Care Home: St Edburgs House

Similar services:

• St Vincents
• Hamilton House
• The Cotswold Home
• Winton House

What the care home does well Prospective residents are given information that will help them make an informed choice about whether to live at the home.There is a clear and detailed assessment process, to ensure that all prospective residents care and support needs are assessed. The process ensures that the service is able to meet people needs before they move in. Care and support plans are based on detailed assessments of peoples needs and support the good quality care provided by staff. People are treated with dignity and their right to privacy is upheld. The people who live at the home are also enabled to take risks, in order that they are as independent as possible. The home has an activity programme in place to ensure that individuals` social and recreational interest and needs are catered for. People are supported to exercise choice and control over their lives. Visitors are welcome to visit at any time this ensures that individuals maintain contact with their families and friends. People are offered a number of menu choices, in order that nutritional needs are met. Personal and healthcare needs are appropriately supported. Staff provide personal support in ways, which people prefer, in order that their needs are best met. Staff clearly promote individuals` physical and emotional health, to keep them healthy and well. Access to additional support from health care professionals is consistent and meets health needs. A number of people told us about the quality of support they receive, "I spent a day at St.Edburgs beforehand and didn`t want to leave! I was thrilled that I was able to come here to live permanently." "The staff are caring and supportive...the staff are the best...the staff definitely listen and act on what I say." "St.Edburg`s provides wonderful care and each and everyone of the staff ensures that all residents are treated with the highest respect and dignity." "They provide a consistently high level of care in a calm and sympathetic atmosphere...I think St.Edburgs relates very well to associated professional and voluntary groups they deal with." "Food is good here, the food is what older people want... I don`t like fancy stuff, you know what younger people like...We love stews and casseroles, roast dinners, fish and chips." Needs arsing from equality and diversity are well met. From the evidence seen, we consider that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs.St Edburgs HouseDS0000036415.V358025.R01.S.docVersion 5.2Page 7The storage and administration of medication ensures the protection of individuals. Medication practice is well managed at the home, to ensure that health and well being are promoted. A clear complaints process is available to the people who live at the home and their representatives. Protection of the people who live at the home is assured by the availability of adult protection guidance, appropriate training and staff awareness. A pleasant and comfortable environment is provided for the people who live at St. Edburgs. People`s bedrooms reflect individuality. The home is clean and hygienic, continuing to guard against the risks of infection and ill health. Staff are attentive and respectful promoting communication and independence in relation to need. Competent and qualified staff work at the home. Training provided to staff ensures that they qualified to meet individual needs. Staff records indicate that the recruitment process generally ensures the protection of the people who live in the home. The manager has a good understanding of the needs of the people who live at St.Edburgs, providing leadership; guidance and direction to staff to ensure people who live in the home receive consistent and good quality care. The home is well managed and run in the best interests of the people who live in the home. People who live in the home are protected from financial abuse by the homes policies and procedures. Health and safety systems ensure that the people who live and work in the home are protected from harm. What has improved since the last inspection? Pre-admission information relevant to the ongoing care of people who move to the home is now transferred to the care plans to ensure that individuals needs can be met at all times. CARE HOMES FOR OLDER PEOPLE St Edburgs House Old Place Yard Church Lane Bicester Oxfordshire OX26 6AS Lead Inspector Nancy Gates Unannounced Inspection 29th February and 3rd March 2008 1:30 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 Edburgs House DS0000036415.V358025.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 Edburgs House DS0000036415.V358025.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Edburgs House Address Old Place Yard Church Lane Bicester Oxfordshire OX26 6AS 01869 252343 01869 250403 manager.stedburgs@osjctoxon.co.uk www.oxfordshire.gov.uk The Orders Of St John Care Trust 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) Andrea Woods Care Home 40 Category(ies) of Dementia - over 65 years of age (18), Old age, registration, with number not falling within any other category (40), of places Physical disability over 65 years of age (1) St Edburgs House DS0000036415.V358025.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The total number of persons that may be accommodated at any one time must not exceed 40. As vacancies arise the PD/E category will be removed. The continued registration of this service past April 2007 is dependent upon the physical environment meeting standards. 