Inspection on 17/09/08 for St Edmunds

This inspection was carried out on 17th September 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

St Edmunds 25/09/07

St Edmunds 17/08/06

St Edmunds 06/10/05

St Edmunds 17/05/05

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 13/03/2009.

CARE HOMES FOR OLDER PEOPLE St Edmunds 3-5 Marine Parade Gorleston Great Yarmouth Norfolk NR31 6DP Lead Inspector Debra Allen Unannounced Inspection 17th September 2008 08:30 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.V371498.R02.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.V371498.R02.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@btinternet.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.V371498.R02.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. 25th September 2007 Date of last inspection Brief Description of the Service: St Edmunds is a residential home located on the sea front in Gorleston, which 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, which runs 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 a number of communal areas and many people have rooms with sea views. The home offers a hotel style environment for residents who have low dependency support needs with a condition that residents who live on the first floor are independently mobile. Fees range from £325.00 to £460.00 per week and additional charges are made for personal requisites, private telephone facilities, newspapers, hairdressing and private chiropody. St Edmunds DS0000027497.V371498.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. 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, by using information from previous inspections, information from the providers, the residents and their relatives, as well as others who work in or visit the home. This has included a recent unannounced visit to the home. This report gives a brief overview of the service and the current judgements for each outcome group. This inspection was carried out over a period of six and a half hours and included a tour of the premises, inspection of staff and residents’ records and the home’s records relating to health and safety. Discussions also took place with the manager and some of the staff and residents. No CSCI questionnaires had been completed or returned by residents, relatives/carers or staff prior to the inspection, although the manager had completed the Annual Quality Assurance Assessment (AQAA) and a copy was submitted to the Commission accordingly. Four requirements and two recommendations have been made as a result of this inspection. What the service does well: St Edmunds is generally a very well run service with a very happy, comfortable and homely atmosphere. All residents have their needs fully assessed prior to moving in. Each person has a care plan which describes their health, personal and social care needs. Residents also have access to healthcare professionals and they are protected by the home’s medication policies and procedures. People living at St Edmunds have the opportunity to take part in a number of activities, hobbies and pastimes and are supported to maintain contact with family, and friends, according to their wishes. Residents, their families and friends know their complaints will be listened to, taken seriously and acted upon. St Edmunds DS0000027497.V371498.R02.S.doc Version 5.2 Page 6 Staff are well trained and procedures are in place to help protect service users from abuse. St Edmunds provides a clean, safe and well-maintained environment for the people living there and the indoor and outdoor communal facilities are safe and comfortable. Staff are well trained and competent. 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. The summary of this inspection report can be made available in other formats on request. St Edmunds DS0000027497.V371498.R02.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.V371498.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (Standard 6 is not applicable.) Quality in this outcome area is good. All residents have their needs fully assessed prior to moving into St Edmunds, to ensure the service can meet those needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans for four residents were examined during this inspection, which included Pre-placement Agreements from social services and evidence that full needs assessments had been carried out for each person. A discussion with the manager and proprietor confirmed that a Statement of Purpose, Service User Guide and information brochure is given to each person before they move in. Evidence was also seen within some files to confirm that standard assessments are also carried out for people who stay at St Edmunds for respite or on a short-term basis. St Edmunds DS0000027497.V371498.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. Each person at St Edmunds has a care plan which describes their health, personal and social care needs. Residents also have access to healthcare professionals and they are protected by the home’s medication policies and procedures. All of these factors help ensure that residents’ health care needs are fully met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four care plans were looked at in-depth, and a number of others were accessed randomly, during this inspection. These plans were seen to contain detailed information under various headings, with information such as: Daily Notes/Comments Sheet Personal Information & Next of Kin St Edmunds DS0000027497.V371498.R02.S.doc Version 5.2 Page 10 Personal Hygiene: (information seen to confirm whether assistance is required from one or more