Inspection on 18/12/08 for St Edith`s Court

This inspection was carried out on 18th December 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 14/01/08

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 17/02/2010.

CARE HOMES FOR OLDER PEOPLE St Edith`s Court 18 Hillside Crescent Leigh On Sea Essex SS9 1EN Lead Inspector Michelle Love Unannounced Inspection 18th December 2008 10:45 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.V373218.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.V373218.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 patricia.welch@anchor.org.uk 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.V373218.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th July 2008 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 to £595.00. 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.V373218.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 one day and lasted a total of 8.15 hours, with all but one key standard inspected. Additionally, the managers progress against previous requirements and recommendations from the last key (January 2008) and random inspection (July 2008) were also inspected. A specialist pharmacist inspector was also present for part of this inspection to examine medication practices and procedures within the home. Prior to this inspection, the registered provider had submitted an Annual Quality Assurance Assessment (AQAA). This is a self-assessment document, required by law, detailing what the home does well, what could be done better and what needs improving. Information given in this document has been incorporated into this report. 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. The manager and other members of the staff team assisted the inspector/pharmacist inspector. Feedback on the inspection findings, were given as a summary to the manager and the opportunity for discussion and/or clarification was given. As a result of concerns highlighted at the last key inspection (January 2008) and the issuing of an Immediate Requirement Notice relating to poor medication practices and procedures an additional random inspection was undertaken to the care home in April 2008, by a Specialist Pharmacist Inspector. As a result of continued breaches of regulation relating to medication, documents were taken as part of Code B (Police and Criminal Evidence Act 1984) and on 15th May 2008 a Statutory Requirement Notice was issued as a result of failure to comply with the Care Standards Act 2000 and the Care Homes Regulations 2001. Subsequent visits to St Edith’s Court were undertaken in June and July 2008 and inspectors found that the registered provider had not fully complied with the requirements as set out within the Statutory Requirement Notice. A representative of Anchor Homes and the registered manager attended an interview at the local CSCI office in September 2008. St Edith`s Court DS0000015468.V373218.R01.S.doc Version 5.2 Page 6 The investigation concluded that there was sufficient evidence of a breach of regulations, which could give grounds for an offence to be prosecuted, however a decision was made that it was not in the public interest for us to pursue further. However, failure to comply with regulations on future occasions will, be pursued by the Commission for Social Care Inspection. What the service does well: What has improved since the last inspection? What they could do better: Regular formal supervision for staff needs to improve. St Edith`s Court DS0000015468.V373218.R01.S.doc Version 5.2 Page 7 Staff training records/record keeping, needs to be kept up to date so as to determine training attained by staff and future training needs. Further training for staff is required in relation to those conditions associated with the needs of older people. Care planning/risk assessing processes and recording needs to continue to develop. This will ensure that the care needs of individual people in the home are clearly identified, record staff interventions and actual delivery of care provided. Risk areas will be identified and clear steps as to how these are to be minimised will be in place, ensuring people’s health and wellbeing. 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.V373218.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Edith`s Court DS0000015468.V373218.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 5 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who come to live at the care home can be confident that they will assessed prior to admission and that their needs will be met. EVIDENCE: There is a Statement of Purpose and Service Users Guide in place at St Ediths Court. This provides specific information about the service so that prospective residents and other interested parties have the information they need so as to make an informed choice as to whether or not this is the right care home for them. There is a formal pre admission assessment format and procedure in place, so as to ensure that the staff team are able to meet the prospective residents needs. In addition to the formal assessment procedure, supplementary information is sought from the individual residents placing authority and/or hospital. St Edith`s Court DS0000015468.V373218.R01.S.doc Version 5.2 Page 10 The AQAA details that many people have been admitted to the care home through recommendation