Inspection on 16/02/07 for St Edith`s Court

This inspection was carried out on 16th February 2007.

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

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

Other inspections for this house

St Edith`s Court 18/12/08

St Edith`s Court 14/01/08

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 Diane Roberts Unannounced Inspection 09:30 16 and 23 February 2007 th rd 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.V327211.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.V327211.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 sharon.blackwell@anchor.org 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.V327211.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd March 2006 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 Westcliff-on-Sea, 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. St Edith`s Court DS0000015468.V327211.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 10 hours, spread over two days and was carried out as part of the annual inspection programme for this home. The registered manager was available on the second day of the inspection. The inspection focused upon all of the key standards. A partial tour of the premises was undertaken. Evidence was also taken from the Pre Inspection Questionnaire completed by the home and submitted to the CSCI. 5 residents and four staff were spoken to during the inspection and 13 residents completed feedback sheets, some with the help of staff. All these comments were taken into account when writing the report. Whilst residents commented that they were happy living at the home and that they were generally happy with the care and services provided, many had adverse comments regarding the food and the availability of the staff. These issues are reflected more fully in the body of the report under Section 3 and 6. Medication management at the home was noted to be poor and an immediate requirements notice was left. The CSCI will follow this up with an inspection from a registered pharmacist. What the service does well: What has improved since the last inspection? The quality assurance programme has developed since the last inspection and is currently being implemented. St Edith`s Court DS0000015468.V327211.R01.S.doc Version 5.2 Page 6 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.V327211.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.V327211.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. Standard 6 is not applicable to this home. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The assessment process for admission into the home has significant shortfalls that need to be addressed to ensure the safety and welfare of residents. EVIDENCE: Staff at the home stated that the manager or her deputy undertake preadmission assessments. A new resident was cased tracked, but staff were unable to locate the pre-admission assessment. These should be easily available to key care staff. Case notes showed that some assessment documentation had been completed, two weeks after admission, but key documents and recordings such as baseline weight and falls risk assessment had not been completed. Daily notes showed no recording regarding the admission of the resident. Parts of the care plan had been competed stating that the resident had signed documents, such as the self-medication risk assessment, but records showed that this was not St Edith`s Court DS0000015468.V327211.R01.S.doc Version 5.2 Page 9 actually the case, two weeks after admission. Records indicated that assessment forms and parts of the care plan had been completed with the resident, when this work was yet to be done. Whilst the resident was very happy with their admission to the home and how well they had settled in, the documentation relating to this key episode was seen to be poor. The resident was able to confirm that they had yet to be involved with signing any care related documents. The manager needs to improve systems surrounding admission to the home in order to evidence that residents needs can be met and that initial key assessments are completed to promote the safety and welfare of the residents. Many of the residents who commented chose the home as they felt that it had a good reputation locally or they knew people already in the home. Residents also felt that they had made a good choice with the home and did not regret their decision. St Edith`s Court DS0000015468.V327211.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. Whilst residents are generally happy with the care services provided, records do not always reflect a proactive approach to care management, which can affect outcomes for residents. Medication management in the home also needs to improve to ensure resident safety. EVIDENCE: The home has a care planning system in place. The manager states that this is due to change later this year. The current format consists of a person centred ‘individual lifestyle agreement’. These are written in the first person and are the results of a consultation with the resident regarding different aspects of their daily lives and outlines their choices and preferences throughout. These were seen to be very positive records and where able residents have signed these. In addition to this there care plans and risk assessments. St Edith`s Court DS0000015468.V327211.R01.S.doc Version 5.2 Page 11 It was noted that care plans are not being regularly reviewed and in particular, residents personal and physical/medical care needs were not accurately reflected. Care plans for residents, whose care had changed significantly had not been updated and neither had their manual handling risk assessment, falls risk assessment or their nutritional risk assessment. Reviews sheets within the care planning system state that care plans should be reviewed monthly but records showed that care plans had not been reviewed since September 2006. This needs to be addressed. The homes own health and safety audit dated February 2007 identifies care plan reviews as a shortfall. Daily notes were inconsistent with some being informative and reflecting the resident and their day whilst others were either not in place or gave very little indication of the care and services provided. One