12th December 2006 Date of last inspection Brief Description of the Service: . St Edburgs is situated in the centre of the market town of Bicester. It is a care home providing support for older people who do not require nursing care. The home itself was built some time ago and, as such, the design was dictated by the principles of that time. As a result, the building provides people with small rooms, double rooms and a lack of en-suite facilities. However, the managers and staff make the best of the environment and endeavour to make it as homely and comfortable as possible. The home is owned and managed by The Orders Of St John Care Trust, which is a large charitable organisation. As the home no longer meets the current spatial standards as set out in the Care Homes Regulations, a new home is to be built in another part of the town to address these issues. It was anticipated that the move to new premises will take place sometime in 2007, but issues with the identified site for the new home has prevented the start of building works Information regarding the services offered is available from the home on request. The fees for care range from £600.00 - £650.00 per week. Items not covered by fees include, chiropody, hairdressing, visits from the beautician and newspapers. St Edburgs House DS0000036415.V358025.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. The inspection of the service was a surprise visit and was a ‘key inspection’. We arrived at the service at 1.30 a.m. on a weekday and returned on the following day at 10.00 a.m. The total number of hours spent at the home was 9 hours. The time spent at the home allowed for a thorough look at how well the service is doing. The inspection took into account detailed information provided by the registered manager, the Annual Quality Assurance Assessment and took into account information that CSCI has received about the service since the last key inspection in December 2006. We asked for the views of twelve people who live at the home and also asked the views of others who support the needs of the people who use the service via a questionnaire/survey that we sent out. Fifteen surveys were returned to us, twelve from the people who live at the home, one from relatives/carers/advocates and two from health and social care professionals (care managers, health professional’s and GP’s.). All information we have received from the surveys and information we have received since the last inspection, about this service was taken into account when producing the key inspection report. Staff and the people who live at St. Edburg’s House were very welcoming. Discussions with six people who live in the home, four staff members, and the registered manager took place within the site visit. We looked around the home including the bedrooms of individuals at their invitation. A number of records were viewed including individuals care plans, staff recruitment records, staffing rotas and maintenance/health and safety records. We looked at how well the service was meeting the standards set by the government. The report includes judgements about the standard of the service. What the service does well: Prospective residents are given information that will help them make an informed choice about whether to live at the home. St Edburgs House DS0000036415.V358025.R01.S.doc Version 5.2 Page 6 There is a clear and detailed assessment process, to ensure that all prospective residents care and support needs are assessed. The process ensures that the service is able to meet people needs before they move in. Care and support plans are based on detailed assessments of peoples needs and support the good quality care provided by staff. People are treated with dignity and their right to privacy is upheld. The people who live at the home are also enabled to take risks, in order that they are as independent as possible. The home has an activity programme in place to ensure that individuals’ social and recreational interest and needs are catered for. People are supported to exercise choice and control over their lives. Visitors are welcome to visit at any time this ensures that individuals maintain contact with their families and friends. People are offered a number of menu choices, in order that nutritional needs are met. Personal and healthcare needs are appropriately supported. Staff provide personal support in ways, which people prefer, in order that their needs are best met. Staff clearly promote individuals’ physical and emotional health, to keep them healthy and well. Access to additional support from health care professionals is consistent and meets health needs. A number of people told us about the quality of support they receive, “I spent a day at St.Edburgs beforehand and didn’t want to leave! I was thrilled that I was able to come here to live permanently.” “The staff are caring and supportive…the staff are the best…the staff definitely listen and act on what I say.” “St.Edburg’s provides wonderful care and each and everyone of the staff ensures that all residents are treated with the highest respect and dignity.” “They provide a consistently high level of care in a calm and sympathetic atmosphere…I think St.Edburgs relates very well to associated professional and voluntary groups they deal with.” “Food is good here, the food is what older people want… I don’t like fancy stuff, you know what younger people like…We love stews and casseroles, roast dinners, fish and chips.” Needs arsing from equality and diversity are well met. From the evidence seen, we consider that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. St Edburgs House DS0000036415.V358025.R01.S.doc Version 5.2 Page 7 The storage and administration of medication ensures the protection of individuals. Medication practice is well managed at the home, to ensure that health and well being are promoted. A clear complaints process is available to the people who live at the home and their representatives. Protection of the people who live at the home is assured by the availability of adult protection guidance, appropriate training and staff awareness. A pleasant and comfortable environment is provided for the people who live at St. Edburgs. People’s bedrooms reflect individuality. The home is clean and hygienic, continuing to guard against the risks of infection and ill health. Staff are attentive and respectful promoting communication and independence in relation to need. Competent and qualified staff work at the home. Training provided to staff ensures that they qualified to meet individual needs. Staff records indicate that the recruitment process