Inspection on 16/08/05 for St Edmunds

This inspection was carried out on 16th August 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.

Other inspections for this house

St Edmunds 24/04/07

St Edmunds 26/04/06

St Edmunds 21/02/06

St Edmunds 20/01/05

St Edmunds 20/07/04

St Edmunds 26/03/04

St Edmunds 03/02/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE St Edmunds Surrogate Street Attleborough Norfolk NR17 2AW Lead Inspector Judith Huggins Announced 16 August 2005 09:30 th 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 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 Edmunds I55 s35075 St Edmunds v235912 AN 160805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service St Edmunds Address Surrogate Street, Attleborough, Norfolk. NR17 2AW 01953 452011 01953 457463 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Norfolk County Council - Community Care Ms T McWilliams Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places St Edmunds I55 s35075 St Edmunds v235912 AN 160805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1 The home can accommodate up to 35 Service Users who are Older People, not falling into any other category. 2 That Service Users who need a wheelchair to assist with independent mobility at point of admission can only be accomodated in rooms 30, 35, 36, 40, 41, 44, 72, 74 and 75. 3 The home may accommodate one (1) named Service User who is mentally disordered. Maximum not to exceed 35. Date of last inspection 20 January 2005 Brief Description of the Service: St Edmund Home is situated close to the market town of Attleborough. It is a purpose built home, providing residential care to up to thirty-five elderly people, operated by Norfolk County Council. Accommodation is on two floors and there are bedrooms, sitting and dining rooms on both floors. Access between the floors is by a shaft lift or one of three staircases. The premises were not built to comply with space standards now applicable under the Care Standards Act 2000. This has been partially resolved by a reduction of numbers of service users and the attachment of conditions in relation to rooms occupied by those needing wheelchairs to move independently around their rooms. The home itself is situated by the side of part of the one-way, traffic system around the town centre and there is limited parking on the site. St Edmunds I55 s35075 St Edmunds v235912 AN 160805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was announced and lasted 91/4 hours. During the inspection, the manager, and two members of staff were interviewed. Five residents and one visitor were also spoken to. Written comments were received from thirteen residents and from seven relatives. Where appropriate their comments are included in the report. A sample of records was checked and a partial inspection of premises was made. Interactions between staff and residents were observed or heard throughout the day. What the service does well: What has improved since the last inspection? A new system for identifying needs and recording the care needed to meet them has been introduced for people who have recently moved to the home (see also below). This sets out people’s needs and the support needed more clearly than the previous system, when it is fully completed. Some redecoration has taken place. The six staff vacancies noted at the last inspection have been filled, and all but one of the staff recruited have now been cleared to start and are working on shift. There has been some training in managing pressure areas, and also in protecting people from abuse, with further training planned. St Edmunds I55 s35075 St Edmunds v235912 AN 160805 Stage 4.doc Version 1.40 Page 6 Progress has been made in developing a questionnaire so that residents, relatives and other relevant people, can say what they think about the quality of the service. Visits on behalf of the organisation which runs the home (Norfolk County Council) are now being made regularly, and reports show what is going well as well as what needs to improve. Since her appointment, the manager has continued to do what she can to make sure that requirements made at inspection are attended to, where these fall within her remit. She has also improved risk assessments, the assessment of residents, care planning, and the overall “organisation” of records held. 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 Edmunds I55 s35075 St Edmunds v235912 AN 160805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection St Edmunds I55 s35075 St Edmunds v235912 AN 160805 Stage 4.doc Version 1.40 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 standard(s) 3 Prospective residents have their needs assessed, although a more searching approach is needed to determine whether these can be fully met. EVIDENCE: The pre-admission assessment form for one person was inspected. This shows that there is some confusion. Additional information had been obtained from the social worker regarding needs, which indicates further problems in this area but states there is no specific diagnosis. The manager indicates deterioration following admission and that now needs are not being fully met. Notes show that an alternative placement is considered necessary. St Edmunds I55 s35075 St Edmunds v235912 AN 160805 Stage 4.doc Version 1.40 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 standard(s) 7, 8 and 10 Residents health, personal and social needs are set out in an individual plan of care, however, inconsistencies between documentation mean that health care needs are not demonstrated as fully met. Residents feel that day care staff treat them with respect and uphold privacy, although this is compromised on occasions. EVIDENCE: Each person has a plan of care setting out their support needs. New documentation has been introduced for some people, which clearly specifies a range of useful information and support as