Inspection on 17/05/05 for St Edmunds

This inspection was carried out on 17th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 17/09/08

St Edmunds 25/09/07

St Edmunds 17/08/06

St Edmunds 06/10/05

St Edmunds 19/01/05

St Edmunds 13/07/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE St Edmunds 3-5 Marine Parade Gorleston Great Yarmouth NR31 6DP Lead Inspector Hilda Stephenson Announced 17 May 2005 9.30am 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 Version 1.10 Page 3 SERVICE INFORMATION Name of service St Edmunds Address 3-5 Marine Parade Gorleston Great Yarmouth NR31 6DP 01493 662119 01493 651282 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) Mr Richard Pendle, Mrs Penelope Pendle, Mr Anthony Barfield Ms Susan Jayne Harvey Care Home 32 Category(ies) of Old Age (32) registration, with number of places St Edmunds Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: Thirty-two (32) persons may be accommodated in the category Older People. Service Users who are accommodated on the second floor must be independently mobile. Date of last inspection 19 January 2005 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 User’s rooms have views of the sea. St Edmunds Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over seven hours as an announced inspection from 09.30am until late afternoon. A full tour of the premises was undertaken as well as visiting some residents in their own rooms. Sixteen of the thirty-one residents, three visitors and four staff were spoken to as well as the manager and proprietor. A large number of comment cards were received from residents, relatives and visiting professionals, in addition to the observation and necessary checks that took place were included in the overall results of this inspection visit. The home offers a hotel style environment for low dependency residents. It was extremely clean and tidy with a high standard of decoration throughout. The building is on three floors with the second floor not used for either residents or staff. Bedrooms are situated on both floors with access by the new shaft lift. There are three communal lounges, one dining room and a small seating area within the reception area. The home is surrounded by well-maintained gardens. What the service does well: The home has a consistent loyal staff team who were observed to treat residents with dignity and respect. The home offers a ‘hotel style’ service to residents who are admitted with low dependency needs enabling the staff to continue with a high standard of care. Social activities are arranged with outside entertainers visiting, not forgetting individual interests. Several residents were out walking along the seafront at Gorleston, others were being offered a manicure, with one resident enjoying gardening. Communication between the home and relatives appeared to be open and inclusive with a high number of visitors seen during the day. The home offers a comfortable environment with plenty of communal space, with a variety of bedroom sizes, the majority having a view of the sea. St Edmunds Version 1.10 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. St Edmunds Version 1.10 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 Version 1.10 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) 1,2,3,4,5,6 The home has a clear admission procedure. Written details are available to inform prospective residents about the service. EVIDENCE: There are written details made available for all new residents admitted to St Edmunds. The service users guide requires information about the complaints policy although it contains basic information regarding the service offered. The home states that they offer accommodation for residents with low dependency needs and that if residents do become frail or highly dependent they would be requested to find alternative accommodation. The terms and conditions should include the room number to be occupied and contains all the other relevant information. A copy of this is given to each resident. The manager visits prospective residents to assess whether the home can tend to their needs, and are invited to visit the home for a day. St Edmunds Version 1.10 Page 9 A month after admission an initial review meeting takes place to allow the resident to make up their mind whether they wish to stay at St Edmunds. St Edmunds Version 1.10 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 standard(s) 7,8,9,10,11 Written care plans that contain personal, health and social needs of each resident are identified, reviewed and are met by staff that appear to have a good understanding of their needs. EVIDENCE: Three care plans were examined and each one contained details of the resident’s personal care, health care and a good wide range of social interests. The care plans were easy to follow and provide the staff with the information to allow them to care for the residents and gain a good overall background of the residents past life. The residents confirmed that many were aware of the care plans and had been included with the details written about them, that is good practice. St Edmunds Version 1.10 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. This was observed when a GP visited several residents during this inspection. The home administers medication, several of the record sheets were seen with several having gaps when a clear direction should have been included, the sheets should be totally complete and a requirement was issued to leave no gaps in the recording system. The medication is stored in a secure room. Staff that has attended medication training administers all medication. The home stipulates on admission that they can attend to low dependency residents only, although occasionally they have cared for a resident who was dying. One resident whose partner died within the home commented ‘the staff couldn’t have done enough for me, they were wonderful in looking after my husband’. The manager confirmed that their clergy or priest who offer spiritual support visits some residents, and several have communion on a regular basis. St Edmunds Version 1.10 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) 12,13,14,15 Social activities are well managed within the home taking into account individual interests, arranging social functions and making meal times into a sociable event. EVIDENCE: The home has a large dining room that can seat four to a table, 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 meals are rotated over a two-week menu and the chef includes resident’s favourite dishes. The menu contains a good choice of wholesome meals. Some residents stay in their rooms for their meals and the staff respect their choice, although the majority do sit in the dining room. One resident stated ‘I really like the food served here, it’s so tasty