Inspection on 13/11/06 for The Eadmund

This inspection was carried out on 13th November 2006.

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 found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Eadmund 08/01/08

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 The Eadmund 68 & 70 Brighton Road Coulsdon Surrey CR5 2BB Lead Inspector Barry Khabbazi Key Inspection – 1 Announced and 1 Unannounced visit. 13th and 14th November 2006 9:00am The Eadmund DS0000067667.V319224.R01.S.doc Version 5.2 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 The Eadmund DS0000067667.V319224.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 Adults 18-65. 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. The Eadmund DS0000067667.V319224.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Eadmund Address 68 & 70 Brighton Road Coulsdon Surrey CR5 2BB 020 8645 2680 020 8668 6656 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) Nellben Limited Mrs Sara Louise Lock Care Home 15 Category(ies) of Learning disability (11), Physical disability (4) registration, with number of places The Eadmund DS0000067667.V319224.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: The Eadmund is a residential care home for adults with learning disabilities. The home is also registered to provide a service to people who also have a physical disability, and has a number of built in adaptations to facilitate this. There is level access to the front entrance and rear of the building. In those bedrooms identified for the use of people with disabilities there are wider than normal automatic opening bedroom doors, remote opening windows, freemoving tracking hoists in bathrooms, and electrical outlets at a level that that can be accessed from a wheel chair. There is also a height adjustable work surface in the kitchen. The Eadmund is comprised of two semi-detached houses with a shared drive affording a number of parking spaces. The home is situated in Coulsdon between the town centre and Purley, and facilities from both these areas are therefore within a few miles. The home is registered to provide a service to up to 15 people within the two buildings. All bedrooms are single with en-suite facilities and many also contain their own shower. Bedrooms either meet or exceed the room size standard of 12 sq. metres. Each of the two buildings that comprise the home have their own garden, lounge, dining room and kitchen, as well as a quiet area. The home has recently been renovated, and as a result is newly refurbished and re-decorated throughout. There is also an accessible patio in each garden which takes up about one quarter to one third of the garden. The rest of the garden to each building is raised and not currently fully accessible. The fees currently start at £1600 per week The Eadmund DS0000067667.V319224.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection for this new home and the inspection was therefore announced to allow the managers and Director to be present to facilitate the more detailed first inspection required for a new home. To compare how the home performs when not expecting an inspection, a brief surprise unannounced visit was also conducted the following day. This inspection report refers to information gathered on both those occasions. Our inspections currently focus on the key standards, but as this was a new home and to some extent an unknown quantity, other non key standards were also inspected on this occasion. It was also not possible to fully assess a number of standards as many of the home’s practices had not occurred for a sufficient period to provide the level of evidence required. For example staff appraisals can not occur until they have been employed for one year. These areas affected by the newness of the home are clarified in the report. At this inspection records, policies, risk assessments, complaints, protection systems, care plans, and the building were examined, as were the residents’ bedrooms. The registered manager and Director were interviewed. Only two residents had been placed by the time of this inspection, one of whom was away. The resident present appeared happy and relaxed with the staff and the home. As this was the first inspection, the Commission’s service user and relative surveys were not available, however the manager did present two letters from relatives which contained only positive comments, these relatives have given their permission for me to use this information in this report. The extracts below have been modified slightly as follows, to protect confidentiality: 1, we feel that we are all friends with the staff, yet there is always respect shown when we visit, our relative is encouraged to participate in as many activities as possible, we have not seen our relative as happy and relaxed for a long while, The manager is to be congratulated for ensuring that staff encourage my relative to help themselves as much as possible whilst being lovingly looked after. 