Inspection on 24/04/07 for St Edmunds

This inspection was carried out on 24th April 2007.

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 26/04/06

St Edmunds 21/02/06

St Edmunds 16/08/05

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 Mr Pearson Clarke Unannounced Inspection 24th April 2007 10:15 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 DS0000035075.V338475.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 DS0000035075.V338475.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Edmunds Address Surrogate Street Attleborough Norfolk NR17 2AW 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) 01953 452011 01953 457463 terri.mcwilliams@norfolk.gov.uk www.norfolk.gov.uk Norfolk County Council-Community Care Mrs Susan Brockett Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places St Edmunds DS0000035075.V338475.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home can accommodate up to 35 Service Users who are Older People, not falling into any other category. That Service Users who need a wheelchair to assist with independent mobility at point of admission can only be accommodated in rooms 30, 35, 36, 40, 41, 44, 72, 74 and 75. The Home may accommodate one (1) named Service User who is mentally disordered. Maximum not to exceed 35. 26th April 2006 3. Date of last inspection Brief Description of the Service: St Edmunds 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. The current fee levels for the home are individually assessed with a maximum weekly charge of £368.72. St Edmunds DS0000035075.V338475.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 by using information from previous inspections, information from the providers ,the residents and their relatives, as well as others who work in the agency. This has included a recent unannounced visit to the agency and this report gives a brief overview of the service and current judgements for each outcome. What the service does well: What has improved since the last inspection? The service is admitting and caring for people whose needs it can appropriately meet. The approach to the recording of complaints and concerns is much improved with clear evidence of the positive way in which the home seeks to address issues raised. There have continued to be general improvements to the environment. These include commissioning of the homes new lift, greatly improved lighting in bedrooms and much redecorating, re-carpeting and new curtains Staffing hours have improved and are enabling current levels of need to be effectively met. St Edmunds DS0000035075.V338475.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. The summary of this inspection report can be made available in other formats on request. St Edmunds DS0000035075.V338475.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 DS0000035075.V338475.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. That people admitted to the home are confident that their needs will be met as they have had those needs appropriately assessed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Unlike the last inspection of the service the inspector was able to track two recent admissions to the home. As such it was evident that a needs led assessment process had taken place and discussion about the admission process with the manager showed an appreciation of the importance of good admissions based on thorough assessment. The inspector spoke to both of the people involved who felt that their needs had been understood and were being met. The home is no longer accommodating people whose needs made them inappropriate for the care offered. St Edmunds DS0000035075.V338475.R01.S.doc Version 5.2 Page 9 St Edmunds DS0000035075.V338475.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. The staff deliver personal and health care in a way that residents wish for and which helps ensure their welfare. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Sample plans of care were inspected at the site visit and were found to reflect the needs and wishes of residents. Plans had been reviewed, contained risk assessments and service users spoken to were aware of their plans. From these plans and discussion with residents the inspector could see that the health care needs of residents were being met. Written comment from doctors serving the home showed them to believe that good quality care is offered and indicated good working relationships which residents benefit from. Both residents and staff were aware of the importance of care being delivered with respect for privacy and dignity and felt that the home operated on these principals. The providers reports show arrangements for the management of medication are generally sound and it is noted that high temperatures in one St Edmunds DS0000035075.V338475.R01.S.doc Version 5.2 Page 11 drug storage room have been responded to with an air conditioning unit ordered. St Edmunds DS0000035075.V338475.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. That people living at the home enjoy a lifestyle where they are in control and can enjoy a good range of stimulation and activity if they wish. There continues to be variance in the quality of food served. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is considerable evidence that the home is providing good outcomes for residents through the provision of regular and varied activity. During the site visit the inspector saw posters advertising an extensive range of events and there is activity on every day of the week. People spoken to were very happy with what is offered, particularly the weekly reminiscence based sessions which are provided by a group called creative ageing. The most recent of these was a “ Dad’s Army day” which included a war time lunch, entertainment from the period and a large display of period objects used for reminiscence. People told the inspector that the home was a relaxed place to live and that they felt able to exercise choice and control over their day to day lives and this was supported by the providers visiting reports and observation on the day. The St Edmunds DS0000035075.V338475.R01.S.doc Version 5.2 Page 13 home is ideally placed to access the town and staff reported how they took people out to shops and other facilities. They have also managed to access the use of a mini bus and weekly outings take place including a recent trip to the circus. One visitor was spoken to and confirmed that visitors are made welcome and that there is good communication with staff. Written comment received supported this picture. The home is continuing to experience variable quality in the provision of food, with entries in the services complaints record largely relating to this area. This was discussed with the service manager and the inspector is satisfied that the concerns are being effectively managed with continued monitoring and some new training for staff. St Edmunds DS0000035075.V338475.