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Inspection on 05/12/05 for St Edith`s Court

Also see our care home review for St Edith`s Court for more information

This inspection was carried out on 5th December 2005.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home provides residents with an excellent standard of accommodation and a stimulating and varied life that is supported by a dedicated team of staff. Residents are able to organise their particular daily routines and maintain as much independence as is possible. The staff team is well trained and able to meet the different needs of the residents. The standard of care is good and the home has a happy lively atmosphere. Relationships between staff, residents, relatives and visitors are strong and maintained.

What has improved since the last inspection?

Requirements and recommendations highlighted at the home`s last inspection have been successfully addressed, with further systems being looked at to improve the care and support of residents. This is in relation to the further development of the quality assurance process. Care planning systems have been highlighted as needing to be replaced and a change may be implemented after further consultation with other managers.

What the care home could do better:

Further effort is required to successfully meet all of the standards in the timescales set out in this report. All of the requirements and a recommendation have been partially met. Work has progressed on the quality assurance system, formal supervision sessions are taking place but not for all staff, and NVQ training needs to be promoted in order to encourage more participants.

CARE HOMES FOR OLDER PEOPLE St Edith`s Court 18 Hillside Crescent Leigh On Sea Essex SS9 1EN Lead Inspector Ray Burwood Unannounced Inspection 5th December 2005 10:00 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.V272408.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Edith`s Court DS0000015468.V272408.R01.S.doc Version 5.0 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 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.V272408.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th December 2004 Brief Description of the Service: St.Ediths 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.V272408.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on the 5th December 2005 with the assistance of the home’s registered manager, residents, care staff and administration staff. The inspection took six hours to complete with a total of eighteen standards inspected. Fifteen standards were met, two of which exceeded the standard, and three were partially met. The home provides a comfortable environment that is maintained to a very high standard and a good quality of care offered. Time was spent looking around the premises, and the examination of service users’ and staff records. Interviews took place with residents, staff, visiting professionals and relatives visiting the home, and their views of the home heard. On the day of the inspection, service users were complimentary about the home and the staff who supported them. What the service does well: The home provides residents with an excellent standard of accommodation and a stimulating and varied life that is supported by a dedicated team of staff. Residents are able to organise their particular daily routines and maintain as much independence as is possible. The staff team is well trained and able to meet the different needs of the residents. The standard of care is good and the home has a happy lively atmosphere. Relationships between staff, residents, relatives and visitors are strong and maintained. St Edith`s Court DS0000015468.V272408.R01.S.doc Version 5.0 Page 6 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. St Edith`s Court DS0000015468.V272408.R01.S.doc Version 5.0 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.V272408.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 & 6. The home provides residents with contracts and statements of terms and conditions at the point of admission detailing fees, rights, and obligations. EVIDENCE: Contracts and Statements of terms and conditions issued by the local council and contracts for those purchasing their care privately are contained in residents’ personal files and signed by all concerned. Copies of the statement of terms and conditions and contracts are kept secure in the home’s main office. The home does not offer intermediate care. St Edith`s Court DS0000015468.V272408.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Residents’ healthcare and personal needs are well met by the home and carried out in a dignified and private manner. The home’s medication policy and procedures ensures the protection and wellbeing of residents. EVIDENCE: Care plan records sampled were sufficiently up to date, detailed and contained clear information to enable staff to meet the needs of individual residents. Preadmission details were comprehensive with “Individual Lifestyle” agreements signed and dated. Also, individual risk assessments documented and agreed with residents. Care plans are reviewed on a regular basis. The home’s manager suggested that a new care planning process and documentation was being considered to replace the existing format. “Daily Living” plans include nutrition profiles with up to date information and records in relation to weight and continence. A community nurse visiting the home stated that the home is very supportive regarding procedures/protocols, and follow up treatment under her direction and agreement. Three residents St Edith`s Court DS0000015468.V272408.R01.S.doc Version 5.0 Page 10 are currently being treated by the community nurse with one diabetic who has her insulin injection given each morning. Records relating to accidents and tissue viability were inspected and found to be correct. The home’s manager confirmed that she signs off records monthly. Electronic records are also kept of incidents. Residents spoken with and information gathered from one relative confirmed that personal and care needs are met by a dedicated approach by staff in a respectful and private manner. The home’s medication policies and procedures were inspected and are being well maintained. Staff who administer medication have received the appropriate training and maintained good links with the local pharmacy. Residents who administer their own medication are provided with lockable facilities in their kitchenettes. St Edith`s Court DS0000015468.V272408.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 & 14. Residents experience a stimulating and varied life with visitors encouraged and activities made available. EVIDENCE: Most of St. Edith’s residents remain very capable, independent, and are able to organise their social and recreational interests outside of the home without having to rely on the home. For those residents who do not have the same expectations and preferences, staff provides a range of activities within the home both individually and as a group activity. The home supplements these activities with visiting entertainers and visits to local places of interest. A religious service is provided in the home for those wishing to attend. During the day of the inspection, it was noted that visitors to the home were observed and relatives were involved in taking their relatives out on various appointments and trips. The home offers advice and support to residents regarding their financial affairs and advocacy services if there are no relatives available. During the inspection and a tour of the home, it was noted that many residents had brought into the home personal possessions. St Edith`s Court DS0000015468.V272408.