2, I am really pleased with the home, the staff are fantastic, My relative is going from strength to strength, the staff are caring, when I visit my relative I can see they are really enjoying their new home life and are very well cared for. There are 4 requirements and 4 recommendations in this report. It was reassuring to see that the manager had started to address these areas before the end of the inspection period. At this inspection the home was found to be very well set up and to a high standard, with lots of potential for many of the current practices to result in positive outcomes for the residents. The building is suitable, and although some changes to policies and procedures have been identified as needed, the majority of policies and procedures had generally been well thought out. The Eadmund DS0000067667.V319224.R01.S.doc Version 5.2 Page 6 What the service does well: 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. The Eadmund DS0000067667.V319224.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Eadmund DS0000067667.V319224.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards: 1, 2, 4, and 5. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home provides most of the information needed for potential residents to make an informed decision about moving in to the home. Prospective residents needs are assessed so that they are known to staff and can be met. Prospective residents have the opportunity to visit the home before moving in so they can see what it would be like to live there. Each resident has a contract to define their rights as a resident. EVIDENCE: The Eadmund DS0000067667.V319224.R01.S.doc Version 5.2 Page 9 {The judgement of adequate for this area has also been affected by the lack of time this home has been operating. For example the residents’ views required in the service users guide could not have been recorded as residents were not previously living at the home to provide a view.} This home does have a Statement Of Purpose and a text and a pictorial Service Users Guide that are well laid out, and contain almost all of the elements required under Standard 1. The one element missing are the views of the residents. Quality assurance questionnaires have been produced and once the quality assurance annual cycle has occurred these should provide the residents views in a suitable manner. These can then be transferred to the service users guide. As the home has only just started to provide a service, the quality assurance system has not existed long enough to gather the residents’ views. In addition only two residents are placed at this time and have only been placed for a short period of time. As all the systems required are in place and it is too soon for these systems to bear fruit, a requirement would not achieve the desired outcome at this stage. The home is therefore reminded only at this time to transfer the views of the residents to the service users guide once they are available. Both the service users placed had a care plan and assessment from their placing authority as required under Standard 2. Initial six week reviews had also occurred. The home is reminded that 6 month reviews will be eventually required and one of those will need to be conducted by the home themselves. The home also conducts its own assessments which is not required under Standard 2 for funded placements but is advisable. Standard 3 requires staff to have received specific training to meet the specific and individual needs of the service user group. For example Brain Injury training if the home admitted resident with this condition. As there only two people have been placed so far and not for very long, it was not possible to see if the staff had all the skills to meet the potential range of needs presented once the home is more fully filled. Standard 3 will therefore be more fully assessed at a future inspection. However it is recognised that some evidence that the needs of the two people placed were being met was presented at this inspection. The current two residents were offered trial visits with a flexible duration based on their needs and choice. These included an opportunity to sample meals and stay overnight. This meets the requirements under Standard 4. The potential service user was first visited in their own home. They then visited the home as described above. Once placed the placement is then reviewed following a 3 month settling in period. Relatives are also involved in the process. Emergency admissions are not accepted. The Eadmund DS0000067667.V319224.R01.S.doc Version 5.2 Page 10 As required under Standard 5, each resident has a contract. However, contracts did not contain reference to the identified room to be occupied. The following recommendation is now set to address this: Contracts should contain reference to the identified room to be occupied. The Eadmund DS0000067667.V319224.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7, 9, and 10. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Care plans need to contain all the elements required, and in particular cultural and religious needs. This is needed to ensure all needs are known to staff and can therefore be met. Residents make decisions about their own lives with support as needed. Minor restrictions of liberty or pre-planned restraints are occuring without being fully recorded and evidenced {e.g. cotsides}. This could perpetuate unnecessary restrictions of liberty for the residents, and leave the home in a vulnerable legal position if they are challenged. Residents know that information about them is handled in a manner that will protect their confidentiality. EVIDENCE: The Eadmund DS0000067667.V319224.R01.S.doc Version 5.2 Page 12 The home’s care plans are called ‘Action Plans’. Each sheet covers a particular area required under Standard 6 and is followed by a basic risk assessment on the same sheet of paper. Care plans were available for all residents but they did not all record all of a resident’s needs and how these are to be met and in particular cultural and religious needs. The following requirement is now set: Care plans must contain all the elements required under Standard 6, namely those set out under Standard 2.3. and in particular cultural and religious needs. There was evidence in relatives’ letters and from records and observation that residents are encouraged to make decisions about their own lives with support as needed as required under Standard 7. { See the summary for relatives’ comments.