resident who had returned from hospital had not been written about for three days and their care and condition had changed significantly. Care planning in the home needs to improve in order to ensure the welfare of residents. The home has a good relationship with the gp’s who visit and this was evident on both days of the inspection. Interaction between the staff and the GP was good. Care planning and records need to improve in order to accurately reflect residents’ health/medical needs. Risk assessments and associated care plans need to be maintained up to date to give an informed view. Nutritional assessments were out of date for residents with significant dietary changes and weight records were inconsistent. In addition to this residents who had poor appetites or other dietary needs had not care plans in place. Whilst the manager reports that there are not residents with pressure sores in the home there is little evidence that residents have been identified as at risk and refereed to the district nursing team for full assessment. Residents identified, as at risk of falls within a care plan, had no falls risk assessment in place and manual handling risk assessments were out of date for residents whose needs had changed. There was evidence that the falls prevention team had been contacted for advice but their visit was not recorded. Health issues that could affect other aspects of residents’ behaviour or wellbeing had been identified but no follow up or care plan was seen to be in place which may show lack of forward thinking/understanding by staff which could unduly affect outcomes for residents. Records in relation to visits by other healthcare professionals were inconsistent, for example chiropodists, optician etc. But from receipts/bills it was possible to see that visits had occurred but obtaining a full picture was difficult. Residents who were able said that they had seen the chiropodist etc. and were happy with the healthcare services at the home. Overall care plans in relation to healthcare and records in general were poor and possibly do not reflect the input given by the team at the home and certainly do not evidence a proactive approach to residents’ healthcare. St Edith`s Court DS0000015468.V327211.R01.S.doc Version 5.2 Page 12 Medication systems at the home were inspected. The home uses an MDS system and bottle to mouth. The home has a good relationship with the visiting GP’S and staff report that they are good at carrying out medication reviews. Quite a few of the residents self medicate but staff stated that the morning medication round is still taking seniors up to two hours to complete due to interruptions etc. This should be reviewed. MAR sheets were seen to be neat but it was noted that there was a significant amount of missing signatures for medications not in the blister packs. It was also noted that tablets had been signed for as given, that were still in the blister packs. Its was also noted that some residents were missing significant amounts of medication, for various reasons and that the overall approach to this was not being reviewed and thought through in order to overcome the issue in the residents best interests. Whilst some residents had self-medicating risk assessments in place these were not all signed by the resident and some required review. An immediate requirements sheet was left with the person in charge on the first day of the inspection to address the shortfalls noted. On the second day of the inspection a review of the medication system was undertaken but was limited, as a new month/sheet had just commenced. It was still noted that there were missing signatures on the MAR sheets and that staff were carelessly signing to say that they had given weekly medications on a daily basis. Where they had organised the MAR sheet well they were signing correctly. Staff need to implement a stricter approach to the management of medicines in order to ensure safe handling and to promote the health and welfare of residents. It was noted that the manager has written to all staff dealing with medication but this appeared to have had little effect. The home has a clear medication policy/procedures in place, which staff should be following. The CSCI will be referring the home to a pharmacist for a further inspection. St Edith`s Court DS0000015468.V327211.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ lifestyle in the home generally meets their needs but could be improved with regard to the meal and activity provision. EVIDENCE: From discussion with residents, it is clear that they have choices with regard to their daily routine. This is helped by the provision of kitchen facilities in each room. Comments included ‘your routine is what you make of it’. Some residents prepare their own breakfasts. A large number of the residents have keys to their own rooms. Residents spoken to and were observed going out of the home spending their time as they wished. They confirmed that they were encouraged to go to the main dining room for lunch and the majority did this although they acknowledged that there was choice regarding this. Staff spoken to clearly understand residents’ rights to choose and their need for independence as far as possible. The residents’ lifestyle agreement shows their preferences with regard to daily routine and personal care, although some of these were seen to be out of date. St Edith`s Court DS0000015468.V327211.R01.S.doc Version 5.2 Page 14 Overall residents spoken to and who commented were satisfied with the range of activities on offer. On one of the inspection days it was noted that activities displayed were not taking place as the activities officer was having to act as chef due to absence. Residents spoken to confirmed that there had been some staffing issues surrounding this for the past few weeks. Residents’ life histories are recorded and these include their preferences regarding social activities. Its is not clear from records that social activities are necessarily meeting the individual needs of residents and residents who commented gave some mixed responses on whether the activities were suitable for them, saying that the activities only ‘sometimes’ meet their needs. A few residents spoken to choose not to attend the