either by friends, relatives, and existing residents or by healthcare professionals. People are seldom admitted in an emergency situation and a waiting list for placement at St Ediths Court is in place. As part of the inspection process, two care files for the newest people to be admitted to St Ediths Court were examined. These showed that both pre admission assessments were conducted prior to the persons admittance to the care home. Both pre admission assessment documents were noted to be informative and detailed. Records showed that the prospective resident and/or their next of kin was offered the opportunity to visit the care home prior to admission and where possible both the resident and/or their representative were involved within the admission process. The AQAA details under the heading of what we do well, we encourage prospective residents to visit the home as many times as they wish prior to making a decision to move in on a trial basis and we undertake a full pre admission assessment for all new residents prior to admission and where able and in agreement with the resident include relatives in discussions. St Edith’s Court does not provide intermediate care. St Edith`s Court DS0000015468.V373218.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 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. People who live at the home can expect to have the majority of their care needs identified, however further development is required to ensure positive outcomes for people. EVIDENCE: There is a formal comprehensive care planning system in place to help staff identify the care needs of individual residents and to specify how these needs are to be met by care staff. As part of this inspection, a random sample of 4 care files were examined and these included formal assessments relating to manual handling, pressure area care, nutrition and falls. It is evident at this inspection that following the last key inspection (January 2008) and subsequent random inspection (July 2008) where a Serious Concern letter was issued pertaining to inadequate care planning/risk assessing, much work has been undertaken by the senior care/management team of the home to address previous identified shortfalls and deficits. St Edith`s Court DS0000015468.V373218.R01.S.doc Version 5.2 Page 12 This is seen as positive, however additional work is required to further develop care planning processes to ensure that any improvement made is sustained and all areas of identified need are clearly recorded within each persons care plan. The AQAA details under the headings of how we have improved in the last 12 months and our plans for improvement in the next 12 months, we have worked hard in understanding and inputting the information required into the new service user plan format and to maintain and assess improvements achieved. It was positive to note that following the random inspection undertaken in July 2008 and the subsequent issuing of a Serious Concern letter, a care plan pertaining to one persons specific physical healthcare need was devised and implemented. The care plan at this key inspection was now observed to contain clear, informative and detailed information about the persons physical condition and how this impacts on their activities of daily living. Additionally there were clear guidelines for staff detailing the care required and an appropriate risk assessment had also been devised and implemented. However a further care plan highlighted at the same random inspection in relation to the persons poor nutritional care needs, had not been devised and compiled for a further 14 days, after the initial random inspection raised concerns. Records showed that although the person was weighed weekly, they continued to lose weight and this weight loss was still prevalent as of December 2008. On inspection of the persons care plan at this site visit (diet and nutrition), this was seen to contain detailed and comprehensive information detailing their specific care needs in this area. Evidence showed that the care plan was reviewed in October and November 2008 but not September 2008. On inspection of food record charts, records showed these were not completed consistently and/or daily. The team leader on shift at the time of the site visit when asked where as to the location of further documents were stated, staff say theyve completed them, but dont know where theyve gone. The care file for one person newly admitted to St Ediths Court was examined. The pre admission assessment recorded the person as having swallowing difficulties, requiring food to be liquidised and having a preference for small food portions. On inspection of the persons weight record, this evidenced the person as having a weight loss of approximately 5KG over a period of 3 months. Although a care plan/risk assessment was devised pertaining to the persons swallowing difficulties, food requiring to be cut up/liquidised, nothing was recorded in relation to their weight loss and the steps to be taken to proactively manage this. There was evidence to show that the care plan was evaluated in October and December 2008 (not November 2008), however no change to care plan and no change to plan was recorded. Daily care records provided additional evidence that the person regularly refused and/or ate small meals since October 2008. St