} Standard 8 – ‘consultation’ was not assessed on this occasion as the home has not operated long enough to provide sufficient evidence in this area for the inspector to reach a judgment. However, systems are in place for consultation and have started, for example residents meetings. A little more time is required to fully assess this area in practice. In addition, although the service user guide and complaints procedure had already been made more accessible, all the other lesser resident relevant policies will be examined for accessibility at the next inspection, for example access to files policies. Minor restrictions of liberty or pre-planned restraints are occuring without being fully recorded and evidenced, which could perpetuate unnecessary restrictions of liberty for the residents, and leave the home in a vulnrable leagal position if they are challanged. As stated under Standard 6, a basic risk assessment is recorded at the bottom of care planning sheets. The risk assessment form does not contain the information required under Standard 9.4, in particular details of how training and other options have been explored before any restrictions of liberty are applied, and the involvement of relatives or independent advocates. The following requirement is therefore now set: Risk assessments must be produced where any restrictions of liberty or pre-planned restraints are assessed as necessary for the protection of service users. These risk assessments must also contain details of how training and other options have been explored before any restrictions of liberty are applied, and the involvement of relatives or independent advocates. All the elements under Standard 10 were in place. The home has a confidentiality policy and procedure. It is the home’s policy for information not to be shared with service users’ friends or relatives when this is against the service users’ wishes. The home has an Access to Files Policy. The Eadmund DS0000067667.V319224.R01.S.doc Version 5.2 Page 13 Residents files and documents were sampled and observed to be kept in a filing cabinet that can be locked when not in use. Staff files were also locked in a filing cabinet that only the manager holds a key for. The Eadmund DS0000067667.V319224.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards; 13, 14, 15, 16, and 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents have the opportunity to be part of the local community and are able to take part in appropriate activities and holidays. This promotes inclusion and quality of life. Residents are supported in maintaining appropriate relationships, so that their social lives are maximised within chosen boundaries. Residents rights are respected and responsibilities recognises. The food provided is sufficient in quantity, and it is sufficiently nutritious which is important to ensure good health. EVIDENCE: The Eadmund DS0000067667.V319224.R01.S.doc Version 5.2 Page 15 {The judgement of adequate for this area has been also affected by the lack of time this home has been operating. Only two residents have been placed so far and then only recently. In addition to this making Standards 11 and 12 difficult to assess, there was less evidence of a range of activities to meet the various individual needs and wishes of a group of residents.} Standard 11 refers to a resident’s progress in maximising personal development and independence. The home has not operated long enough for residents to have progressed sufficiently to accurately measure progress in maximising personal development and independence. It is recognised however that systems and practices are in place to potentially facilitate this process. This standard will therefore be looked at, at a future inspection where it can be more accurately assessed. Standard 12 examines education and employment. None of the current two residents are currently in work related schemes. Basic money awareness training occurs where required during shopping trips. Opportunities for education are also promoted through local educational resources. For example art and computer courses. As with the previous standard, the home has not operated long enough and does not yet have sufficient residents to fully evidence practice under this standard. This standard will therefore also be looked at, at a future inspection where it can be more accurately assessed. Access to the local community is assisted by the home having its own transport which can accommodate wheelchairs. Venues like the local, parks, restaurants, cafes, church, and shops are accessed. Staff are available to support service users while accessing the community and this occurs in the evenings as well as during the daytime and at weekends. This was strongly confirmed by relatives’ letters to the home. Please see the summary for details. Trips out are