needed, and efforts have been made to improve the collection of personal “life stories”. In the front of files there is a summary of care needs. On most files there is a clear record that residents are consulted, and new documentation provides for signatures agreeing the care plan. Notices show the pressure relieving equipment that is available for each individual, and files have a risk assessment for maintenance of tissue viability. However, bathing records show for one person, no entries between 18th July and 14th August. On each of these occasions notes indicate the person has a St Edmunds I55 s35075 St Edmunds v235912 AN 160805 Stage 4.doc Version 1.40 Page 10 sore and “broken” bottom. The risk assessment for preventing pressure sores indicates that systems in place adequately control risk, completed on 29th May. The person’s condition has deteriorated based on bathing records and therefore interventions based on the risk assessment have not adequately controlled risk. Additionally, the district nurses action and review sheet shows the attention of the district nurse to a similar problem in March and April, and the provision of equipment, but no subsequent referral following the development of the problem in July, continuing in August. The same person is identified as diabetic, although there have been no entries on the chiropody record since May (important in ensuring good foot care and the prevention of gangrene). A second person has no indication on assessment or care plan of whether chiropody treatment is necessary, although this is noted as provided at a previous placement. There is no documentation showing that this has been arranged, or how often it might be needed. Continence information for one person is inconsistent. Two pieces of information refer to the person needing a “pad in case of accident”, and “Kylie on bed in case of accident.” However, the care plan sheet showing “care plan personal needs/choices” records continence as “good, no aids needed.” Notes show that residents are weighed regularly in order to monitor any unintended or unexpected weight change. However, one person’s notes record a weight in November of 81.2kg, and in January of 70.4kg. The recorded loss of in excess of 10kgs (over one and a half stone) has not been investigated and there is no indication of whether the scales were considered faulty or the person improperly positioned for accurate weighing. Notes show that residents are encouraged to maintain mobility. One person advised the inspector that hearing aids obtained were not working properly that not all staff were able to help fit and check these properly, and expressed distress at lack of hearing affecting interaction, and ability to join in activities, or to enjoy the television and radio. However, the inspector acknowledges that all of the thirteen people completing comment cards say that they feel well cared for and respected, and that all seven relatives are satisfied with the overall standard of care provided. Staff report being “stretched” in attempting to deliver care in the manner they would wish, due to dependency levels and staffing levels. All residents spoken to confirm that staff knock on their doors before entering, and all those completing comment cards say their privacy is respected. However, the inspector was present in one room when a staff member entered without knocking. One relative described most staff as being good, but some St Edmunds I55 s35075 St Edmunds v235912 AN 160805 Stage 4.doc Version 1.40 Page 11 being abrupt. Issues expressed by residents to the inspector about staff manner were discussed with the manager. All interactions heard or observed during the inspection, were respectful and residents were heard laughing and joking with the staff on duty – suggesting they were at ease. One spoken to has a key to a locked drawer in the bedroom, although the inspector was informed that a second person felt that staff might access this without permission. The resident did not identify the second person so it was not possible to explore this issue further. Notes show that property services are considering fitting bedroom locks to three rooms where residents have expressed a wish for them. This represents progress. There are no suitable locks on any doors. Residents are not able to protect their own privacy in this way, and notes show that one confused person has regularly intruded on others while they are in bed or using the commode. One person is able to call for assistance when this happens or to address the situation without staff support. The manager indicated that another person had not been able to summon assistance and was distressed. One person told the inspector that although they had not said they wanted a key or to be able to lock their door behind them to prevent such intrusions, or while they were not in the room, they would not object to being able to do so. Requirement made at the last but one inspection, and previous inspections has not been met. St Edmunds I55 s35075 St Edmunds v235912 AN 160805 Stage 4.doc Version 1.40 Page 12 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 standard(s) 12 and 13 Although residents express general satisfaction with lifestyle, preferences and expectations are not always addressed. Residents are able to maintain contacts as they wish. EVIDENCE: Residents acknowledge that staffing issues mean that they are not always able to receive the help and support that they need for routines of daily living. Two people spoken to felt that they were not able to rise at their preferred time, and when needing assistance to get on and off the commode, might have to wait for some time. Both say that sometimes they are helped on, but have to wait 15 minutes or more to be assisted off, because staff are busy. This was particularly noted as early in the morning. One person noted that their preferred choice of clothing had