Care Home: St Edmunds

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What the care home does well Prospective residents are able to make an informed choice about where to live and information is provided to assist them to do this. Each person has a contract and a copy of the statement of Purpose and Service user’s Guide. Residents have their needs assessed prior to moving to St Edmunds and are confident that the home will meet these needs. Each resident has a detailed care plan which describes their health, personal and social care needs. Access is available to healthcare professionals and people are protected by the home’s medication policies and procedures.St EdmundsDS0000027497.V378426.R01.S.docVersion 5.2Residents and their families are treated with respect and dignity throughout good health, illness, dying and death. Residents have the opportunity to take part in a number of activities, hobbies and pastimes and are supported to maintain contact with family, friends and the local community, according to their wishes. The meals and mealtimes are of a very high standard, the food is wholesome and nutritious and additional food and drinks are available outside normal mealtimes. Residents and their families and friends know their complaints will be listened to, taken seriously and acted upon. Residents are protected from abuse. St Edmunds provides a clean, safe and well-maintained environment for the people living there and the indoor and outdoor communal facilities are safe and comfortable. St Edmunds has robust recruitment policies and practices, the staff have a good mix of skills and they are trained and competent, which ensures residents’ are in safe hands at all times. St Edmunds is a well run home and benefits from competent day-to-day management by the manager and proprietor, who genuinely have the residents’ best interests at heart. What has improved since the last inspection? One of the proprietors shares the managerial duties on a regular basis with the manager, who also has allocated ‘management/administrative’ time, so the home has a very efficient management structure in place. Staff supervision is more formal and regular, which helps with the ongoing development of staff. Staff files have evidence of clear, enhanced, CRB (Criminal Records Bureau) disclosures having been received. Two written references are received, and maintained on staff files, before they start working at St Edmunds.St EdmundsDS0000027497.V378426.R01.S.docVersion 5.2 What the care home could do better: A separate audit of accidents, incidents and falls would make it easier to identify any particular patterns or trends and enable any remedial action to be more effective. The complaints procedure in the Service User Guide should have the Care Quality Commission’s new details included. The carpet on the stairs near the reception is getting worn on the edge of the tread and it is recommended that this is looked at and prevented from becoming a hazard. The large maintenance store room would benefit from having a lock or bolt fitted to it, to prevent residents from accessing it unintentionally. Key inspection report CARE HOMES FOR OLDER PEOPLE St Edmunds 3-5 Marine Parade Gorleston Great Yarmouth Norfolk NR31 6DP Lead Inspector Debby Ames Key Unannounced Inspection 11th September 2009 08:30 DS0000027497.V378426.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. St Edmunds DS0000027497.V378426.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address St Edmunds DS0000027497.V378426.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.V378426.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. Date of last inspection Brief Description of the Service: St Edmunds is a residential home located on the sea front in Gorleston, which provides twenty-four hour care for up to thirty-two older people. The Home offers easy access to local shops and amenities and there is a local bus to Great Yarmouth, which runs on a regular basis. People in the home are encouraged to make use of all the local amenities and staff can support people when required. All the rooms are tastefully decorated with a number of communal areas and many people have rooms with sea views. The home offers a hotel style environment for residents who have low dependency support needs with a condition that residents who live on the first floor are independently mobile. Fees range from £325.00 to £460.00 per week and additional charges are made for personal requisites, private telephone facilities, newspapers, hairdressing and private chiropody. St Edmunds DS0000027497.V378426.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 3 stars. This means the people who use this service experience excellent quality outcomes. Care Services are judged against outcome groups, which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out, by using information from previous inspections, information from the providers, the residents and their relatives, as well as others who work in or visit the home. This has included a recent unannounced visit to the home. This report gives a brief overview of the service and the current judgements for each outcome group. This inspection was carried out over a period of five and a half hours and included a tour of the premises, inspection of staff and residents’ records and the home’s records relating to health and safety. Discussions also took place with the proprietors, manager and some of the residents. No CQC questionnaires had been completed or returned by residents, relatives/carers or staff prior to the inspection, although the manager had completed the Annual Quality Assurance Assessment (AQAA) and a copy was submitted to the Commission accordingly. Meanwhile, a letter to the manager and staff at St Edmunds was noted in one person’s care plan, which read: “Thanks for an enjoyable stay and a first class service on all counts.” This person has since moved in as a permanent resident. Four recommendations have been