currently occurring daily and at weekends. The residents are offered a seven-day holiday paid for by the home as part of the contracted price. There is an open visitors policy. Visitors can be seen in any of the homes communal areas as well as the service users bedrooms. Family and friends are invited to any social events held at the home as well as reviews. The relatives letters {see summary} commented positively about being kept informed of their relative’s progress at the home. Personal and sexual relationships are supported where appropriate and residents are protected from inappropriate relationships where legally identified as needed. The house rules and daily routines are as flexible as possible, bearing in mind the weekday commitments of the service users. At the weekends there is more The Eadmund DS0000067667.V319224.R01.S.doc Version 5.2 Page 16 flexibility with breakfast and bedtimes. Service users are encouraged to help out with some household tasks such as clearing the table or taking out the bins. The service users are given a choice of having keys to their bedrooms and the front door of the home. The service users that have not taken up this option have the reasons are recorded on their personal files. It is the home’s policy not to enter a service user’s room alone when they are not there. Pets are allowed subject to risk assessment and agreement of the service user group and manager. It is the home’s philosophy to promote independence and individual choice, and the daily routines and house rules do generally promote this. For example there are no ‘bath times’ or getting up times to suit staff. All service users can have keys for their own rooms, and those that can access the lock can have keys for the front door. Staff were observed to talk to residents and not exclusively with each other. Residents can choose when to be alone or when to have company. Staff enter bedrooms only following the resident’s permission. Meals preparation and eating areas were clean and congenial settings. This was also the case on the unannounced visit. Meals are unrushed and service users can take as much time to eat, as they want. Meals are regular and appeared nutritious. Residents have been involved in design the menus are able to take meals at flexible times and are also able to choose alternatives. Snacks and drinks are available at all times. Food preferences were recorded from and nutritional monitoring and dietician support occur where required. The Eadmund DS0000067667.V319224.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19, and 20. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Personal care is carried out in a way that residents prefer so that dignity and choice are maintained. Residents’ physical health needs are met by this home. This ensures that the residents’ physical health is well maintained and therefore the quality of life experienced is also maximised. Residents’ medication is not well managed as staff have not had approved and accredited medication administration training. This is required to promote safer medication administration. EVIDENCE: The service user group all need assistance with their personal care and where possible a person of the same sex offers support with personal care. Personal care is provided in private, and timings of this are also flexible, for example residents can have a bath when they are not booked in for this. The home operates a key worker system, which takes into account the wishes of the resident. The Eadmund DS0000067667.V319224.R01.S.doc Version 5.2 Page 18 Residents have access to relevant professional support to maximise independence, including physiotherapists, occupational therapists and speech therapists. Residents have aids and adaptations to assist general independence - see Standard 29 for details. residents choose their own clothes and staff support with shopping for personal items of clothing or toiletries where required. Residents are supported to attend regular health checks, outpatient appointments and other medical appointments as required. All residents have regular medical reviews. Systems and practice to facilitate access to chiropody, dentists and audiologists was demonstrated. Evidence was seen of regular monitoring of residents health. Residents have a choice of G.P and can retain their original G.P. Residents are encouraged to administer their own medication where possible, and they have a lockable space in their rooms to facilitate this. Medication is only provided through the G.P and prescriptions are sought for homely remedies to ensure secure record keeping and insure against combining medication in a haphazard way. Medication is stored securely in a lockable cabinet fixed to the wall. System to record controlled drugs are in place although there are currently no residents requiring this at this home. There were no records of the service users’ consent to medication. The following recommendation is set to address this shortfall. Consent to medication should be sought from the service users. Where verbal consent is not possible, the home must obtain this through the use of independent advocates. Any advocated view of non-consent must also be recorded. Staff have received guidance from the manager regarding medication administration but have not received approved and accredited medication administration training. Once pointed out the manager was happy to set up this training with the pharmacist. The following requirement is now set to address this current shortfall: All staff who administer medication must have approved and accredited medication administration training. This has been highlighted as a priority requirement for the home to urgently implement. The Eadmund DS0000067667.V319224.R01.