staff spoken with demonstrated a good understanding and awareness of safeguarding procedures. On inspection of training records for staff, this evidenced that the majority of staff had received safeguarding training. St Edith`s Court DS0000015468.V353940.R01.S.doc Version 5.2 Page 19 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): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. St Edith’s Court provides a clean, comfortable and safe environment for residents, which meets their needs and promotes independence. EVIDENCE: A partial tour of the premises was undertaken at various times of the day. St Edith’s Court is a purpose built home that presents as homely and comfortable for residents use and each of the 39 rooms are equipped with en-suite facilities and 37 rooms have a small kitchen area adjacent to their main room where they are able to make drinks and prepare snacks. This is seen as very positive as this enables residents to exert and maintain a level of independence and helps to promote a sense of self worth. Of those individual rooms seen, all were observed to be personalised and individualised with many personal items on display. St Edith`s Court DS0000015468.V353940.R01.S.doc Version 5.2 Page 20 In addition to individual rooms for residents, there are 4 lounge areas and one large communal dining area. All communal areas were observed to be spacious, light and pleasantly decorated. Sufficient toileting and bathing facilities are situated within the home. The home was seen to be clean, tidy and odour free and there were no health and safety issues noted at the time of the inspection. The home benefits from a large and very well maintained landscaped garden, which is accessible for residents use. Resident’s comments relating to the home environment were generally very positive. The only areas of discontentment related to other resident’s televisions being rather loud and some people found this annoying and it occasionally disturbed them at night. This was highlighted within one resident questionnaire, one complaint record and from discussion with some residents. Both the manager and the Annual Quality Assurance Assessment stated that since the last inspection, external redecoration has been undertaken to the home. Over the next few months all en-suite facilities for residents are to be refurbished and it is hoped for a walk in shower room to be newly created before 31st March 2007. Additionally it is planned for internal redecoration to be undertaken within all areas of the home, carpet to be replaced in the main dining room, resident’s rooms to have their carpets and curtains replaced as necessary and an activity room to be created on the first floor. A random sample of safety and maintenance certificates showed that equipment and services in the home were kept in good order. The home has a fire safety risk assessment in place and all other fire safety records were seen to be in order. The manager was advised to consider ensuring that fire drills for staff are more frequent to ensure that all staff receive, regular training. Water temperatures were checked at random throughout the home and were found to be satisfactory and within acceptable guidelines. The maintenance person undertakes these checks monthly and although there were some gaps, records in the main were seen to be appropriate. Staff training records and the Annual Quality Assurance Assessment detail that all staff had received training relating to infection control and the majority of staff had up to date training pertaining to health and safety, fire safety and first aid. St Edith`s Court DS0000015468.V353940.R01.S.doc Version 5.2 Page 21 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): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst outcomes for residents are generally sound, the level of staffing on occasions restricts the ability of the service to deliver person centred care and to ensure that residents needs, can be met and that they are safe. Shortfalls in staff training pertaining to those conditions associated with the needs of older people mean that some staff may not be able to meet the needs of the residents living at the home. EVIDENCE: The manager advised the inspector that the home’s staffing levels remain at 1 team leader and 6 care staff between 08.00 a.m. and 15.00 p.m., 1 team leader and 5 care staff between 15.00 p.m. and 22.00 p.m. and 1 team leader and 2 waking night staff between 21.00 p.m. and 07.30 a.m. each day. The manager’s hours are supernumerary Monday to Friday and the deputy manager works as a team leader every other weekend, whilst all other shifts are supernumerary. In addition to the above a chef is employed between 07.30 a.m. to 18.30 a.m., a kitchen assistant between 09.00 a.m. and 18.30 p.m. each day, an activities co-ordinator for 20 hours per week Monday to Friday, a maintenance person for 25 hours per week and an administrator for 30 hours per week. Current staff vacancies are for 2 members of care staff whilst staff, are on maternity leave. St Edith`s Court DS0000015468.V353940.R01.S.doc Version 5.2 Page 22 On inspection of four weeks staff rosters, it was evident that staffing levels as detailed above have not always been maintained or met and no Regulation 37 notifications have been received by us detailing a reduction in staffing levels and the measures undertaken by staff to deploy additional staff to the care home to meet resident’s needs. On the day of inspection it was positive to note that call alarm facilities for residents were answered promptly during the morning, however in the afternoon/early part of the evening, there were occasions when the first floor was not adequately covered by staff and this could possibly leave some residents feeling isolated and without support. It was positive to note that the use of agency staff within the home is minimal. The Annual Quality Assurance Assessment detailed that it is hoped within the next 12 months to eliminate the need for agency staff. On inspection of 2 staff files for those staff newly employed at St Edith’s Court, the majority of records as required by regulation were available, however gaps were noted in relation to no photograph or job description for either employee, no health declaration for one person and the written references for one person were not from their last employer. Additionally no record of induction was available for either person and one person confirmed that they had not received an induction. The inspector was advised that new staff, are issued with a portfolio/induction workbook upon commencement of employment at the care home. This document was seen to be comprehensive and in line with Skills for Care. Training records for staff were examined and evidenced the majority of staff had received training relating to manual handling, fire safety, health and safety, safeguarding, first aid, infection control and introduction to dementia care. Since the last inspection some staff had received training relating to care planning. The manager and deputy manager were advised that consideration must also be undertaken for training relating to those conditions associated with the needs