carers and to what extent – i.e. washing). Personal Care: (information seen to confirm whether assistance is required from one or more carers for aspects such as times and locations preferred for eating and drinking, drinks required – i.e. tea, coffee etc. bathing routines, daily and night-time routines and requirements. Day to day information such as diet: (i.e. small amounts to be served, otherwise will be put off. Likes and dislikes. Information was also noted to confirm whether people required assistance with food being cut up, whether they are safely able to serve themselves with food and drink and whether they prefer a cup or a mug). Mobility: Whether the person is independently mobile and whether any mobility aids are required such as frame, walking stick, toilet stand, wheelchair etc. Risk assessments were also seen to confirm whether people are at risk of falling and whether they are safely able to go out alone. Social Care: This section included information such as “likes to keep themselves to themselves” or “likes to interact/socialise with other residents”. Information was also seen in respect of family history, friends history, emotional state (i.e. a bit low at times) memory (i.e. short term memory loss), hobbies and interests, Problem Areas (i.e. pressure sores or other issues. Financial: Information regarding funding, what cash, if any, is held at St Edmunds, Solicitors’ details if relevant. Medication: Included details of medication currently prescribed, any creams or ointments required and whether self-medicating or administered by senior staff. Placement History: I.e. whether lived at own home or another service before moving to St Edmunds. Care Plan Reviews: These were seen to cover areas such as medication, personal care, social care, medical care, comments on the review and a care plan summary. Evidence was also seen, and records maintained, to confirm people’s visits to/from various healthcare professionals such as the district nurse, GP, chiropodist, optician and dentist. St Edmunds DS0000027497.V371498.R02.S.doc Version 5.2 Page 11 Meanwhile, although each person has their own section within the care folders now, it is still recommended that each person actually has their own individual folder, to contain all aspects of their health and care needs. During the inspection observations were made of staff knocking on doors before entering and addressing people appropriately. From this the opinion was formed that the people living at St Edmunds are treated with respect and have their privacy upheld. Discussions with two residents in particular also confirmed this fact. The manager and proprietor confirmed that staff receive training prior to being able to administer medication, which is only carried out by the manager, deputy or a senior carer, and the records looked at confirmed that people are protected by the home’s policies and procedures. Medication continues to be safely stored in a locked room and facilities are in place for the storage, recording and use of controlled drugs. St Edmunds DS0000027497.V371498.R02.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is excellent. People living at St Edmunds have the opportunity to take part in a number of activities, hobbies and pastimes and are supported to maintain contact with family, and friends, according to their wishes. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The residents spoken to during the inspection confirmed that they were able to come and go as they wished and regularly enjoyed going for a walk or to the local shops. One person said they often had a friend come and visit and they would go out together. The people spoken to also said they were able to choose whether they wanted to join in with any of the in-house activities or not, such as scrabble or cards. Observations also confirmed a very sociable atmosphere during mealtimes and the people spoken to, plus the results/feedback from St Edmunds’ Quality Assurance survey indicated that the meals were wholesome and enjoyable and that people could choose where and when they wanted to eat. It was also noted that the chef keeps a note of individuals’ likes and dislikes and nutritional requirements are recorded in each person’s care plan. St Edmunds DS0000027497.V371498.R02.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. Residents, their families and friends know their complaints will be listened to, taken seriously and acted upon. Staff are well trained and procedures are in place to help protect service users from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A discussion with the manager and proprietor confirmed that all complaints were recorded, responded to and dealt with straight away in accordance with the home’s complaints procedure, although it was also confirmed that no complaints have been received since the last inspection – only compliments. Staff records showed that staff had received training in adult protection and the manager confirmed that she was fully aware of the procedures in this area. All the residents spoken to during the inspection said they were very happy at St Edmunds and had absolutely no complaints about anything whatsoever. However, they also confirmed that they knew what to do and who to speak to if they ever did want to make a complaint. St Edmunds DS0000027497.V371498.R02.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is excellent. St Edmunds provides a clean, safe and well-maintained environment for the people living there and the indoor and outdoor communal facilities are safe and comfortable. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the premises was carried out as part of this inspection and St Edmunds was found to be clean, homely and free from offensive odours. The communal areas were warm and inviting and the standard of furnishing and décor was very good throughout. No safety hazards were noted during the inspection. Some individual bedrooms were looked at, with permission from the respective residents, and these were seen to be very personal, with decoration and furnishings to people’s individual taste. St Edmunds DS0000027497.V371498.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. St Edmunds generally has robust recruitment policies and practices and the staff are trained and competent. However, a record of clear CRB (Criminal Records Bureau) disclosures having been received for each staff member should be maintained on their file and two written references (at least one of which should be from a professional source) must be acquired for each new staff member and a copy held on their file. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Observations, discussions and the records looked at during the inspection confirmed that there are adequate numbers of staff on duty at all times. Meanwhile, personnel files were looked at for four staff members and these were seen to contain records of induction and training, references, identification, application, employment contracts and supervision notes. However, although these files showed that the home generally followed robust recruitment procedures, one file contained only a refusal following a request for a professional reference, with no other reference on file, although details of two referees were stated in the application form. Also, although the manager and proprietor confirmed that CRB disclosures had been requested and St Edmunds DS0000027497.V371498.R02.S.doc Version 5.2 Page 16 received for each staff member prior to their starting work at St Edmunds, only one file looked at contained evidence of this. Meanwhile, training records were looked at and good evidence was seen of courses attended such as first aid, fire safety, health & safety, patient handling, moving & handling, infection control, food hygiene, medication, COSHH, continence awareness and adult protection. St Edmunds DS0000027497.V371498.R02.S.doc Version 5.2 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 Quality in this outcome area is adequate. Although the home is generally run and managed by a competent manager, who has the best interests of the residents at heart, there is still room for improvement with regard to areas such as regular staff supervisions and to consistently have time allocated for undertaking administrative and managerial duties. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Discussions with the manager and proprietor confirmed that the manager continues to share some of the managerial responsibilities with the proprietor but, although some additional time has been specifically allocated for administrative and managerial duties to be carried out (off the care rota), St Edmunds DS0000027497.V371498.R02.S.doc Version 5.2 Page 18 these times are often compromised or cancelled due to staff sickness or holidays. Supervision notes were seen to be maintained in the staff files but supervision sessions are still not being carried out regularly enough. Residents’ meetings continue to take place on a regular basis and questionnaires are given to residents, their relatives and visitors to provide feedback in respect of the quality of the service provided at St Edmunds. The results of the last Quality Audit were seen to be very positive, with some additional comments made by people such as “I would like to put excellent to most of the questions!” It was noted however, that the last audit was not dated and no feedback or action plan had been compiled. Detailed health and safety records and risk assessments were seen to be up to date and relevant, thus confirming the health and welfare of service users and staff are promoted and protected. St Edmunds DS0000027497.V371498.R02.S.doc Version 5.2 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X 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 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 3 St Edmunds DS0000027497.V371498.R02.S.doc Version 5.2 Page 20 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP31 Regulation 10 Requirement The manager must have allocated days to allow her to undertake managerial tasks and not be included on the care rota. Repeated Requirement The manager must formalise staff supervision for the ongoing development of staff. Repeated Requirement. A record of clear CRB (Criminal Records Bureau) disclosures having been received for each staff member must be maintained on their file. Timescale for action 15/12/08 2. OP36 18 15/12/08 3. OP29 19 15/11/08 4. OP29 19 Two written references (at least 15/11/08 one of which should be from a professional source) must be acquired for each new staff member and a copy held on their file. St Edmunds DS0000027497.V371498.R02.S.doc Version 5.2 Page 21 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 OP7 OP33 Good Practice Recommendations Care plans should be stored in individual folders to allow easier access for residents if they wish to read them. It is recommended that quality audits are dated and that feedback and an action plan is produced. St Edmunds DS0000027497.V371498.R02.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Edmunds DS0000027497.V371498.R02.S.doc Version 5.2 Page 23 - 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. 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