CARE HOMES FOR OLDER PEOPLE
St Edmunds 3-5 Marine Parade Gorleston Great Yarmouth Norfolk NR31 6DP Lead Inspector
Hilda Stephenson Unannounced Inspection 17th August 2006 11:30 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 Edmunds DS0000027497.V309139.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 Edmunds DS0000027497.V309139.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service St Edmunds Address 3-5 Marine Parade Gorleston Great Yarmouth Norfolk NR31 6DP 01493 662119 01493 651282 RICKPEN@TINTERNET.COM 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) Richard James Pendle Mrs Penelope Pendle, Mr Anthony Barfield Ms Susan Jayne Harvey Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places St Edmunds DS0000027497.V309139.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Thirty-two (32) persons maybe accommodated in the category Older People. Service Users who are accommodated on the second floor must be independently mobile. 6th October 2005 Date of last inspection Brief Description of the Service: St Edmunds is a residential home located on the sea front in Gorleston. It provides twenty-four hour care for up to thirty-two older people. The Home offers easy access to local shops and amenities and there is a local bus to Great Yarmouth on a regular basis. People in the home are encouraged to make use of all the local amenities and staff can support people when required. All the rooms are tastefully decorated with many communal areas; many of the Service Users rooms have views of the sea. The home offers a hotel style environment for low dependency residents with a condition that residents who live on the first floor are independently mobile. Fees range from £300 to £460. St Edmunds DS0000027497.V309139.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Care services are judged against outcome groups, which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out using information from the providers, the service users as well as others who work at or visit the home. This report gives a brief overview of the service and the current quality judgements for each outcome group. What the service does well: What has improved since the last inspection?
The home had been previously issued with one requirement to improve the records for administrating medication. This was checked and improvements have been maintained. St Edmunds DS0000027497.V309139.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Edmunds DS0000027497.V309139.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Edmunds DS0000027497.V309139.R01.S.doc Version 5.2 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 The outcome of these standards are good. Clear written guidelines are in place to enable prospective residents to make a decision to move into the home. All residents are assessed to ensure the home can meet their needs prior to moving in. EVIDENCE: The information was collected by case tracking two residents. One was a recently admitted resident and the other was chosen at random. The home has written guidelines which are distributed to prospective residents and is given out when the manager or her deputy visit them after the initial enquiry. An assessment is undertaken; sometimes a relative or social worker is involved with this initial meeting. The manager invites the prospective resident or their representative to look round the home before moving in, some have stayed for lunch in the past. St Edmunds DS0000027497.V309139.R01.S.doc Version 5.2 Page 9 When the resident has made up their mind to move into St Edmunds then arrangements are made for transferral. The initial assessment details are written in the care plan and any specialist equipment is obtained prior to admission. The home tends to admit residents who are not highly dependent and have a condition to their registration that anyone admitted to a second floor bedroom must be independently mobile. However, there are currently no bedrooms in use on the second floor. St Edmunds DS0000027497.V309139.R01.S.doc Version 5.2 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 The outcomes of these standards are good. Residents are aware that a plan of care is in place for each one and are regularly asked questions during their stay to ensure their personal and health needs are being met. EVIDENCE: Evidence was seen when examining care and medication records of two residents who were selected for case tracking. Both care plans included their personal care needs and instruction on how these should be carried out; with the care records showing evidence that residents wishes and input were included. Several residents who spoke to the Inspector were aware that a written record was kept and some were able to name their key worker suggesting that they continued to remain involved with their own care plan reviews. St Edmunds DS0000027497.V309139.R01.S.doc Version 5.2 Page 11 Occasionally, a district nurse visits residents when they require nursing input, with the information being transferred to the care records. All personal care and visits by other professionals are carried out in resident’s rooms to enable them the privacy that the home promises within the service user guide. The medication record sheets were checked which show that the record keeping has improved since the previous visit, with the manager regularly auditing the supply of medication. Overall, five other residents were spoken to and all stated ‘they were happy with the care and attention they received’. St Edmunds DS0000027497.V309139.R01.S.doc Version 5.2 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 the following standard(s): 12,13,14,15 The quality outcome of these standards are good. Residents can choose if they wish to take part in the arranged social activities and continue with their own interests and hobbies. Visitors are welcomed into the home. Residents can enjoy a wide variety of seasonal meals from the menu. EVIDENCE: Social activities are organised by care staff during the week including both group activities such as quizzes, topical discussion, cards or more personal activities such as manicures, crosswords, reading and going out for a walk along the sea front. Some residents organise and hold their own game of scrabble. The majority of residents tend to congregate within the lounges and conservatories during the morning, with several taking a rest after lunch or going to their own rooms. Several visitors were seen during the inspection and were offered tea. St Edmunds DS0000027497.V309139.R01.S.doc Version 5.2 Page 13 The home has a large dining room with good sized tables that seat 2. The meals are served in the manner of a restaurant where residents can help themselves or be served their food by the staff. Several residents enjoy an aperitif before lunch. The majority of residents tend to meet up at lunchtime. Copies of the menu were seen and contained seasonal fruit and vegetables; the menu is rotated over two weeks. 87 of residents stated they liked the choice and variety of food offered. One resident stated ‘it is so good to be offered so much fresh fruit and vegetables’. Staff respect the wishes of those residents who prefer to stay in their own rooms for their meals, although the majority were seen in the dining room or conservatory taking their lunch. St Edmunds DS0000027497.V309139.R01.S.doc Version 5.2 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 the following standard(s): 16,18 The outcomes of these standards are good. Residents’ views and concerns are listened to and acted upon. EVIDENCE: The information provided from residents prior to the site visit showed that 100 stated that ‘staff listened and acted on what they said’. The home has a complaints procedure in place, a copy is displayed in reception and is now included in the written service users guide. The home appears to encourage residents to put their points of view to the management with regular discussion groups. No complaints were received during this visit. Since the previous inspection the manager has dealt appropriately with two complaints. Procedures are in place for responding to allegations of abuse; new staff receives tuition and written guidelines on basic awareness of adult protection during the induction programme, with the manager explaining her role within this procedure. Some staff having attended an awareness of adult protection course.