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents feel their views are listened to and acted upon. The home’s policies and procedures relevant to this Standard generally facilitate protecting service users from abuse. EVIDENCE: There had been no official complaints made to the home or the Commission. The complaints procedure was clear and contained all of the elements required to meet Standard 22 including a minimum response time of less than 28 days and details of how to contact the Commission. The complaints procedure had been also translated into a text and pictorial format. Policies were observed that protected the service users, and records were in good order. The home has a Restraints Policy, a Whistle Blowing Policy, a Gifts/Gratuities Policy, and a copy of the Local Authority Adult Protection Procedure on site. These were all suitable and met the National Minimum standards except there were elements missing from the gifts policy and the restraint policy. The Gifts Policies did not include a directive to staff precluding them from being involved in the making of, or from supporting residents in making wills. The following recommendation is therefore set: The home’s policies should include a directive to staff precluding them from being involved in the making of, or from supporting residents in making wills. The Eadmund DS0000067667.V319224.R01.S.doc Version 5.2 Page 20 The restraints policy starts from a good position, i.e. we do not restrain. However it needs to be expanded to give staff guidance about how to restrain a resident safely {and then record the incident} where the home’s duty of care requires them to restrain to protect the resident or other residents from harm. The following requirement is therefore set to address this: The restraints policy must be expanded to give staff guidance about how to restrain a resident safely {and then record the incident} where the home’s duty of care requires them to restrain to protect the resident or other residents from harm. The Eadmund DS0000067667.V319224.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards, 24, 25, 26, 27, 28, and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents live in a homely and generally safe environment The environment and furniture met the residents’ needs, and the environment promotes the residents well being. The toilets and bathrooms exceed the minimum number required and are suitably varied in accessibility location and type. This therefore provides more facilities for the residents and therefore more privacy, dignity and independence. The home is particularly hygienic and clean, and comfortable. This environment therefore facilitates the residents’ health and emotional wellbeing. EVIDENCE: The Eadmund DS0000067667.V319224.R01.S.doc Version 5.2 Page 22 {The judgement of good for this area has been also affected by the lack of time this home has been operating. For example maintaining the home to a good standard was not possible for the home to evidence as it has only recently opened. In addition Standard 29 could not be fully assessed – see that standard for details} The home has a maintenance book which records when an item requiring repair has been identified and when that work occurred. The home’s premises were accessible and in keeping with the local community. At the time of the inspection the premises were newly decorated in an appropriate style. The grounds were observed to be well kept and mostly accessible. The premises were bright, airy and clean, and free from offensive odours on both the announced and unannounced parts of this inspection. There was suitable lighting and ventilation. The premises were wheelchair accessible on the ground floor. See also brief description of services for further details. Bedrooms all met or exceeded the 12 sq.m required and had been personalised by the residents. There are no shared communal bedrooms at this home. There are hand basins with thermostatic mixer valves and toilets in all of the service users’ bedrooms. Many also have their own shower. Automatic fire door closing devises are fitted to fire doors. Each of the two buildings that comprise the home have their own garden, lounge, dining room and kitchen, as well as a quiet area. The home has recently been converted for the purpose of providing care and as a result is newly refurbished and fully re-decorated throughout. There is also an accessible patio in each garden which takes up about one quarter to one third of the garden. The rest of the garden to each building is raised and not currently fully accessible. The home has 2 baths and 3 toilets in each of the two buildings. All baths are controlled by thermostatic mixer valves. In addition temperatures are tested with a thermometer at the time of bathing and these temperatures are recorded. Good practice under Standard 27. Many bedrooms have their own shower in addition to the toilet and washbasin required by the National Minimum Standards. There are 11 out of 15 bedrooms with a shower in the bedroom en-suite facility. The Eadmund DS0000067667.V319224.R01.S.doc Version 5.2 Page 23 