made as a result of this inspection. What the service does well: Prospective residents are able to make an informed choice about where to live and information is provided to assist them to do this. Each person has a contract and a copy of the statement of Purpose and Service user’s Guide. Residents have their needs assessed prior to moving to St Edmunds and are confident that the home will meet these needs. Each resident has a detailed care plan which describes their health, personal and social care needs. Access is available to healthcare professionals and people are protected by the home’s medication policies and procedures. St Edmunds DS0000027497.V378426.R01.S.doc Version 5.2 Page 6 Residents and their families are treated with respect and dignity throughout good health, illness, dying and death. Residents have the opportunity to take part in a number of activities, hobbies and pastimes and are supported to maintain contact with family, friends and the local community, according to their wishes. The meals and mealtimes are of a very high standard, the food is wholesome and nutritious and additional food and drinks are available outside normal mealtimes. Residents and their families and friends know their complaints will be listened to, taken seriously and acted upon. Residents are protected from abuse. St Edmunds provides a clean, safe and well-maintained environment for the people living there and the indoor and outdoor communal facilities are safe and comfortable. St Edmunds has robust recruitment policies and practices, the staff have a good mix of skills and they are trained and competent, which ensures residents’ are in safe hands at all times. St Edmunds is a well run home and benefits from competent day-to-day management by the manager and proprietor, who genuinely have the residents’ best interests at heart. What has improved since the last inspection? One of the proprietors shares the managerial duties on a regular basis with the manager, who also has allocated ‘management/administrative’ time, so the home has a very efficient management structure in place. Staff supervision is more formal and regular, which helps with the ongoing development of staff. Staff files have evidence of clear, enhanced, CRB (Criminal Records Bureau) disclosures having been received. Two written references are received, and maintained on staff files, before they start working at St Edmunds. St Edmunds DS0000027497.V378426.R01.S.doc Version 5.2 Page 7 What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. St Edmunds DS0000027497.V378426.R01.S.doc Version 5.2 Page 8 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.V378426.R01.S.doc Version 5.3 Page 9 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, & 5 (standard 6 is not applicable). People using the service experience good quality outcomes in this area. Prospective residents are able to make an informed choice about where to live and information is provided to assist them to do this. Each person has a contract and a copy of the statement of Purpose and Service user’s Guide. Residents have their needs assessed prior to moving to St Edmunds and are confident that the home will meet these needs. We have made this judgement using a range of evidence, including a visit to this service. St Edmunds DS0000027497.V378426.R01.S.doc Version 5.3 Page 10 EVIDENCE: Discussions with the manager and staff and information seen in the care plan confirmed that people are provided with ample information about St Edmunds and people are actively encouraged to stay for a ‘holiday’ prior to making a decision, so they can have first hand experience of what life is really like there. A letter to the manager and staff at St Edmunds was noted in one person’s care plan, which read: “Thanks for an enjoyable stay and a first class service on all counts.” This person has since moved in as a permanent resident. A full needs assessment is carried out by the manager of St Edmunds prior to people staying at St Edmunds and information is gathered from as many people as possible including the prospective resident, relatives and medical/ healthcare professionals. The information obtained is then incorporated into the individual’s care plans. Each person was noted to have been given a Statement of Purpose, Service User Guide and Residency Agreement. It is stated in the Statement of Purpose that residents are encouraged to remain as independent as possible and assistance will be offered when people’s needs change. However, it is also clearly stated that St Edmunds is a residential home and cannot offer nursing care, nor can it accommodate people with severe confusion or dementia. The concluding paragraph in the Statement of Purpose reads: “We at St Edmunds offer a free and easy lifestyle for Residents who meet our criteria. We are proof that quality of life does not end when you move into a residential home.” St Edmunds DS0000027497.V378426.R01.S.doc Version 5.3 Page 11 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11 People using the service experience excellent quality outcomes in this area. Each resident has a detailed care plan which describes their health, personal and social care needs. Access is available to healthcare professionals and people are protected by the home’s medication policies and procedures. Residents and their families are treated with respect and dignity throughout good health, illness, dying and death. We have made this judgement using a range of evidence, including a visit to this service. St Edmunds DS0000027497.V378426.R01.S.doc Version 5.3 Page 12 EVIDENCE: It was clearly evident that a huge amount of work has been undertaken since the last inspection in respect of the storage, organisation and content of each resident’s care plans. The general contents of the care plans were seen to include information in areas such as: 1) 2) 3) 4) 5) 6) 7) 8) 9) 10) Pre-admission Assessment – including information about physical and mental health and wellbeing. Mobility