activities offered. It may be of value to consult further with residents regarding the current programme offered to ensure it is, as far as possible, to their satisfaction. Activities displayed in the main hall included, skittles, light exercise, coffee morning and manicures. Records show that residents go out to the local shops and also visit local clubs in the community but records overall reflecting activities were poor in the care plans. From discussion with residents it is clear that where possible they maintain good contact with friends and family in the community. Some residents attend church or value the local vicar/priest visiting the home. Visitors coming to the home were seen to be very friendly with staff and other residents and senior staff responded well to any queries that they had. Residents who commented had mixed views about the standard of the meals at the home. Some were satisfied whilst others said that the ‘meat was tough’, ‘food was cold when served’, ‘quality of ingredients was poor’ and that there was ‘not enough green veg’. Other residents’ felt that the food varied in quality sometimes it was good sometimes it was not. Further comments included ‘ pastry like cement’ and ‘not always sufficient portions’. Several residents made the same comment. From observation and discussion, it is apparent that the home has had staffing issues with regard to covering the kitchen. The main midday meal was observed in part and was seen to be a relaxed affair with most of the residents attending. However it was noted that a member of staff, who was standing up, feeding one resident and trying to put food in their mouth saying ‘do you want this’. This was seen to be intimidating and undignified for the resident. This was raised with the person in charge at the time of the inspection. St Edith`s Court DS0000015468.V327211.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager has systems in place, which help to ensure that residents concerns will be listened to and acted upon. The manager has systems in place, which help to ensure the protection of vulnerable adults. EVIDENCE: The home has a satisfactory complaints procedure in place. This can be found in the main reception displayed in large print and in the service users guide. Comment/complaint cards are also available in reception that people are able to complete and post should they so wish. The last inspection report is available as is a copy of the service users guide and statement of purpose. Residents spoken to and who commented said that they would be comfortable raising any concerns they had with the manager or a team leader. The majority who commented knew about the complaints procedure. The manager keeps a log of all complaints, the investigation and outcomes. These were recorded well and statements kept where appropriate. The manager records all levels of complaints/concerns and records show that they were dealt with appropriately and objectively. St Edith`s Court DS0000015468.V327211.R01.S.doc Version 5.2 Page 16 The home has comprehensive adult protection policies and procedures in place, which includes local guidance. The manager appropriately referred one complaint to POVA but it was found that there was no case to answer. Training records show that there is a very good level of compliance for staff training on this subject. St Edith`s Court DS0000015468.V327211.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents’ benefit from a well appointed and maintained home that has facilities, which promote their independence. EVIDENCE: A partial tour of the home was undertaken. Whilst the home has only 39 beds the footprint of the home is large as the standard sizes of rooms is very good. Bedrooms are all ensuite and each has a small kitchen, apart from the respite room. This allows residents a significant amount of independence and must help to promote their own wellbeing. Rooms are well decorated. A range of lounges and bathrooms are also available. A large dining room is at the centre of the home and residents are encouraged to eat their main meal here for social stimulation. The manager reports that over the next financial year all the bathrooms are due for refurbishment and also at the time hot water valves St Edith`s Court DS0000015468.V327211.R01.S.doc Version 5.2 Page 18 will be renewed where required. It was noted from the records of checks that some hot water outlets were above the required temperature and the manager is aware of this and some valves have already been changed when required. The home benefits from a large and very well maintained garden, which all the residents spoken to commented positively on. Some rooms upstairs also have a sea view. A fire safety risk assessment was seen to be in place, completed in November 2006. Other fire safety checks and documentation were seen to be in order. Other maintenance certificates inspected for services in the home such as gas and electric were seen to be in order. The home was seen to be very clean and no odours were noted. Residents who commented said that the home was always clean and that they were able to choose décor in their rooms including colour of the carpets. St Edith`s Court DS0000015468.V327211.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A competent staff team who have been adequately trained generally meets residents’ needs. However, skills in relation to care planning could be improved. EVIDENCE: From discussion, the manager keeps the staffing levels at the home under review. An increase is proposed as it has been assessed that many of the residents at the home are choosing to stay in their own rooms and this has increased the burden of care for staff in the home. Whilst staffing levels on paper are acceptable, the staff at the home are very busy, the home has a large floor area to cover. Residents are also able to and actively do use the nurse call system. Records show that the staff do well to answer buzzers very promptly. The inspector would concur with the manager’s current view regarding the staffing. Residents who commented said that ‘there is not enough help when I need it’, ‘sometimes staff are busy or there is a shortage of staff’ and ‘sometimes I have to wait a while as staff are busy’ , ‘sometimes