Standard 29 ‘aids and adaptations’ will not be assessed on this occasion. Although the home has had many general aids and adaptations fitted as standard {see ‘brief description of service’ for details}, this standard also addresses individual and specific needs for aids and adaptations based on the specific disability of individual residents. This may for example include things like lowered chairs, oversize TV remotes, a talking microwave, a ‘light’ flashing alarm, a talking book audio tape player, a loop system etc., dependant on need. This standard will therefore be more fully assessed at a future inspection when a range of residents have been placed, and for a reasonable period of time, so that the home’s effectiveness at meeting their individual access needs can be better assessed. The Eadmund DS0000067667.V319224.R01.S.doc Version 5.2 Page 24 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 31, 32, 34, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from clarity of staff roles. The residents are supported by staff that are currently qualified to a higher level than required. This raises the quality of staff, their knowledge and their practices. The home’s recruitment procedures protect the residents through vigorous staff vetting. The staff are well supervised and receive supervision EVIDENCE: {The judgment of this area could move to ‘excellent’ once the home has been operating long enough for the current good practices to have achieved measurable positive outcomes for the residents.} The Eadmund DS0000067667.V319224.R01.S.doc Version 5.2 Page 25 Staff demonstrated an understanding of individual user’s needs and an ability to understand the different speech patterns, body language, and gestures. Staff were observed to be acting within their roles and demonstrated an understanding of others’ roles. Staff all have job descriptions and are provided with copies of the General Social Care Council code of conduct. Currently 4 out of the 9 staff have a NVQ 2. As there are more full time staff in the NVQ group this represents practically 50 of the staff group. This will be currently accepted as meeting the standard, as it is only a slightly below the 50 required under Standard 32, the home and it’s NVQ programme are new, and this is supported by the good practices identified below. Good practice under Standard 32. 1,The home has not stopped at the NVQ 2 required, two staff have a NVQ 3 and one has a NVQ 4. 2, Staff working towards their NVQ 2 is mandatory at this home. Standard 33 could not be assessed at this time. All night staff are waking. This means no sleep in room is required. Staffing is currently only 2 staff at all times day and night as only two service users are currently present out of a possible 15. The inspector agreed to this temporary reduction but the home is reminded to consult the Commission regarding staffing changes to those agreed at registration. Until the home is fuller it will not be possible to assess the staffing against the accumulated individual level of need of the residents placed. The staff files sampled contained all the recruitment checks required under Standard 34 including Criminal Record Bureau checks. The manager wanted to know if they could be destroyed following their purpose being met {which includes inspection}, I suggested that if the manager did want to destroy the CRBs following inspection, a list containing reference numbers names and dates should be set up which is signed once vetted by the home and signed by the inspector once checked by the inspector. Once seen and signed for these could then be destroyed with only new CRB disclosures then kept until seen by the inspector. Standard 35 refers to 6 weeks staff induction and then 6 months foundation training to Skill Sector Council workforce training targets. This could not be fully assessed as the home has not been operating long enough for the above process to have occurred. This area will therefore need to be assessed at the next inspection. Good practice under Standard 36. Supervision sessions occur every six weeks which is 50 more often than the minimum required under the National Minimum Standards. The Eadmund DS0000067667.V319224.R01.S.doc Version 5.2 Page 26 This should provide a better supervised workforce. The Eadmund DS0000067667.V319224.R01.S.doc Version 5.2 Page 27 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 37, 39, 40, 41 and 42. Quality in this outcome area is adequate, This judgement has been made using available evidence including a visit to this service. Service users benefit from a well run home and appropriately qualified management. The home’s quality assurance system that once fully implemented could involve the residents and relatives, and provide feedback to them, to allow them to be involved in improvements and measure improvements in the home for themselves. All the testing of systems required at this stage were present but the annual testing required could not have occurred yet as the home has not been running for a year yet. EVIDENCE: The Eadmund DS0000067667.V319224.R01.S.doc Version 5.2 Page 28 {The judgement of adequate for this area has been also affected by the short time this home has been operating. For example annual maintenance checks could obviously not be evidenced yet. } The manager has in addition to the required NVQ 4 Registered Managers award, a NNEB Nursery Nurse qualification, an NVQ assessors award, a City