generally ensures the protection of the people who live in the home. The manager has a good understanding of the needs of the people who live at St.Edburgs, providing leadership; guidance and direction to staff to ensure people who live in the home receive consistent and good quality care. The home is well managed and run in the best interests of the people who live in the home. People who live in the home are protected from financial abuse by the homes policies and procedures. Health and safety systems ensure that the people who live and work in the home are protected from harm. What has improved since the last inspection? What they could do better: The home is due to be relocated to a purpose-built site, however the new build remains at the early stages of the project due to problems with the ground works on the site. The manager was not able to confirm when the building works are due to start and cannot provide a date for completion to the people living in the home. St Edburgs House DS0000036415.V358025.R01.S.doc Version 5.2 Page 8 A relative commented that, “A note once a quarter on the progress of the new home would be useful.” Timescales for the start and estimated completion of the new home should be established or a decision should be made as to whether the project will continue to ensure that people are regularly informed about the future of their home. The required staff recruitment information must be held on staff files for the protection and safety of the people who live in the home 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 Edburgs House DS0000036415.V358025.R01.S.doc Version 5.2 Page 9 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 Edburgs House DS0000036415.V358025.R01.S.doc Version 5.2 Page 10 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&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are given information to help them make an informed choice about the service. The home has an assessment procedure to ensure that prospective residents’ needs are assessed and that the home can meet those needs. EVIDENCE: Admission to the home is not agreed until an assessment of prospective residents needs is completed with the individual, their representatives and health and social professionals. Where possible prospective residents are invited to spend some time at the home, for a meal or an overnight stay to help them decide if it is somewhere they would like to live. One person told us, “I spent a day at St.Edburgs beforehand and didn’t want to leave! I was thrilled that I was able to come here to live permanently.” St Edburgs House DS0000036415.V358025.R01.S.doc Version 5.2 Page 11 Admissions are not made to the home until a full needs assessment has been completed and all parties agree that assessed needs can be met. A trial period is agreed to ensure that either party is sure that the service offered at the home suit the persons needs. We looked at the admission records for four people and they showed that a clear but detailed, standardised admissions process involving the individual and relevant professionals at all stages is completed. This ensures care needs are fully assessed before admission enabling the manager to decide whether the home can provide the support and care the person needs. Care plans are developed from all the available assessment information. Two people who live in the home told us that they or their family members/representatives had received enough information about the home to help them decide if it was the right place for them. They also told us that staff were very helpful and took time to make sure they understood what their individual support needs were before moving in. Whenever a new person moves to the home, the manager ensures that a dedicated member of staff supports the individual for the whole day of admission in an effort to reduce the persons’ level of anxiety and to allow the person to ‘settle in’ with constant support. This demonstrates that there is clear recognition of a person emotional support needs and potential anxiety and is considered good practice. Standard 6 is not applicable, as the home does not offer intermediate care. The current scale of fees for this service is £600.00 to £650.00 per week. St Edburgs House DS0000036415.V358025.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The personal and healthcare needs of the people who live in the home are appropriately recorded and supported. Needs, preferences and wishes are respected. Privacy and dignity is respected and confidentiality is protected. Access to additional support from health care professionals is consistent and meets individuals’ health needs. Medication is stored securely and administration is accurate, ensuring that health and well-being are promoted. EVIDENCE: We looked at the care plan files of five people who live at the home. Each file contained assessment information including care plans that describe peoples’ needs and ensure that staff have a clear understanding of those needs. St Edburgs House DS0000036415.V358025.R01.S.doc Version 5.2 Page 13 Care plans continue to be informative and include a short profile of an individuals back ground, their health and personal care needs, risk assessments, regular reviews and other information, which would enable staff to fully meet the needs of the individual. Health care needs continue are assessed and recorded appropriately, including details regarding specialist equipment supplied, visits by GP’s, district nurses and other healthcare professionals. A number of people who live in the home told us that they are were happy with the health care support provided at the home and also with the support provided to access the doctor or district nurse on a regular basis or in the event of an emergency. We also received very positive comments from a relative of an individual who lives in St.Edburgs, “..my mother has been unwell and without the love, care and attention she received by the staff…she would not have recovered.” Medication administration and recording is managed by the ‘care leaders’ and is of a good standard. Individuals