and I get a good size portion’. With another stating ‘its lovely to have the food served in front of you’. St Edmunds Version 1.10 Page 13 The home was very busy during the morning with residents going out, several going for walks along the seafront, one resident was enjoying gardening and two had gone out with relatives. Several visitors were seen during the inspection. Residents appear to enjoy a good overall social life within the home with four residents enjoying playing cards with each other; several were having a manicure, while others were reading. One of the residents who came from a professional background was included with devising the next residents quiz. The staff organise outside entertainers to visit and encourage individual residents to continue with their hobbies and interests that was seen during this visit. It was observed that residents make their own decisions and staff attend to them when they require assistance. St Edmunds Version 1.10 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) 16,17,18 The home has a complaints system in place but this requires advertising to ensure that residents are aware of it. EVIDENCE: The complaints procedure is displayed in the reception area but needs to be included within the service users guide to inform prospective residents that all complaints are investigated and taken seriously. Complaints have been recorded in the past including the action taken. Several residents commented ‘I would speak to the manager or Penny if I had a problem’. Another stating ‘I couldn’t complain about the care I get, because it’s so good’. A comment received from a visitor ‘they look after my father so well, and we are always offered a cup of tea with him, it’s the little things that make this such a good home’. There were no complaints recorded within the comment cards or when speaking to both residents and relatives during this visit. Procedures are in place for responding to allegations of abuse, staff are taught a basic awareness of adult protection. It was recommended that staff continue to update their awareness of the new POVA guidelines. St Edmunds Version 1.10 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 standard(s) 19,20,21,22,23,24,25,26 The standard of décor is good with evidence of regular maintenance and future improvements. EVIDENCE: St Edmunds has been developed from a hotel, situated on Gorleston seafront. There are gardens surrounding the premises. It consists of three floors, but the bedrooms are situated on the ground and first floor. There are large comfortable communal lounges, a dining room and a sun lounge. The bedrooms vary in size with more than half overlooking the sea. The bedrooms contain personal furniture and items to make them more to the residents’ tastes. Each room can be locked; the central heating, windows and radiators are in line with regulations. St Edmunds Version 1.10 Page 16 The home undertakes residents’ personal laundry. The whole of the premises was clean, tidy with no unpleasant odour and was well decorated to a high standard. St Edmunds Version 1.10 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 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) 27,28,29,30 Sufficient numbers of staff were on duty with extra staff brought in to cover busy periods. EVIDENCE: An immediate requirement was issued during the previous inspection regarding the recruitment of new staff; the required checks and references have now been implemented using the recruitment checklist. Several staff files were seen and the induction and mandatory training has been continued with samples of first aid, fire, medication, infection control, with moving and handling arranged for all staff later this month, to include the use of the home’s first hoist. The care staff should continue to be encouraged to develop their skills through the recognised NVQ training. There are two care staff and one senior carer on duty during the day, with a waitress serving breakfast and a housekeeper in charge of the laundry. Two care staff attend to the residents overnight. Extra staff are brought in during busy periods or when special events are arranged. The manager works during the week and takes it in turn with the proprietor and the deputy manager to be on call. St Edmunds Version 1.10 Page 18 A chef cooks all the meals, with the proprietor cooking on the chef’s days off. Adequate numbers of domestic staff work during the week keeping the home extremely clean and tidy. The second proprietor undertakes the maintenance of the home. St Edmunds Version 1.10 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 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) 31,35,37,38 The management of the home is satisfactory with clear plans in place to ensure the health and safety of residents and staff. EVIDENCE: The home has a registered manager Susan Harvey who is well supported by both proprietors. She has worked at the home for many years and became the manager last year. She attends training courses to keep her skills up to date, having achieved NVQ 2 & 3 and D32/33 assessors certificate. St Edmunds Version 1.10 Page 20 The home retains some personal spending money for some residents and these were checked with the records clear and concise. The home has regular fire and environmental health visits with the previous requirements having been complete. Several records and certificates for the electrical appliances, fire, accidents, water; risk assessments and insurance were seen and found to be satisfactory. St Edmunds Version 1.10 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. Where there is no score against a standard it has not been looked at during this inspection. 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 2 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 4 COMPLAINTS AND PROTECTION 4 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 3 3 3 x x x 3 x 3 3 St Edmunds Version 1.10 Page 22 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. 2. 3. Standard 1 9 2 Regulation 5 13 & 17 17 Requirement The service user guide must contain details of the complaints procedure. The MAR charts must have no gaps within the records. The terms and conditions must include the room number that residents are to occupy. Timescale for action By 30/6/05 Ongoing By 30/6/05 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. Refer to Standard 18 28 Good Practice Recommendations Staff must update their knowledge of the POVA guidelines. Staff must continue to improve their skills through the recognised NVQ training. St Edmunds Version 1.10 Page 23 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. Extracts may not be used or reproduced without the express permission of CSCI St Edmunds Version 1.10 Page 24 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!