not been supported by a staff member. Staff acknowledge that they are not always able to attend to people promptly and to spend the time they would like over tasks. Particular examples were given of the difficulty helping people up for breakfast at a reasonable time and that this meant breakfast would be later than some people liked, with lunch due too soon afterwards. St Edmunds I55 s35075 St Edmunds v235912 AN 160805 Stage 4.doc Version 1.40 Page 13 However, activities are posted and residents spoken to say that they are able to join in a variety of things. One person’s comment card says that suitable activities are provided “sometimes”, 11 say they are provided (one did not answer the question). During the afternoon of the inspection, three people were involved in a computer group. The recent “sausage tasting” was clearly a popular event. There is goodwill among staff for supporting activities outside the home, and the inspector is aware of one individual shopping trip organised in a staff member’s own time, and of a seaside trip with staff volunteering to assist. This is greatly appreciated by residents. Relatives completing comment cards all say that they feel welcome in the home at any time. However, one person completing written comments says that staff are sometimes “ a bit sharp.” One visitor spoken to described it as unusual not to be offered a cup of tea when visiting and the tea trolley came round. (This had not happened during the inspection.) The manager has created an additional visitors’ room for those who do not visit in people’s own rooms or communal areas. The quiet lounge on the first floor has tea-making facilities. There is a variety of small sitting areas through the home that can also be used. Visitors were noted as coming and going regularly during the inspection, making use of lounges and also of the garden, as the weather was nice. The new care plan format being introduced, provides for recording whether there are any contacts that residents do not wish to maintain, having moved into the home. Residents are sometimes taken across the road for visits to local shops or amenities, staffing permitting. St Edmunds I55 s35075 St Edmunds v235912 AN 160805 Stage 4.doc Version 1.40 Page 14 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 standard(s) 16 and 18 Residents know who to speak to if they have concerns and that the manager will listen to their concerns. Overall, residents are protected from abuse, although there are some occasions when residents are exposed to unwanted intrusion and potential distress. EVIDENCE: Residents spoken to are confident they know who to go to if they have concerns, but are reluctant to make “complaints” as they “don’t want to get anyone into trouble”. As a result, some aspects of care practice are not raised and addressed. The inspector discussed some issues of concern with the manager, including that residents might not be assisted on to, or off the commode as they need, depending on the time they request assistance. One relative writes that some staff can be “abrupt” on occasions. . Four out of seven relatives say they are not aware of the complaints procedure. Two residents completing comment cards say they do not know who to go to if they have concerns. All of the remainder do, and the residents’ information package contains material about complaints. Notes show that some residents have their privacy compromised by unwanted intrusions and inappropriate behaviour or dress of another, and that on most occasions this is at night time. Some people have experienced this intrusion when using the commode. For some people this is distressing, particularly where the person may be unable to summon assistance. See also standards 10, 27 and 38. St Edmunds I55 s35075 St Edmunds v235912 AN 160805 Stage 4.doc Version 1.40 Page 15 Training has been arranged for staff in recognising and responding to abuse, and the organisation has good policy guidance and systems for ensuring this is responded to properly. St Edmunds I55 s35075 St Edmunds v235912 AN 160805 Stage 4.doc Version 1.40 Page 16 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 standard(s) 19, 20 and 26 There are some shortcomings in the maintenance of the building and requirements outstanding from previous inspections. Residents have access to comfortable indoor and outdoor shared facilities. The home is generally clean, pleasant and hygienic. EVIDENCE: No action has been taken regarding the security of ground floor windows from intruders (and windows have been identified as a risk for one current resident). Property services are aware of this, based on an e-mail seen, and are seeking alternatives and possible replacements for some windows. However, completion dates have not yet been identified, and previous timescales remain unmet. The Yale lock on the internal door, used during the daytime to prevent unauthorised access, has broken. St Edmunds I55 s35075 St Edmunds v235912 AN 160805 Stage 4.doc Version 1.40 Page 17 Work required at previous inspections, to clean up and redecorate areas that are stained and dirty from heat rising off pipes has not been undertaken (particularly noticeable in WC’s). Not all bedrooms were seen, but two were noted as needing attention to damaged paintwork. Information from property services shows that they are aware of peeling paint and exposed woodwork to the exterior of the home, particularly window ledges and outer framework. Examination of some of these areas to one side of the home, window ledges and the base of framework to sides of sills shows that some of the wood is rotten and requires more than repainting. There are some tiles missing from bathroom/WC walls. The removal of a fireplace in one ground floor sitting area means that the carpet no longer fits properly. The risk of residents tripping on this has been minimised by the arrangement of furniture, although this will