Edith`s Court DS0000015468.V373218.R01.S.doc Version 5.2 Page 13 The shortfalls identified, potentially place people at risk of not having all of their care needs met and provides staff with inaccurate and not up to date information. The resident was spoken with during the site visit and confirmed their appetite was poor on occasions. Several surveys were returned to us by members of staff. Mixed comments were noted in relation to some people feeling they had been provided with up to date information about individual residents needs, while others stated usually and/or provided an additional comment. Comments included, care plans are kept up to date. Regular handovers among staff keep us informed about residents needs and depends on team leader on shift. Care plans not always easy to find information quickly. Handover not always done in the morning and carers talking before a shift is often more beneficial. Another survey recorded, Information should be passed on e.g. a new resident came in and carers did not know anything about them or that this person was being admitted. Improvement was noted in relation to the quality of information recorded within individuals daily care records, however in some cases these were not written daily and some records contained more detailed information than others. The manager advised that staff had worked very hard to improve their recording for residents, however she recognised there was room for further improvement. Healthcare records for those people case tracked showed they have access to a range of healthcare professionals and services as and when required e.g. GP, District Nurse Services, Chiropody, Optician, and a Parkinson’s Nurse Specialist. Residents spoken with confirmed that they are either supported by members of their family or by care staff to attend healthcare appointments. Throughout the site visit staff were observed to have a good rapport and relationship with individual residents. Care provided to people living at the care home was observed to be provided in a timely manner and with due care, respect and dignity. Residents and relatives spoken with were very positive about the care provided by staff at St Ediths Court. Comments included, Its absolutely perfect here, you cant grumble about staff they are so helpful and kind, staff are very responsive, if I require assistance, staff provide appropriate care and support, I think that St Ediths meets the needs of the residents as best it can and St Ediths Court gives the best service to all residents and supports its staff. It caters for residents individual needs and is willing to help at all times to sort problems out and to ease any worries residents may have. A pharmacist inspector examined practice and procedures for the safe handling, recording and administration of medicines. Medication is stored securely for the protection of residents and the storage room is temperature St Edith`s Court DS0000015468.V373218.R01.S.doc Version 5.2 Page 14 controlled to maintain the quality of medicines in use, the storage temperature being monitored and recorded each day. The temperature of the fridge used to store medicines is recorded daily but it had been recorded below the accepted temperature on several occasions over the previous 6 weeks without any action taken to investigate this or the quality of medicines stored there. The storage of medicines at incorrect temperatures could put residents at risk of receiving medication that is ineffective. We expect this to be managed by the home rather than make a requirement on this occasion. There is a separate cupboard used to store controlled drugs and this needs to be more secure since it can be moved. Records of controlled drugs were satisfactorily made. We inspected the medication and medication records for several residents and these were generally in good order. Records are made when medicines are received into the home and when they are disposed of. A record is also made of stock carried over from the previous month. This, along with the records made when medicines are given to resident provides a good audit trail of medicines in use. A few discrepancies in the stock balances were found but most of these had also been picked up by the home’s own audit procedures and investigated. The home has introduced new record forms for medication prescribed “when required” or in variable doses e.g. “one or two tablets” and this provide a clear record of when the medication is given and the quantity given so that people do not receive too much or too little medication. The quality and accuracy of medication records has improved considerably over previous inspections and this must be sustained. We watched some medicines being given to residents at lunchtime and this was done with due regard to people’s dignity and personal choice. People were asked if they were ready for their medication and if they needed painkillers. Training has been provided to care staff permitted to give medication to residents and this is of a good standard. Staff, are also assessed to ensure they are competent to administer medication. However, we have been notified of two recent errors concerning medication given to a person on the wrong day and medication given to another resident after it has been stopped by their GP. The management of the home has investigated these