Inspection on 25/09/07 for St Edmunds

This inspection was carried out on 25th September 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 17/09/08

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE St Edmunds 3-5 Marine Parade Gorleston Great Yarmouth Norfolk NR31 6DP Lead Inspector Unannounced Inspection 25th September 2007 09:30 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.V352668.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.V352668.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@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.V352668.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. 17th August 2006 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 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 many communal areas and many of the Service Users rooms have views of the sea. 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.V352668.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit to St Edmunds took place during the day on the 25th September 2007 as an unannounced inspection to check the outcomes of the key standards. These standards were inspected, although not all the elements have been examined. An Expert by Experience accompanied the Link Inspector on this inspection. This person spent the majority of time speaking to residents. The evidence gathered to publish this report was obtained by speaking to sixteen of the twenty eight residents, four visitors, four staff and the manager during the day and checking through care records, policies and procedures. Further evidence was gathered from comments received through the ten comment cards that were returned to the office from both residents and relatives prior to the visit and the information documented within the Annual Quality Assurance Assessment completed by the manager of St Edmunds. The inspection took the form of a tour of the building and the home was found to be clean, tidy and free from odour. The majority of residents were either in their bedrooms or sitting in the lounge and garden areas with several entertaining visitors. What the service does well: The home offers low dependency care and support to older people who can continue with their own hobbies and interests with staff offering assistance when they can, although social activities are organised at various times during the week. Groups of residents arrange their own games of scrabble and cards usually before lunchtime. The home has a consistent loyal staff team who were observed to treat both residents and their relatives with dignity and respect. St Edmunds continues to offer several choices for each meal on the menu, with lunch and tea maintained at set times and breakfast and supper more flexible to accommodate residents’ individual preferences for getting up and going to bed. The home has an ‘open’ policy for the inclusion of views from residents and relatives and this was reinforced by discussions with a number of visitors seen during the day, with comments provided by relatives such as ‘they cannot get better care anywhere else’. St Edmunds DS0000027497.V352668.R01.S.doc Version 5.2 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 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.V352668.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.V352668.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): Quality in this outcome area is good. The key standards were checked. This judgement has been made using available evidence including a visit to this service. Written information is given to residents prior to admission to define the facilities offered at the home. All residents are admitted after an assessment of their needs. EVIDENCE: The care home had a comprehensive and informative Statement of Purpose and Service User Guide. A colour brochure about the care home was also available. One newly admitted resident and her relatives confirmed they had been properly informed about the care home and invited to visit prior to making a decision to live there. St Edmunds DS0000027497.V352668.R01.S.doc Version 5.2 Page 9 The majority of residents had been referred to the care home by social services and issued with social service contracts. The care home also issues contracts that contain the terms and conditions of residence. Residents who returned the five additional comment cards collected on the day of the inspection confirmed that they had a contract with the care home, and that they were informed that this care home might not be able to care for them if their physical or mental needs deteriorated in the future. The files of three residents were examined and each contained evidence that assessments of residents’ needs were always conducted prior to admission being agreed upon. The home does not offer intermediate care. St Edmunds DS0000027497.V352668.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): Quality in this outcome area is good All the key standards were checked. This judgement has been made using available evidence including a visit to this service. Residents’ health care needs are met. Residents are involved when their care plan is compiled and reviewed to ensure that their individual needs are met. Safe medication administration procedures are in place to ensure residents receive the correct prescribed medical treatment. EVIDENCE: Three care plans were read and the same residents spoken to during the day about their care. The residents’ care plans were thoroughly examined and found to contain clear, concise information regarding the physical, mental and social needs of each individual. Residents and their relatives were informed as to the outcome of assessments and care planning and residents’ files contained a signed acknowledgement of this. The care plans are stored within one folder and it was recommended that these should be stored individually to make it easier for residents to have access to their own plans. See Recommendations St Edmunds DS0000027497.V352668.R01.S.doc Version 5.2 Page 11 Residents and relatives spoken with praised the standards of personal and health care offered. It was noted how all residents appeared clean, tidy and well cared for and relatives commented how they too always found this to be the case, whenever they visited. The majority of comments described care assistants as kind and helpful. Evidence of specialist services such as chiropody, physiotherapy, dental care and psychiatric services were regularly sought for those who required these. The manager confirmed that residents admitted from other areas tended to register with the local GP surgery, although some local residents have stayed with their own GP surgery. Residents confirmed that the staff at the home uphold their privacy and dignity at all times, assisting them back to their rooms or the quiet lounge if they require a quiet area. It was observed that staff knock on residents’ bedroom doors before entering their rooms. Some residents stated that they prefer to spend time in their own room and this was respected by the home. Medication was found to be safely stored in a locked room. Facilities were in place for the storage of controlled drugs, though there were none on the premises at the time of this inspection. A medication fridge was in place. Medication was checked in and administered only by the manager, deputy manager and senior carer. St Edmunds DS0000027497.V352668.