need replacing. Some of the windows have clearly been stuck around the frames by “parcel” tape, the residue remaining when this was peeled off. It is not clear, given the time of year, whether this was to address draughts or to stop windows rattling. The manager could not confirm whether it had been removed following a window repair or for another reason. There is a very good range of communal areas accessible to residents, including a large main dining room for meals or activities, other small dining areas, and a range of sitting rooms on each floor. A visitors’ room has been created, and a “computer room” for residents has recently been provided. The grounds are tidy, and there are lots of lawned areas. There is no secure area but residents with dementia should not be accommodated under the existing registration. Residents say they enjoy sitting out at the front of the home to “watch the world go by.” Three people did so during the inspection. Although standard 24 was not fully inspected, it is known that bedroom locks have not been fitted as required at previous inspections, with the most recent timescale of 31st August 2004 not met. The inspector is aware from documentation that there is an intention to prioritise fitting these for three people, but not when this work will be completed, or when work will be completed to all remaining bedroom doors. (See comment under health and personal care standards.) There are measures in place to control infection (see comment under management and administration standards.) Generally the home is clean, although some walls are dirty from the effects of rising warm air. Efforts to wash this off have not been successful, as the paint surface does not lend itself St Edmunds I55 s35075 St Edmunds v235912 AN 160805 Stage 4.doc Version 1.40 Page 18 to this. In only one room visited did the inspector note any odour associated with difficulties managing continence. This room is not currently occupied. St Edmunds I55 s35075 St Edmunds v235912 AN 160805 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 The needs of all residents are not met by the numbers and skill mix of staff. Any further admissions will further compromise the ability of staff to offer adequate support, assistance and supervision as needed. EVIDENCE: At present, based on discussion with staff and the management team, there are 13 residents who are highly dependent, 7 with medium dependency, and 9 with lower care needs. Based on staffing levels applicable as at March 2002, the home would need to provide a minimum of 352 day care hours. After taking into account breaks, and hours provided to day care by night staff (up to 10pm and from 7am), a total of 361.5 day care hours are provided. However, one person is in hospital and will have high care demands should they return. Staffing levels presented if this (or any other admission, including respite care is made) will not then be at the minimum level needed. The residential forum figures, now widely used, show that there should be five staff on duty throughout the day from 7am to 10pm. The duty roster shows generally four in the morning and three in the evening. This is at existing occupancy. Staffing levels are further compromised by the provision of day care to up to three people. One person is presenting considerable concerns during the night when staff supervision is greatly reduced, although this is identified as necessary in order St Edmunds I55 s35075 St Edmunds v235912 AN 160805 Stage 4.doc Version 1.40 Page 20 to prevent incidents and address risk. Other residents report and are recorded as being disturbed by some of the difficulties presented. Additionally, the preinspection questionnaire shows that there are 9 residents who need the help of two staff at nights. The building is extensive in size with many corridors and separate areas, and each member of night staff has an entitlement to one hour’s break – which is unpaid. The manager reports that they frequently do not get these breaks at present, and in any case, were they to be taken, night staffing levels would fall to one person for a total of two hours during the night. The skill mix has been affected as 6 vacancies had accumulated before recruitment of new staff. This means that some shifts have a high proportion of staff who are not used to the home and the residents, and do not have experience of care work before. Residents spoken to say that day care staff are very good, one relative completing written comment describes staff as occasionally sharp but mostly “ok”, but all relatives express their satisfaction with the overall care provided. St Edmunds I55 s35075 St Edmunds v235912 AN 160805 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 36 and 38 There has been an improvement in staff supervision, although this is not yet delivered in accordance with standards. There are measures in place to promote the health, safety and welfare of residents and staff, but these are compromised by presenting risk and behaviour at present, and by the premises. EVIDENCE: Supervision is offered, although for the most part this is delivered in groups. Dates show an improved frequency although there have been lapses. The management team have found it difficult to meet frequencies given the demands of staff on shift (see standard 27). One person is identified as at risk from climbing out of windows. On the first floor there are window restrictors fitted to prevent them opening fully. On the ground floor there are not, although some of the windows are above head height from the ground. (Fitting restrictors for increased security on the St Edmunds I55 s35075 St Edmunds v235912 AN 160805 Stage 4.doc Version 1.40 Page 22 ground floor has been required at previous inspections but is not met.) It has been repeated in the interests of excluding intruders, but also due to documented present risks. See below and comment under