staff are very busy but I don’t mind waiting’ and ‘staff often excuse themselves as they have been ‘too busy’’ It is hoped that the managers new assessment of resident need and staffing levels will overcome these concerns. St Edith`s Court DS0000015468.V327211.R01.S.doc Version 5.2 Page 20 It was noted that systems could be reviewed to reduce the medication round burden first thing in the morning in order to help the Senior in charge manage the shift. This was discussed with the manager. The staff team is generally stable and minimal agency staff are used. The staff recruitment procedures at the home were inspected and files of new staff checked at random. These were found to be in good order with all the required checks and documentation in place. Evidence was available to show that staff are attending a Skills for Care induction programme. It is recommended that interviews records are maintained as part of good practice. This was discussed with the manager. Training records submitted to the CSCI show that compliance levels with required training such as fire safety, manual handling, health and safety, first aid and medication were good. The home has up to date hoists available and a range of slings etc. in good condition. The deputy manager is the back care coordinator for the home and two further senior staff are being trained so that manual handling training can be cascaded down to staff. Records also show that the home has achieved over 50 of care staff with an NVQ qualification of level two or above. Many of the staff have achieved level 3 and the manager aims to have all team leaders with an NVQ level 3 by the end of March 2007. Consideration should be given to providing staff training in relation to care planning and review, to ensue that all residents’ needs are met. St Edith`s Court DS0000015468.V327211.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home is generally sound but some areas of work require attention. The quality assurance programme in the home is developing positively. EVIDENCE: The manager at the home has been in post many years and knows the home and the residents well. She consults with residents and staff via regular meetings and sends out a home newsletter. Training records submitted do not show that the manager has undertaken training in the recent past to keep herself up to date with current thinking and practice. This should be addressed. Discussion with the manager showed and open and objective approach to St Edith`s Court DS0000015468.V327211.R01.S.doc Version 5.2 Page 22 issues in the home, such as shortfalls in the care planning and medication systems. However, the manager should be monitoring standards in the home to ensure key shortfalls such as this do not occur. The management team have a quality assurance system in place that, in parts is still developing. This consists of a self-assessment, completed by the manager which reviews a set of standards in the home and where needed an action plan is drawn up. Evidence of completed assessments were available. Satisfaction questionnaire have been developed and are just starting to be used. These cover a range of subjects and residents, visitors and professionals etc are asked to complete a questionnaire. This may relate to catering, housekeeping, personal care and staff approach etc. These were seen to be very useful tools. The home holds personal monies on behalf of some of the residents in the home. Good records are maintained and a two signature system is in operation. The home has a health and safety policy in place. Anchor housing carry out health and safety audits on the home and records show that one was recently completed. Results were seen to be good and a small action plan was in place for the manager to attend to. Records show that safe working practices risk assessments have been completed and the manager demonstrated an understanding of this system. Accident records were reviewed and found to be completed in detail. St Edith`s Court DS0000015468.V327211.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 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 2 X 3 X 3 X X 3 St Edith`s Court DS0000015468.V327211.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? no STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14 Requirement The registered person must ensure that residents are fully assessed to ensure that the home can meet their needs. The registered person must ensure that residents have a care plan in place that reflects all their needs and that this plan is kept under review. The registered person must ensure that residents’ healthcare needs are met in a proactive manner and that adequate records are maintained. The registered person must ensure that safe handling and administration of medication in the home and ensure positive outcomes for residents. The registered person must ensure that residents’ dignity is maintained. The registered person must ensure that they are providing a meal service that is to the satisfaction of its residents. The registered manager must ensure that standards of care and other related services are DS0000015468.V327211.R01.S.doc Timescale for action 30/04/07 2 OP7 15 30/04/07 3 OP8 12 and 15 30/04/07 4 OP9 13 (2) 14/04/07 5 6 OP10 OP15 12 16 14/04/07 30/04/07 7 OP31 24 30/04/07 St Edith`s Court Version 5.2 Page 25 maintained to a satisfactory level in the home. 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 OP12 Good Practice Recommendations The registered person should ensure that they consult further with residents to ensure that they are meeting their individual and group needs with regard to social activities. The registered person should keep the new staffing levels under review to ensure that they are meeting residents’ needs. The registered person should give consideration to providing staff with training in relation to care planning and general standards of record keeping. The registered person should endeavour to use their QA questionnaires in the near future to obtain feedback from residents. 2 3 4 OP27 OP30 OP33 St Edith`s Court DS0000015468.V327211.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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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