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): Quality in this outcome area is good. All the key standards were checked. This judgement has been made using available evidence including a visit to this service. Residents can enjoy a varied and nutritional menu ensuring personal tastes are taken into account. Sociable activities are organised on a regular basis that take place during various times of day. Visitors are welcomed into the home by friendly polite staff. EVIDENCE: The home displays a social activities list for the current month. The staff keep a record of who attends, although staff respect residents who do not wish to take part in activities and who prefer to stay in their room. The majority of residents continue to go out to the local shops, or for a walk along the sea front and staff assist when requested. The Expert by Experience who accompanied the Link Inspector spent the majority of time speaking at length with seven residents and four relatives. The Expert by Experience commented on how the majority of residents continue with an active lifestyle and that several residents organise their own games and tournaments within the home, with Scrabble or cards played most days. St Edmunds DS0000027497.V352668.R01.S.doc Version 5.2 Page 13 Menu’s and observation during lunchtime confirmed that the home offers a varied, consistent and nutritionally balanced diet, taking suggestions from residents during lunchtime discussions. The home has a large dining room with additional tables within the conservatory for those who prefer a smaller environment. One resident stated ‘its so nice to get so many fresh vegetables with our meals’. Lunch was a relaxed sociable occasion, with staff and waitresses in attendance serving meals in the style of a hotel, after an aperitif was offered pre-lunch. All residents confirmed that meals and the amount of food was excellent and could not be improved. The cook had residents’ likes and dislikes in the kitchen and the nutritional needs of residents were recorded within the care plans. St Edmunds DS0000027497.V352668.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): Quality in this outcome area is good. The key standards were checked. This judgement has been made using available evidence including a visit to this service. Residents and their relatives are confident that the proprietors would deal with their complaints satisfactorily and the home tries to ensure residents are protected from abuse and kept safe. EVIDENCE: The manager confirmed that complaints were recorded and dealt with immediately, either by herself or the proprietor. She explained the adult protection procedure. Senior staff confirmed that they were aware of the adult protection procedure and had attended training during the year. Residents who were spoken to were adamant that they have no complaints about the care and attention they receive at the home. They were aware that they should speak to the manager or proprietor if they had any concerns. St Edmunds DS0000027497.V352668.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): Quality in this outcome area is good. The key standards were checked. This judgement has been made using available evidence including a visit to this service. The environment is kept clean and nicely decorated so residents can enjoy a clean, comfortable home. EVIDENCE: St Edmunds is a large house overlooking the sea front at Gorleston. There are four main lounge areas all on the ground floor, with a large dining room and small dining area within the front conservatory. There are small sitting areas throughout the home where residents can entertain visitors. The bedrooms are situated on both floors and are furnished to resident’s own taste. There are well-maintained gardens to the front and side of the house. The home was very well decorated throughout. Furniture was of a high standard, comfortable and with no hazards seen throughout the building. St Edmunds DS0000027497.V352668.R01.S.doc Version 5.2 Page 16 Equipment seen during the tour was of good quality and had been regularly serviced. One of the proprietors maintains the building and decoration and maintenance records are in place. St Edmunds DS0000027497.V352668.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): Quality in this outcome area is good. All the key standards were checked. This judgement has been made using available evidence including a visit to this service. Residents are cared for by well-trained polite friendly staff. Residents are protected and supported by the manager using a good recruitment process. EVIDENCE: There were sufficient staff on duty. Two members of staff were spoken with and both had achieved the NVQ level 2 with one having level 3. They both spoke of the training courses they had attended during the past year. A good induction programme is in place for new staff to complete within the first twelve weeks of employment. Records showed that nine out of the sixteen care staff have achieved the NVQ training and the home is commended for this. The recruitment process for the most recently appointed member of staff was looked at. The manager had followed a good clear recruitment procedure, obtaining references and CRB before the employee commenced work. The rota confirmed that an adequate amount of staff were on duty. The change of staff at 2.30/3.00pm confirmed that adequate time for handover was built in to part of the duties. St Edmunds DS0000027497.V352668.R01.S.doc Version 5.2 Page 18 During the day two care staff and senior carer or the manager attend to residents with additional staff attending to the cooking, domestic chores, laundry and general maintenance. Discussion with staff during handover confirmed that none of the staff had any concerns they wished to discuss and they stated that they felt supported by the manager and proprietors who appeared to work well together and shared some of the management tasks. St Edmunds DS0000027497.V352668.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): Quality in this outcome area is adequate. All the key standards were checked. This judgement has been made using available evidence including a visit to this service. Management arrangements are meeting the needs of residents, although improvement is required to monitor staff supervision on a more formal basis. The manager must have specific management time to undertake managerial duties and not be included as part of the care team so that good managerial and administrative practices are monitored and maintained. EVIDENCE: The manager shares some of the managerial responsibilities with the proprietors, and is also included on the duty rota reducing management hours. See Requirements. St Edmunds DS0000027497.V352668.R01.S.doc Version 5.2 Page 20 The proprietor must allocate days where the manager has specific time to undertake her management duties such as the formal supervision of staff. See Requirements. The manager continues to audit the services at the home gaining evidence from questionnaires of residents and visitors. Residents meetings to discuss future changes within the home are held throughout the year, usually on an informal basis after lunch when the majority of residents are together. The manager holds personal spending money for some residents and these records were checked. Records show that health and safety issues are attended to with regular maintenance of fire equipment and training. The accidents and deaths rates at the home showed no abnormalities. Risk assessments for individual residents were seen in care plans, with general assessments of the homes policy and procedures to ensure the safety of the staff as well as residents. Comments received from the ten comment cards confirmed that the home is managed in an open and friendly manner by the manager and proprietors with one of them in attendance on most days. St Edmunds DS0000027497.V352668.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 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 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 2 x 3 x 3 2 x 3 St Edmunds DS0000027497.V352668.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 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. The manager must formalise staff supervision for the ongoing development of staff. Timescale for action 30/12/07 2 OP36 18.2 30/12/07 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 OP7 Good Practice Recommendations Care plans should be stored in individual folders to allow easier access for residents if they wish to read them. St Edmunds DS0000027497.V352668.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 DS0000027497.V352668.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. 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. 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