and Guild 3253 in Advanced Care Management, and a post graduate diploma. The manager has a job description that supports her role and has ensured that licences, registration certificates, insurance details, and the health and safety at work poster is displayed. Standard 38 could not be properly assessed at this time as the home has not been operating long enough for the manager’s ethos to be fully expressed in the home and its staff. However, from what was seen it is expected that the manager’s ethos will create an open, positive and inclusive atmosphere. The quality assurance tools currently include residents and relative satisfaction surveys, residents meetings, auditing, one to one discussions, inspections, Regulation 26 visits, and a complaints system. There was however no current annual development plan. The following recommendation is therefore set under Standard 39. An annual development plan should be produced, and once the quality assurance system has been completed for this financial year, the relevant results and any following action points should be recorded in this document. Standard 40 refers to the policies required by the home. These range of policies required was recently checked by the registration inspector and therefore not re-checked in their entirety at this inspection. However, specific policies were checked for appropriate content at this inspection and were found to be well thought out and generally contained all the information needed. This is recorded under the relevant standard to the policy concerned. Where gaps were present this has also been identified under the specific standard. See Standard 23 ‘protection’ for details. Shortfalls under connected standards regarding policies will therefore also affect this standard. Service users’ medical and care records were sampled and were observed to be up to date, in good order, comprehensive, and held in a secure manner as required under standard 41. There is an Access to Files Policy and the home encourages service users to help maintain their own records through contributing to their individual plans at reviews. The Director completes monthly Regulation 26 visits and these have now been passed to the Commission. The Eadmund DS0000067667.V319224.R01.S.doc Version 5.2 Page 29 Control Of Substances Hazardous to Health policies and data sheets were available. Items included in the Care Homes Regulations, Schedules 1-4 are kept securely in the home. Criminal Record Bureau checks are only accessible to the registered manager and Directors. All of the health and safety policies and procedures relevant to this standard have been seen to be present. Moving and Handling, Fire Safety, First Aid, Food Hygiene, Infection Control, and Handling and Disposal of Clinical Waste policies are all also included in staff induction. This area has been also affected by the short time this home has been operating. For example annual maintenance checks and the testing of systems required in Standard 42 could obviously not be fully evidenced yet. However, initial checks were in place, for example portable appliance testing. The Eadmund DS0000067667.V319224.R01.S.doc Version 5.2 Page 30 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 2 3 3 3 4 x 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 x 30 2 3 x 2 3 3 LIFESTYLES Standard No Score 11 x 12 x 13 3 14 3 15 3 16 3 17 STAFFING Standard No Score 31 3 32 3 33 x 34 3 35 x 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 x 3 x 3 x 2 3 3 Version 5.2 Page 31 The Eadmund DS0000067667.V319224.R01.S.doc 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 YA6 Regulation 15 Requirement Timescale for action 01/01/07 2. YA9 3 4 YA20 YA23 Care plans must contain all the elements required under Standard 6, namely those set out under Standard 2.3. and in particular cultural and religious needs. 17[1]a 13[7] Risk assessments must be produced where any restrictions of liberty or preplanned restraints are assessed as necessary for the protection of service users. These risk assessments must also contain details of how training and other options have been explored, and the involvement of relatives or independent advocates. 13[2] All staff must have approved and accredited medication administration training. 17[1]a 13[7] The restraints policy must be expanded to give staff guidance about how to restrain a resident safely {and then record the incident} where the home’s duty of care requires them to restrain to protect the resident or other residents from harm. DS0000067667.V319224.R01.S.doc 01/01/07 15/12/06 01/01/07 The Eadmund Version 5.2 Page 32 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 3 4 Refer to Standard YA5 YA20 YA23 YA39 Good Practice Recommendations Contracts should contain reference to the identified room to be occupied. Consent to medication should be sought from the service users. The home’s policies should include a directive to staff precluding them from being involved in the making of, or from supporting residents in making wills. An annual development plan should be produced and once the quality assurance system has been completed for this financial year, the relevant results and any following action points should be recorded in this document. The Eadmund DS0000067667.V319224.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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. 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