with a satisfactory outcome. A few people look after and take their own medicines and the risks to themselves and to other people in the home has been assessed and documented well in care notes. However, for one person whose notes state that medication will be stored “in a locked drawer in kitchen”, medication was found on a bedside table. The room was unoccupied, the door to the room open and the medication accessible to unauthorised people. We expect this to be managed by the home rather than make a requirement on this occasion. St Edith`s Court DS0000015468.V373218.R01.S.doc Version 5.2 Page 15 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. People who live at the care home can expect to have their social care needs met. EVIDENCE: An activity co-ordinator is employed at the care home for 20 hours per week (Monday, Wednesday and Friday). We were advised from discussion with the activities co-ordinator that this is flexible so as to encompass residents wishes and activities undertaken in the evenings and at weekends. It is unclear that the above hours are sufficient for the numbers/needs of existing residents and we were made aware that several residents require a high level of 1-1 support in order for their social care needs to be adequately met. While we recognise the manager as having input in providing additional activities for residents, we were advised by the activities co-ordinator that care staff working within the care home provide little support in meeting residents social care needs. When discussed with the manager, the manager refuted this and claimed the above was not accurate. On the day of the site visit, only the activities co-ordinator was observed to provide input with individual residents as care staff undertook more routine St Edith`s Court DS0000015468.V373218.R01.S.doc Version 5.2 Page 16 based tasks (personal care to residents, providing the morning and afternoon tea round, providing assistance to residents during the lunchtime/teatime meals, asking residents their meal preferences for the next day etc). We were advised that a formal activity programme had been devised, however this was not available for inspection. We were advised following discussions with the activities co-ordinator that activities available for people included gentle exercises, knitting, film afternoons, flower arranging, personal shopping for individual residents, religious observance once monthly and once weekly coffee morning. Additionally some residents have the opportunity to access external clubs within the local community and special functions for residents can be arranged e.g. special birthday, themed day or other notable events. On the day of the site visit, a notice-board on the ground floor was observed to evidence a list of events available for people to enjoy the week prior to Christmas e.g. celebration lunch for a residents 100th birthday, carol singing by a local church choir, pre Christmas lunch, Christmas bingo and mince pies/sherry and a residents and relatives Christmas party. Residents spoken with were very complimentary regarding the above activities, commenting they had enjoyed the Bucks Fizz at the pre Christmas lunch. Several people spoken with confirmed they would like to have more opportunities to access the local community for shopping and to go to the theatre/have meals out. The AQAA details under the heading of what we could do better, weather and transport permitting we could arrange more planned outings. There is an open visiting policy at the care home, whereby visitors can see their member of family and/or friend at any reasonable time. There was evidence to show that people living at St Ediths Court are actively encouraged and supported to maintain friendships and relationships. The AQAA details under the heading of what we do well, visitors to the home are made welcome and residents are able to receive their visitors privately. There is a rolling 4-week menu in operation at the home, which is displayed outside of the dining room. Several residents spoken with on the day of the site visit were aware of the meal choices available. On inspection of the menus, these were observed to offer residents a varied diet, including alternatives to the menu e.g. jacket potatoes, salad, soup or sandwiches. The lunchtime meal was observed within the main dining room. Dining tables were attractively laid, with jugs of juice and condiments readily available for residents. As stated at the previous inspection to the home, 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. People living at the care home also have the option to have their meals in the comfort of their own room if they prefer. Where some residents require assistance by staff to eat their meal staff were observed to undertake this with care and sensitivity and the dining experience St Edith`s Court DS0000015468.V373218.R01.S.doc Version 5.2 Page 17 for residents was observed to be positive. Of those residents spoken with, the majority of comments about the quality and quantity of food provided was positive and included, the food is very good, oh, I have no complaints the meals here are absolutely lovely and yes the quality of food is very good, with good portions. One resident spoken with confirmed they prepare their own breakfast each day from their kitchenette facilities. St Edith`s