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Arrangements for dealing with complaints, together with appropriate policies and procedures, help ensure the protection of residents. EVIDENCE: The home’s complaints policy and procedures were examined and found to contain the stages of the procedure and time scales. Further information was published and made available on the resident’s information board in the home’s foyer together with other agencies such as Anchor Care Line and the Commission for Social Care Inspection (CSCI). Adult protection policies and procedures were seen together with local policies and guidelines. Staff confirmed their training had been undertaken internally through videos. Management and senior carers access Adult Abuse training externally. St Edith`s Court DS0000015468.V272408.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21 & 26. Residents live in safe, warm, nicely decorated and furnished home that is regularly maintained to a high standard. EVIDENCE: The home continues to be presented to an excellent standard that creates a comfortable homely ambience that is maintained through a regular programme of redecoration and refurbishment. The grounds are laid out and designed to include part of the home’s historical past. The gardens provide safe access to wheelchair users and there is sufficient seating. Residents spoken with whose bedrooms face the gardens, said how lovely they are, particularly in the summertime. Private contractors maintain the grounds and garden areas. All residents are provided with en-suite facilities and sufficient bathrooms and toilets that are designed and fitted with equipment to meet the physical needs and different lifestyles of residents. One bathroom currently not in use has been identified to be turned into a walk in shower room. Sluicing facilities are provided although the home does not have a continence problem at present. St Edith`s Court DS0000015468.V272408.R01.S.doc Version 5.0 Page 14 The premises are kept very clean by a team of domestic workers who provide cover seven days a week. Following a recommendation made at the home’s last inspection a trolley is now in place to carry soiled and clean linen around the home. Policies and procedures are in place for the control of infection. Laundry facilities are provided with a dedicated worker employed during daytime hours. Washing machines have the specified programming ability to meet disinfection standards. Flooring finish is impermeable and wall finishes cleanable. Hand washing facilities are provided in all areas where infected material and/or clinical waste may be handled. St Edith`s Court DS0000015468.V272408.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 & 29. The home operates a robust recruitment process that protects residents living in the home. Staff at the home are well trained and supported in their studies, however, 50 of care staff should have NVQ Level 2 by 2005. EVIDENCE: The home continues to promote National Vocational Qualification (NVQ) training, and have two assessors in the staff team. Currently two members of staff have completed the NVQ Level 3 and two have completed the NVQ Level 2. A further eight members of staff are undertaking Level 2 and four undertaking Level 3. Overall the training opportunities for staff are good and appropriate to the needs of residents. The home’s manager is qualified to NVQ Level 4 in Management and holds the RMA (Registered Managers award). The files of two members of staff were sampled and inspected. Both files contained the required information as detailed in Schedule 2, (Regulation 19). St Edith`s Court DS0000015468.V272408.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 36 & 38. The systems for residents’ consultation are good with a variety of evidence that indicates that residents’ views are sought, however, this should be further developed and a report published on the findings. Care and management responsibilities were not sufficiently balanced to ensure formal supervision sessions were taking place regularly. Safe working practices in the home promote and safeguard the health, safety and welfare of the people using the service. EVIDENCE: The home’s quality assurance process has been undertaken on the basis of a self-assessment and feedback system through the residents and staff meetings. The home’s newsletter has updated both residents and staff with information related to the quality of care and general issues. The home’s manager discussed the changes being implemented for future survey’s with St Edith`s Court DS0000015468.V272408.R01.S.doc Version 5.0 Page 17 Lang Buisson carrying future survey’s for Anchor homes and publishing a report of the findings. Staff files examined during the course of the inspection relating to formal supervision sessions revealed that there was some shortfalls in the amount of one to one sessions being carried out. The home’s manager agreed that there had been some difficulties carrying out all of the supervisions in the past but hopefully these had been remedied. Records relating to the health, safety and welfare of residents and staff were inspected and found to be correct. Issues regarding radiators had been resolved. Staff spoken with confirmed that they had completed health and safety training in safe working practices. St Edith`s Court DS0000015468.V272408.R01.S.doc Version 5.0 Page 18 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 3 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X 4 X X X X 3 STAFFING Standard No Score 27 X 28 2 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X 2 X 3 St Edith`s Court DS0000015468.V272408.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? 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 OP33OP33 Regulation 24 (1)(a) (2)(3) 18 (2) Requirement Timescale for action 31/03/06 2 OP36OP36 The registered person must ensure that the quality of care is reviewed and a quality assurance report published. The registered person must 28/02/06 ensure that all staff working in the home are appropriately supervised and records kept. 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 OP28OP28 Good Practice Recommendations The registered person should ensure that a minimum of 50 of care staff have completed their NVQ Level 2 qualification in care by 2005. St Edith`s Court DS0000015468.V272408.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Edith`s Court DS0000015468.V272408.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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