Environment section. A risk assessment shows that windows in the person’s vicinity are to be shut, although daily records show that the person has been found in other areas, and opening windows. The supervision available at night is not adequate to control the risk, and evening, night and early mornings are noted as presenting particular problems. See comment under staffing. Fire detection equipment is tested regularly, and staff training is in place. Additionally, the local fire brigade use the home for practice purposes and involve staff in evacuation procedures and arranged to do this shortly after the inspection. There is a fire risk assessment, although recommendations arising from this are still under consideration. This includes that the alarm system needs to be upgraded and that there are not appropriate detectors in all locations. There is guidance for staff on infection control. Appropriate protective equipment and alcohol hand cleanser as well as antibacterial soap is provided, including in residents’ shared WC facilities. There is good evidence of moving and handling training, including practical involvement, and of updating staff regarding the use of particular pieces of equipment. St Edmunds I55 s35075 St Edmunds v235912 AN 160805 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 2 x x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 1 9 x 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 x COMPLAINTS AND PROTECTION 2 3 x x x x x 3 STAFFING Standard No Score 27 1 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x x x x 2 x 2 St Edmunds I55 s35075 St Edmunds v235912 AN 160805 Stage 4.doc Version 1.40 Page 24 NO 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 8 Regulation 12(1), 13(1)(b), 13(6), 17(1)(a) Schedule 3, number 3(n) 12(1), 13(1)(b) 12(1), 13(1)(b) Requirement The registered persons must ensure that concerns regarding tissue viablity are promptly referred, and that risk assessments and care plans are updated when increased intervention is needed. Treatment must be recorded. The registered persons must ensure that residents needs for foot care are assessed, recorded and met. The registered persons must ensure that care plans and assessments are consistent, and clearly set out the support or aids needed to maintain continence. The registered persons must submit a programme with timescales for fitting appropriate locks to all bedrooms doors, prioritising residents whose risk assessment and consultation process shows their desire and ability to hold keys. All residents must be offered keys subject to risk assessment. TIMESCALE OF 31 AUGUST 2004 AND PREVIOUS NOT MET. The registered persons must Timescale for action 09/09/05 2. 8 09/09/05 3. 8 09/09/05 4. 10 and 24 12(1) to 12(4), and 13(4) 30/09/05 5. 19 12(1), 30/09/05 Page 25 St Edmunds I55 s35075 St Edmunds v235912 AN 160805 Stage 4.doc Version 1.40 13(4), 23(2)(a) and (b) 6. 19 13(4) and 23 23(2)(d) 7. 19 8. 19 23(2)(b) and (d) 9. 27 10(1), 12(1), 12(5)(b), 13(4), 13(6), 18(1)(a) 10. 27, 18 and 38 12(1)(b), 12(4)(a), 13(4), 13(6) and 18(1)9a) 11. 38 10(1), 13(4), 23(4) ensure that action is taken to prevent intruders from entering the building via ground floor windows. (This will also help to address current and documented risks.) OUTSTANDING - INITIAL TIMESCALE OF MAY 2004 UNMET The registered persons must ensure that the lock to the internal front door is repaired/replaced. The registered persons must ensure that areas that are stained and dirty from heat rising off heating pipes/radiators are cleaned and redecorated. TIMESCALE OF 31 JULY 2004 NOT MET. The registered persons must submit a schedule of works for addressing refurbishment of internal areas needing attention, and repair and redecoration of the exterior woodwork. The registered persons must not admit further residents to the home until day time staffing levels are revised to reach or exceed the minimum required based on the assessment of dependency and need. This must include additional provision to address the needs of those receiving day care. The registered persons must ensure that an additional member of staff is available during the waking night shift, to meet current needs for supervisoin during the night time period. IMMEDIATE REQUIREMENT ISSUED. The registered persons must submit timescales for the completion of work identified for the reduction of risks associated with fire. 09/09/05 31/10/05 30/09/05 09/09/05 19/08/05 31/10/05 St Edmunds I55 s35075 St Edmunds v235912 AN 160805 Stage 4.doc Version 1.40 Page 26 12. 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 3 Good Practice Recommendations The registered persons should ensure that information identifying potential concerns regarding mental state and cognition, is fully explored and recorded, to ensure that admissions are not made outside conditions of registration and of people whose needs the home will not be able to meet. The registered persons should adopt uniform documentation for setting out the care needs of each person. The registered persons should ensure that all staff are trained so they are able to fit and clean hearing aids properly, and that residents are consulted about their functioning and any remedial action needed. The registered persons should review how they can increase the awareness of the complaints procedure for visitors to the home, as they may need to support and advocate for residents. The registered persons should ensure that the concerns of residents are noted and followed up, taking into account the reluctance of residents to make formal complaints or to cause trouble. 2. 3. 7 8 4. 16 5. 16 St Edmunds I55 s35075 St Edmunds v235912 AN 160805 Stage 4.doc Version 1.40 Page 27 Commission for Social Care Inspection 3rd Floor Cavell House St Crispins Road Norwich NR3 1YF 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. 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