Court DS0000015468.V373218.R01.S.doc Version 5.2 Page 18 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. People who live at the home can expect to have their concerns taken seriously and to be listened to. EVIDENCE: There is an appropriate complaints policy and procedure in place and this is clearly displayed within the homes entrance hall. Of those residents spoken with, all confirmed that should they have any concerns, they would be comfortable to discuss this with the management team or other members of staff. Relatives spoken with confirmed they were aware of the procedures in place and should any issue arise, they felt confident they could raise this with the management team of the home and any concerns would be listened to and dealt with effectively. The manager was advised that the complaints procedure, needs to be amended to reflect that the Commission for Social Care Inspection does not investigate complaints. The AQAA details under the heading of what we do well, we view and welcome complaints and concerns as a positive means of improving our service. It was positive to note that several compliments about the care provided at the care home were readily available and included, thank you for allowing me to look over St Ediths Court, what a friendly atmosphere hits you when you come St Edith`s Court DS0000015468.V373218.R01.S.doc Version 5.2 Page 19 through the door. I was very impressed with everything, we were incredibly impressed with both the accommodation and wellbeing of the residents we met, we found some totally inspirational and to all the staff, thank you for your kindness and consideration to me during my stay with you. Since the last inspection, the complaint log showed there have been 6 complaints. There was evidence to show that complaints received relate to environmental issues and one care practice issue. Records were well maintained and included evidence detailing the specific nature of the complaint, investigation and action taken. The manager advised that since the last key inspection, a book has been introduced so as to record any comments/concerns raised by residents, relatives or staff. This has enabled the management team of the home to monitor any trends in concerns raised and take appropriate action to improve the service. Policies and procedures relating to safeguarding were readily available. Since the last key inspection to the home, no safeguarding issues have been highlighted. Staff spoken with demonstrated a good understanding and awareness of safeguarding procedures. A random sample of 11 staff training files were examined and these showed that the majority of staff last received safeguarding training in 2006. St Edith`s Court DS0000015468.V373218.R01.S.doc Version 5.2 Page 20 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 excellent. This judgement has been made using available evidence including a visit to this service. People live in a safe, well maintained and comfortable environment, which encourages independence. EVIDENCE: A partial tour of the premises was undertaken at various times of the day. St Ediths 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. Several residents spoken with advised that they found having the freedom to make snacks/drinks as and when they wanted to, very satisfying. St Edith`s Court DS0000015468.V373218.R01.S.doc Version 5.2 Page 21 The home is maintained, decorated and furnished to a high standard and provides residents with a homely and comfortable environment. A random sample of residents rooms, were inspected and all were seen to be personalised and individualised with many personal items on display. Since the last key inspection, some refurbishment within the home has taken place. This refers specifically to, refurbishment of all residents en-suite shower rooms and a bathroom being converted to a large walk in assisted shower room, redecoration of communal areas, replacement of non slip flooring in the dining room and the creation of an activity lounge. The gardens are easily accessible for residents use and includes wheelchair access to all areas of the garden. The AQAA details that within the next 12 months it is hoped that the main kitchen will be upgraded and the carpet in the entrance hall/staircase will be replaced. A maintenance person is employed at the care home for 25 hours per week. A random sample of records were examined pertaining to fire records, and these were seen to be satisfactory. Training records for the maintenance person showed that they had up to date training relating to fire safety awareness, manual handling and health and safety, however no evidence of training was available pertaining to safeguarding, infection control and COSHH (Control of Substances Hazardous to Health). St Edith`s Court DS0000015468.V373218.R01.S.doc Version 5.2 Page 22 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. People who live at the home can expect to be supported by staff however it is difficult to ascertain what training has been attained by staff. EVIDENCE: The staffing levels at the home remain at 1 or 2 team leaders 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 care staff (waking) between 22.00 p.m. and 08.00 a.m. each day. The managers hours are supernumerary Monday to Friday. Additionally a variety of ancilliary staff are employed and these include