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. People who live in the home are protected and feel able to raise complaints and concerns, knowing that any issues will be addressed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People told the inspector that they would have the confidence to raise concerns and complaints, feeling that these would be addressed in a fair and speedy manner. The homes complaints records were inspected and these indicated that any issues were taken seriously and action taken to address them. The provider has thorough adult protection procedures and processes although it would be beneficial to ensure that all staff have adult protection training. St Edmunds DS0000035075.V338475.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. Residents have benefited from the improvements made to the building in the last year, however there is still considerable scope for further improvement. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector toured the building and found all areas to be fresh and clean and people living at the home confirmed that this is the normal situation. Within the last year there has been a significant amount of redecoration, new carpets and new curtains. Light fittings in bedrooms have been replaced addressing issues previously identified. The services new lift has been commissioned giving easier access to the first floor. The highly institutional window restrictors and inadequate heating systems remain, however an improvement plan which should see replacement of all windows and a new heating system has been St Edmunds DS0000035075.V338475.R01.S.doc Version 5.2 Page 16 presented to the commission. This move is to be welcomed however it is noted that formal funding for aspects of the scheme will still need approval and should the approval not be forthcoming the building will continue to have significant deficits when measured against modern provision. St Edmunds DS0000035075.V338475.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. That the service is adequately staffed to meet the needs of the people living there. Residents have confidence in those who care for them and staff are well trained and recruited in a sound manner. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the site visit the inspector spoke to a selection of the people living there. In addition time was taken to observe interaction between residents and staff on duty. People told the inspector that they were very happy with the care received and found the staff to be kind and good at their jobs. People did not have to wait excessively to receive help and based on the views of the staff seen, the increase in staffing hours since last inspected has enabled them to do their job without undue pressure. Staff training records were inspected and showed a generally sound approach to training and the service is currently meeting government targets for NVQ trained staff. Although staff are undertaking a good range of core training the inspector recommends that all care staff undertake adult protection training. The provider has robust recruitment processes and having tracked recent employment during the site visit the inspector is satisfied that the approach is appropriate and offers St Edmunds DS0000035075.V338475.R01.S.doc Version 5.2 Page 18 protection to residents. The providers own visiting reports support the picture seen by the inspector at the site visit. St Edmunds DS0000035075.V338475.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35 and 38 Quality in this outcome area is good. That people living at St Edmunds are benefiting from the strong and effective leadership of the service, which allows them to influence life in the home. The management approach promotes and protects their health and safety. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection of the service the home has had a change of manager. Information received through comment cards and by way of the providers monthly visits show that the new manager is perceived to have had a very positive impact on the home. The inspectors site visit confirmed this picture, with people living in the home, staff on duty and a visitor all talking of St Edmunds DS0000035075.V338475.R01.S.doc Version 5.2 Page 20 the energy and leadership that is now apparent on a day to day basis. The inspectors own observations were of a vibrant atmosphere with a team working together to improve the home. The service has a quality system and at the time of the visit the manager was beginning to collate the results and think of ways in which they would influence change. People spoken to by the inspector felt that the home ran with their best interests and that they could express views which would be taken on board. There are regular residents meetings and the minutes indicate that people attending these meetings do decide on issues, such as how to spend available money, planning activities as well as allowing the opportunity to raise concerns about food etc. The provider has well established health and safety protocols and procedures and there were no indications that peoples health and safety were not being protected. St Edmunds DS0000035075.V338475.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 x x 3 x x x 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 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x x x x x x 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 4 3 x 3 x x 3 St Edmunds DS0000035075.V338475.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. Standard Regulation Requirement Timescale for action 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 OP15 Good Practice Recommendations That the management monitor the provision of food to ensure that service users are consistently happy with the provision. That all staff receive training in adult protection 2 OP30 St Edmunds DS0000035075.V338475.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: 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 DS0000035075.V338475.R01.S.doc Version 5.2 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. 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