are offered the option of managing the administration of their medication with support and after the completion of a risk assessment. Medication is stored within locked cabinets, at the correct temperature and within a medication room. A local pharmacist supplies the home with medication stored within a dispensing system; the pharmacist completes regular audits of medication to ensure that storage, administration and recording ensures the safety of the people who live in the home. All medication entering and leaving the home is recorded to ensure the safety of the people who live at the home. Medication administration records are supplied by the pharmacist to support accurate administration and recording. Recording is accurate, no omissions were noted. We took the opportunity to observe interaction between staff and the people they support to view how individuals’ privacy and dignity are upheld. Staff were observed to very respectful and promote privacy and dignity. People who live in the home also made the following comments about the support they receive. “The staff are caring and supportive…the staff are the best…the staff definitely listen and act on what I say.” “St.Edburg’s provides wonderful care and each and everyone of the staff ensures that all residents are treated with the highest respect and dignity. I would recommend the home to anyone who can no longer look after themselves, and I cannot praise enough the wonderful carers who make this such a happy place to live.” St Edburgs House DS0000036415.V358025.R01.S.doc Version 5.2 Page 14 A professional who visits the home also told us, “They provide a consistently high level of care in a calm and sympathetic atmosphere…I think St.Edburgs relates very well to associated professional and voluntary groups they deal with.” St Edburgs House DS0000036415.V358025.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are opportunities for people to participate in social activities giving people full and flexible choice in how they spend their day. Meals are well managed and provide people with choice and variety, ensuring that their likes and dislikes are catered for. EVIDENCE: The home has an activities co-ordinator, who has a good understanding of the complex and diverse needs of the people currently living in the home. People confirmed that they are happy with the variety of the activities offered and the opportunities to be involved both on a one to one basis, as a small or large group. Activity boards placed in a number of areas in the home detail weekly and regular activities/events; ‘Movement & music’, ‘Coffee morning – cakes and a natter’, ‘Arts and crafts’, ‘prize bingo’, ‘Movie & refreshments’. Sundays also offer people the opportunity to meet for pre-lunch drinks at 12.00. A ‘Men’s club’ is also available offering the opportunity to ‘join us in the lilac room for a St Edburgs House DS0000036415.V358025.R01.S.doc Version 5.2 Page 16 pint or two, offering darts, dominoes, chess, bagatelle, music from the military bands.’ ‘Residents’ meetings remain, are held regularly and are well attended. A number of people who live in the home remain fully active in the local community and manage their own affairs with little input from staff. People continue to be encouraged to maintain as much control over their lives as they are able or willing to do. People confirmed that they were able to fulfil their spiritual and cultural needs whilst living in the home. This was also evident from documentation viewed and discussions with and comments from relatives The home is open to receiving relatives, friends, and members of the local community. There are communal areas such as the main dining/activity room and small lounges that people can use to receive guests. People can also receive visitors in their own rooms. A choice of menu is available and displayed around the home. People are able to eat meals within a pleasantly decorated dining area or within the privacy of their own bedrooms. A variety of options are available and people are asked their preference for each meal. Salad and vegetarian options are provided and fresh fruit is made available. Special dietary requirements can be met if required. We received a number of positive comments about the food/menu choices that are offered. “Food is good here, the food is what older people want… I don’t like fancy stuff, you know what younger people like…We love stews and casseroles, roast dinners, fish and chips.” One person commented that they, “Don’t like having music always on during mealtimes, but it’s alright if it’s kept low.” St Edburgs House DS0000036415.V358025.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people who live in the home are provided with the information about how to complain, and are confident that their concerns will be listened to. The people who live in the home are protected from abuse as far as possible through the home’s adult protection guidance, appropriate training and staff awareness. EVIDENCE: We have not received any formal complaints or concerns about the service offered at the home since the last inspection in December 2006. The people who live in the home told us that they know how to complain, confirming that know where copies of the complaints procedure are held. A copy of the complaints procedure remains in place in the main entrance and other areas of the home. The procedure clearly explains the process and the timescales for response to a complainant. The home continues to receive many letters and cards of thanks from friends and family for the quality service provided to people who have resided in the home in the past. St Edburgs House DS0000036415.V358025.R01.S.doc Version 5.2 Page 18 A whistle blowing and a Safeguarding/Protection of Vulnerable Adults policy and procedure are in place. We looked at training records, which showed that staff have received training regarding the Protection of Vulnerable Adults. Staff confirmed that they have attended training and were able to describe how to respond to incidents or allegations of abuse. St Edburgs House DS0000036415.V358025.