catering staff, housekeepers, administrator and a maintenance person. On inspection of 4 weeks staff rosters these evidence that staffing levels as detailed above have been maintained. Staff deployment within the home was observed on the day of the site visit and evidenced staffing levels as appropriate for the numbers and needs of current residents. The AQAA details that over the next 12 months it is hoped to increase the staffing levels (team leader). Residents spoken with confirmed that support and care provided by staff working within the care home is provided in a timely manner. St Edith`s Court DS0000015468.V373218.R01.S.doc Version 5.2 Page 23 Several staff surveys returned to us, recorded that staffing levels as detailed above are not always maintained as a result of staff sickness. Comments included, sometimes you could do with more staff, especially if someone does not turn up and although the home operates on the appropriate guidelines for staff/resident ratio, the needs of the residents could be served better with a few more staff. One relatives survey returned to us recorded, the only improvement would be staffing levels especially at the weekend. The staff on duty always try to do their best even when they are under pressure due to shortages. The staff files for 4 people were examined. Records showed the majority of records as required by regulation had been sought, however some gaps were noted. These refer specifically to the application form for one person not being signed/dated, the employment history of one person not fully explored, no evidence of a criminal bureau record (CRB) check for one person and no recent photograph for one person. Records of induction were readily available. The AQAA details under the heading of what we do well, all staff are inducted into the home and work at least one week supernumerary alongside an established member of staff. All staff are required to complete the BTEC Foundation Award Induction workbook set by Skills for Care. Following the site visit, an email was forwarded to us by the manager, confirming that a CRB record for the above person was in place. At the time of the site visit, the training matrix was requested, however we were advised that this was not up to date. During the afternoon the manager was given time to update this, however at the time of wanting to examine training records for staff, this remained incomplete and difficult to assess. A random sample of 11 staff training files were inspected on the day of the site visit, with training undertaken since the last inspection relating to Diabetes, Parkinson’s disease, manual handling, fire safety awareness and infection control. Some gaps were noted in relation to food hygiene, safeguarding, first aid and those conditions associated with the needs of older people. A copy of an updated training matrix was forwarded to us following the inspection and this confirmed the above findings. The AQAA details under the heading of how we have improved in the last 12 months, accessed training for particular areas relating to residents issues i.e. Parkinson’s disease, infection control and diabetes. The AQAA (dated 23/10/2008) recorded 13 members of staff as having achieved NVQ Level 2 or above and 3 members of staff registered to undertake NVQ training. St Edith`s Court DS0000015468.V373218.R01.S.doc Version 5.2 Page 24 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 good. This judgement has been made using available evidence including a visit to this service. People living in the home can be confident that it is run in their best interests. EVIDENCE: The manager has been in post at St Ediths Court since 2001 and has experience working in care, both within the private sector and within social services. The manager has achieved the Registered Managers Award, NVQ Level 4 in Management and the D32/33 Assessors Award. The manager advised that the management team of the home have attained training in both core areas and specialist training to meet the needs of older people. The management team encourage an open door policy at St Ediths Court so as to evidence openness and transparency. St Edith`s Court DS0000015468.V373218.R01.S.doc Version 5.2 Page 25 Staff surveys returned to us recorded that the manager is approachable by listening and where appropriate providing advice and support. The Statement of Purpose details Anchor Homes philosophy as, Anchor is committed to providing an excellent service to our residents and their families. Additionally the document details Anchors mission statement and values as, to anticipate and respect the lifestyle choices of older people by providing services they value and Anchor will behave in a manner that: demonstrates passion, pride and professionalism. Delivers a reliable, quality service that customers want; and maintains integrity and provides clarity. Positive comments were noted by both residents and relatives with regards to the quality of care/services provided at St Ediths Court. One relative spoken with stated, I couldnt wish for a better home, the staff team are lovely and caring and I am more than satisfied with the quality of care provided at St Ediths for my member of family. Relative’s surveys returned to us recorded, Staff at St Ediths are committed to the care they give. They must enjoy it, because they are so