St Edmunds DS0000027497.V309139.R01.S.doc Version 5.2 Page 15 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): 19,20,23,24,25,26 The outcomes of these standards are good. Residents live in a clean, tidy and well-maintained home. EVIDENCE: A brief tour of the building showed that the home continues to be well decorated throughout. Two bedrooms were seen and the residents commented on how they were encouraged to bring in their own personal belongings, favourite chair, photographs etc to ensure that they felt as comfortable as possible. 100 of residents commented that the home was always clean and fresh. One of the proprietors carries out the regular maintenance and decoration of the building. St Edmunds DS0000027497.V309139.R01.S.doc Version 5.2 Page 16 Past evidence showed that St Edmunds has been developed from a hotel, situated on Gorleston seafront. There are well-maintained gardens surrounding the premises. It consists of three floors, where the bedrooms are situated on the ground and first floor. There are two large comfortable lounges, a dining room, conservatory and a sun lounge with extra dining facilities. There are also smaller areas containing seats throughout the floors. The bedrooms vary in size with more than half overlooking the sea. St Edmunds DS0000027497.V309139.R01.S.doc Version 5.2 Page 17 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): 27,28,29,30 The outcomes of these standards are good. Competent well-trained staff cares for residents. EVIDENCE: The manager was taking annual leave during this site visit, although came into the home to assist with the inspection. The home has adequate amounts of care staff on duty; several other staff are employed by the home to ensure that the caring staff do not take on domestic duties. A senior carer runs each shift when the manager or deputy is off. The proprietors live next door to the home and continue visiting daily; one undertakes the general maintenance and the other covers the chef’s days off, wages and accountancy duties plus the occasional care shift if there is a shortfall. The management team take it in turns to cover ‘out of hours, on call’. One of the senior staff explained how she was well supported while undergoing training to take on the more senior role, and has commenced NVQ level 3. Two staff records were checked to ensure that the home continued to follow a good clear recruitment procedure. St Edmunds DS0000027497.V309139.R01.S.doc Version 5.2 Page 18 The information provided by the manager prior to this visit confirmed that staff have undertaken fire training, moving and handling, continence awareness, first aid, and NVQ levels 2 & 3 in care. The current care staff that have achieved the recommended NVQ level 2 training is 33 , with four more commencing in September. The home continues to have a low staff turnover which evidences that they obviously enjoy working at St Edmunds. St Edmunds DS0000027497.V309139.R01.S.doc Version 5.2 Page 19 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): 31,33,35,36,38 The quality outcomes of these standards are adequate. Residents and staff live and work in a safe environment. Some quality assessment procedures are required to be put in place, including monthly reports. St Edmunds DS0000027497.V309139.R01.S.doc Version 5.2 Page 20 EVIDENCE: The manager has worked at the home for ten years in total, the last two as manager, and has developed a stable staff team. She continues to attend relevant training to keep up with current trends. Three procedures the home is lacking are quality assurance monitoring in a formal manner with annual results included with the service user guide and a requirement has been issued to ensure this is undertaken. Also the proprietors are required to develop a method to monitor the business as stated in Regulation 26 by introducing their own unannounced inspections to monitor the management, training, and well being of residents. The manager must also send notification of any deaths or incidents to CSCI in writing. A random selection of residents’ personal spending money that is kept for safekeeping was checked and found to have appropriate records in place. The manager has continued to regularly supervise staff and carries out an annual appraisal to ensure that staff keep up to date with policies and procedures. A sample of the maintenance records on fire training and equipment, gas central heating and boiler were in place. Other evidence of equipment checks was taken from the documentation provided by the proprietor prior to this site visit. St Edmunds DS0000027497.V309139.R01.S.doc Version 5.2 Page 21 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 3 3 3 3 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 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 4 3 x x 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 3 x 2 St Edmunds DS0000027497.V309139.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2. Standard OP38 OP33 Regulation 37 (1,2) Requirement Timescale for action 30/11/06 3 OP33 Written notification must be sent to CSCI in accordance with Regulation 37. 24(1a,b,2, An effective quality monitoring 30/11/06 3,) system must reflect residents’ views on how the home is meeting the aims, objectives and statement of purpose with the results published on an annual basis. 26 The proprietors must undertake 30/11/06 (2a,b,c,3, unannounced inspections as 4,5) stated in regulation 26 and send results to CSCI. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Edmunds DS0000027497.V309139.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Norfolk Area Office 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
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