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A clean, safe and comfortable home is provided, however, the home is dated and does not ensure adequate private and communal space. EVIDENCE: Previous inspections have highlighted that the home is outdated and needs significant improvements to meet the standards required, the home was built at a time when many of the standards expected today did not apply. The home is due to be relocated to a purpose-built site, however the new build remains at the early stages of the project due to problems with the ground works on the site. The manager was not able to confirm when the building works are due to start and cannot provide a date for completion to the people living in the home. St Edburgs House DS0000036415.V358025.R01.S.doc Version 5.2 Page 20 A relative commented that, “A note once a quarter on the progress of the new home would be useful.” Timescales for the start and estimated completion of the new home should be established or a decision should be made as to whether the project will continue to ensure that people are regularly informed about the future of their home. Improvements have been made to the personal and communal areas. Many bedrooms have been redecorated and have new furniture, linens and carpets, however many are small and do not comply with floor space standards and the requirement to provide en-suite facilities. Only one room is now used as a double room. The two people sharing the room want to continue to do so and are provided with a curtain to separate the room for privacy. The manager and staff continue to ‘do their very best’ to ensure that the home is as homely and comfortable as possible. We found the home to be clean, comfortable and free from offensive odours. St Edburgs House DS0000036415.V358025.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, skilled and in sufficient numbers to support the needs of the people living in the home. Recruitment procedures ensure the protection of the people who live at the home, however improvements should be made to ensure that required information is held for all staff. EVIDENCE: An appropriate level of staffing was available to support the needs of the people who live at the home during our visit. People who live in the home confirmed that there are always staff around when you need something”, this was also reflected in observations made and staffing rotas viewed. We observed the staff team to be attentive and respectful, promoting communication and independence as far as possible. We talked with four staff members and all were clearly knowledgeable regarding the needs of people who are supported at the home and have a clear understanding of their job roles. We looked at five staff files. Four of the files contained the information required for recruitment and for the protection of the people who live and work St Edburgs House DS0000036415.V358025.R01.S.doc Version 5.2 Page 22 at the home, however the remaining file did not contain adequate proof of identity and only contained one reference. The manager confirmed that two written references are obtained before the commencement of employment. Criminal Record Bureau checks, including POVA first are completed centrally within the organisation, appointments confirmed following the receipt of acceptable references and CRB check. The manager took immediate action and confirmed that the issues identified within our visit have been resolved and that staff files contain the required information. Staff confirmed that they receive supervision on a regular basis and that issues identified at supervision are dealt with appropriately. St Edburgs House DS0000036415.V358025.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of the people who live in the home and health and safety is protected through policies and procedures and staff training. EVIDENCE: The registered manager has experience of managing care homes for older people and has a good understanding of the needs of the people who live in St.Edburgs, ensuring that the best interests of the people who live in the home remain the most important factor in planning and developing the service. St Edburgs House DS0000036415.V358025.R01.S.doc Version 5.2 Page 24 Staff feel the manager supports them and feel that they are able to discuss any concerns. Staff meetings are held regularly to provide opportunities for staff to raise and discuss issues. Health and safety is promoted; training is provided to staff in induction and on an ongoing basis through regular updates. Records held in relation to health and safety, viewed at the site visit were accurate and up to date, promoting the safety of all household members. The provider undertakes formal monthly unannounced visits and prepares a written report on the conduct of the care home. Copies of the reports are available at the home for inspection at any time. A quality survey was completed with the people who live in the home in 2007, the majority of issues raised related to furniture and having personal items in bedrooms, which have been resolved, all other comments received were positive regarding the support provided. The procedure for recording and reporting of incidents and accidents is satisfactory. Policies and procedures relevant to the conduct of the home are available. St Edburgs House DS0000036415.V358025.R01.S.doc Version 5.2 Page 25 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 3 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 3 13 3 14 3 15 3 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 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 St Edburgs House DS0000036415.V358025.R01.S.doc Version 5.2 Page 26 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 OP29 Good Practice Recommendations The registered manager should ensure that staff recruitment information is held on staff files for the protection and safety of the people who live in the home. St Edburgs House DS0000036415.V358025.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Edburgs House DS0000036415.V358025.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!