cheerful! Having worked in the caring profession all my working life-I feel this is the best it gets! and my [name of relative] has very high standards and has been heard to say on more than one occasion, that they wouldnt want to live anywhere else. It was evident at this site visit that the management team/staff team of the home have made many improvements, to address previous identified shortfalls and deficits. We recognise there are some areas as highlighted within the main text of the report, which are much improved and evidence positive outcomes for the people living at the care home, however some further development is required in some areas. This refers specifically to ensuring care plans for individual people are detailed and comprehensive, with associated documentation completed to evidence staffs interventions. Additionally further development is required in relation to the activity programme for residents and ensuring that training records for staff are up to date and staff receive regular formal supervision. All sections of the Annual Quality Assurance Assessment (AQAA) were completed and the document returned to us when requested. Information recorded was seen to be informative and detailed, providing a reasonably accurate account of the current situation within the service. Records of staff supervision showed that the majority of staff are not receiving formal supervision in line with National Minimum Standards recommendations. This refers to the supervision record for one person evidencing that they had not received supervision during 2008. Other records showed that another staff member had only received 2 supervisions in 2008 and no records were available for the maintenance person. The manager confirmed that she was aware of the above shortfalls. St Edith`s Court DS0000015468.V373218.R01.S.doc Version 5.2 Page 26 The AQAA details under the heading of what we could do better, we need to adopt a more structured approach to care staff formal supervision. It also details that in the next 12 months, improvements need to be made to staff supervision. The manager advised that a new self-assessment tool has been introduced and implemented by Anchor Homes and this is to be completed annually to ensure standards are attained and maintained. The manager advised that quality assurance surveys were forwarded to residents and their representatives in April 2008 and specific areas relating to housekeeping, personal care, staff attitudes/approaches and catering were highlighted for people to make comments. At the time of the site visit we were advised that the results of these surveys had not been collated. Records showed there are regular staff meetings and a monthly resident newsletter is compiled. There was evidence to indicate that Regulation 26 visits are undertaken once monthly by the area manager. The AQAA provides a list of policies and procedures currently available within the home. Appropriate health and safety policies were seen to be in place. St Edith`s Court DS0000015468.V373218.R01.S.doc Version 5.2 Page 27 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 2 8 3 9 2 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 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 1 X 3 St Edith`s Court DS0000015468.V373218.R01.S.doc Version 5.2 Page 28 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 OP7 Regulation 15 Requirement Ensure that all residents have a care plan, which fully reflects their individual care needs and details care to be delivered by staff. The care plan must be updated and reviewed to reflect the most up to date information about the individual person so as to ensure people’s wellbeing. Previous timescale of 30/6/07, 14/5/08 and 1/9/08 not fully 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. Previous timescale of 14/5/08 and 1/9/08 not fully met. Ensure that robust recruitment procedures are adopted at all times for the safety and wellbeing of residents. Previous timescale of 14/5/08 and 30/7/08 not fully met. Ensure that staff working at the DS0000015468.V373218.R01.S.doc Timescale for action 18/12/08 2. OP7 13(4) 18/12/08 3. OP29 19 18/12/08 4. OP30 18(1)(c) 01/04/09 Page 29 St Edith`s Court Version 5.2 and (i) care home receive the appropriate training to the work they perform so as to best meet residents needs. The training records for staff must be up to date so as to determine training actually attained by staff. Previous timescale of 1/6/08 and 30/7/08 not fully met. Ensure all staff who work at the care home receive regular supervision so that they feel supported and able to undertake their job effectively. Previous timescale of 1/5/08 and 30/7/08 not met. 5. OP36 18(2) 01/03/09 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. 3. Refer to Standard OP7 OP8 OP16 Good Practice Recommendations Daily care records should be written daily to reflect how people spend their day and to record staff interventions. Nutritional records should be completed consistently, especially for those people who are at risk of poor dietary intake. Complaints procedure to be amended to reflect that CSCI no longer investigates complaints. St Edith`s Court DS0000015468.V373218.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection 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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