of older people e.g. parkinsons disease, sensory impairment, diabetes, nutrition, falls management etc. Records presented to the inspector indicate that 7 members of staff have attained NVQ Level 2, 4 members of staff are currently working towards NVQ Level 2, 6 members of staff have attained NVQ Level 3 and 1 person is working towards attaining their NVQ Level 3 qualification. St Edith`s Court DS0000015468.V353940.R01.S.doc Version 5.2 Page 23 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): 31, 33, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst management arrangements in some areas are generally sound, the shortfalls identified could adversely affect outcomes for residents. EVIDENCE: The manager has been in post at St Edith’s Court since 2001 and has experience working in care both within the private sector and within social services. The manager has achieved the Registered Manager’s Award, NVQ Level 4 in Management and the D32/33 Assessors Award. Although there are some areas as highlighted within the main text of the report, which are good and evidence appropriate management, there are some areas which continue to require, further development and these refer specifically to pre admission assessments, care planning/risk assessing and St Edith`s Court DS0000015468.V353940.R01.S.doc Version 5.2 Page 24 medication practices and procedures. The manager must demonstrate a proactive approach to addressing and sustaining good practice, so as to ensure residents continued safety, wellbeing and positive outcomes. Of those staff and residents spoken with, all were complimentary regarding the management of the home. Staff stated that morale within the home was good and that staff were cohesively working as a team. A Quality Assurance System is in place. The manager advised the inspector that surveys cover a range of areas and these include catering, housekeeping, activities and personal care. Additionally surveys are completed for residents, visitors and other interested parties. The inspector was advised that surveys had recently been completed, however the manager was unable to locate these and the outcome/results from these surveys were unavailable. The results of the survey conducted in 2006 were readily available and included within the, Statement of Purpose document. Evidence was available recording that regular staff meetings are being conducted at the home and records of minutes were available to confirm these had taken place. Records also detailed that resident meetings are regularly held and a newsletter compiled. It was positive to note that at the December 07 meeting, residents were advised of the impending refurbishment to their en-suite shower rooms. The home has a health and safety policy and procedure. Resident accident records were observed to be well maintained and information recorded satisfactory. On inspection of supervision records for staff it was evident that formal supervision, is not happening as frequently as they should and in some cases records indicated that staff had only received, one supervision session within the last 12 months. The manager advised that she is aware of the shortfalls and is looking to address the issue as soon as possible and for other members of the management team to undertake the role of supervisor. The manager was advised to consider providing appropriate training for staff pertaining to supervision, so that they feel confident and competent to undertake this task. The Annual Quality Assurance Assessment confirms under the heading of “what we could do better” that regular supervision is required for staff and it is hoped within the next 12 months to create a supervision planner for staff. St Edith`s Court DS0000015468.V353940.R01.S.doc Version 5.2 Page 25 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 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 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 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X 1 X 3 St Edith`s Court DS0000015468.V353940.R01.S.doc Version 5.2 Page 26 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 OP3 Regulation 14 Requirement Ensure that residents are fully assessed prior to admission to ensure that the home can meet their needs. Previous timescale of 30.6.07 not met. Ensure that all residents have a care plan, which fully reflects their individual care needs and details how care is to be delivered by staff. Previous timescale of 30.6.07 not met. Ensure that risk assessments are devised for all areas of assessed risk so that these can be minimised and ensure residents wellbeing and safety. Ensure that prescribed medication is recorded and administered safely and appropriately to promote resident’s wellbeing and safety. Previous timescale of 14.4.07 and 15.6.07 not met. Timescale for action 14/01/08 2. OP7 15 14/01/08 3. OP7 13(4) 14/01/08 4. OP9 13(2) 14/01/08 St Edith`s Court DS0000015468.V353940.R01.S.doc Version 5.2 Page 27 5. OP9 12(1) Ensure that residents are given medication in accordance with the prescriber’s instructions. Previous timescale of 14.4.07 and 15.6.07 not met. Ensure that all staff authorised to administer medicines have been trained and assessed as competent to do so. This will ensure that unnecessary risks to the health and wellbeing of residents are avoided. Previous timescale of 31.7.07 not fully met. Ensure that at all times there are suitably qualified and competent staff on duty in sufficient numbers as appropriate to meet the needs of residents. Ensure that robust recruitment procedures are adopted at all times for the safety and wellbeing of residents. Ensure that staff working at the care home receive the appropriate training to the work they perform so as to best meet residents needs. This refers specifically to training relating to those conditions associated with the needs of older people. Ensure all staff who work at the care home receive regular supervision so that they feel supported and able to undertake their job effectively. 14/01/08 6. OP9 13(6) and (18)(1) 01/04/08 7. OP27 18 14/01/08 8. OP29 19 14/01/08 9. OP30 18(1)(c) and (i) 01/06/08 10. OP36 18(2) 01/03/08 St Edith`s Court DS0000015468.V353940.R01.S.doc Version 5.2 Page 28 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 OP3 Good Practice Recommendations Residents and/or their representatives should receive written confirmation from the manager/management team at the care home that they can meet the needs of the prospective resident. Develop clear evidence to indicate that prospective residents and/or their representatives are given the opportunity to visit St Edith’s prior to admission. Consider daily care records being written more frequently so as to reflect care provided by staff and how residents spend their day. Information relating to quality assurance to be readily available for inspection and outcomes for surveys collated. 2. 3. 4. OP5 OP7 OP33 St Edith`s Court DS0000015468.V353940.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Eastern Region Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge CB21 5XE 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. 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