Assessment. Personal Care Preferences – i.e. prefers a bath on a Wednesday or Sunday evening. Personal Care Assistance – i.e. requires assistance from one carer. Security – i.e. does the resident require a lock on their bedroom door? Social Care – this included information about friends and family, relationships, hobbies, interests and clubs attended. Special Needs – i.e. requires a diabetic diet. Falls Risk Assessment – i.e. High, Medium or Low ‘Going Out Alone’ Assessment Aids Required – one example of this assessment read: Walking Stick Yes Walking Frame Will Try One Toilet Stand No Wheelchair Required for Long Distances Medication Procedure – signed statements were seen for residents in respect of whether they were self medicating or not. Daily Notes – these were seen to be very respectfully written and detailed information in respect of activities, visitors, telephone calls, meals and drinks. Care Plan Reviews – these particularly covered areas such as medication, physical, social and emotional needs and highlighted any relevant changes. DS0000027497.V378426.R01.S.doc Version 5.3 Page 13 11) 12) 13) St Edmunds Three care plans were looked at in detail and the information was found to be respectful, of good quality and it clearly explained how people wanted to be supported in respect of their needs, requirements and preferences. It was also evident from the information seen that people’s preferences are highly regarded and independence is genuinely promoted within a very enabling environment. During the inspection, the proprietor was overheard asking one person if they were feeling alright, as they sounded as though they had a bit of a cold. She was also heard to offer to make them a drink of hot lemon and honey, which the resident accepted saying it sounded like a good idea. Another staff member was heard to offer another one after lunch. A bathing list was looked at, which showed how each person was able to have a choice of time, day and staff member to assist them with having a bath and individual’s choices were clearly laid out in their care plans, with daily notes, handover information and shift plans confirming that people’s wishes were genuinely respected and adhered to. Good records were seen to be kept in respect of accidents and falls, which included details of the incident and any recommended action to be taken as a result – such as: ‘[name] needs to use a walking stick at all times’ and ‘encourage [name] to wear their slippers and use their frame’. A separate ‘medical’ folder was seen for each person, which included a photograph, hospital notes, chiropodist visits and notes, district nurse visits and comments/action and GP visits and comments/action. Where possible, people were noted to be encouraged and supported to maintain and administer their own medication, for which a risk assessment was seen to have been completed and appropriate storage facilities provided in each person’s bedroom. A very clear but detailed medication procedure was seen to be in place and accessible for all trained staff. The storage facilities were seen to be secure and procedures for the storage and administration of ‘controlled drugs’ were seen to be followed. A number of personal medication records were looked at and no errors or omissions were noted. All medication stocks are regularly checked and audited, including for people who control and administer their own medication. St Edmunds DS0000027497.V378426.R01.S.doc Version 5.3 Page 14 A Medicines Management Visit was carried out in January 2009 by two Pharmacy Technicians with the National Health Service and the full report was seen to be mostly very positive with a few recommendations that were seen to have been acted upon by the proprietor of St Edmunds. Other procedures which were seen to have been reviewed and updated during 2009 included Disposal of Sharps Procedure, GTN (Glyceryl Trinitrate) Spray Procedure, Lifting and Handling Procedure, Emergency Lifting and Handling Procedure (Condensed), Wheelchair Procedure and Use of Blood Glucose Meter. All of these procedures were seen to be detailed, clear, accessible and continually promoted and respected residents’ dignity and independence. Throughout the whole inspection it was evident that residents and their families are treated with respect and dignity during good health, illness, dying and death and although St Edmunds does not provide nursing care, some residents have spent their last days there and received a high standard of care and support during and following short illnesses. All three care plans that were looked at included people’s individual wishes regarding illness, dying and death such as: Do Not Resuscitate, Want to be Resuscitated and Not sure yet. Funeral wishes were also noted and included details of cremation or burial as required. St Edmunds DS0000027497.V378426.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People using the service experience excellent quality outcomes in this area. Residents have the opportunity to take part in a number of activities, hobbies and pastimes and are supported to maintain contact with family, friends and the local community, according to their wishes. The meals and mealtimes are of a very high standard, the food is wholesome and nutritious and additional food and drinks are available outside normal mealtimes. We have made this judgement using a range of evidence, including a visit to this service. St Edmunds DS0000027497.V378426.R01.S.doc Version 5.3 Page 16 EVIDENCE: As stated in the Statement of Purpose; the staff and management at St Edmunds are evidently genuinely striving to provide an enjoyable lifestyle for all the residents who live or stay there. The home was previously run as an hotel, and the very high standards appear to have been seamlessly maintained. Residents were seen to be able to order regular newspaper and magazines of their choice which are delivered to the Home and choices such as ‘likes to have breakfast in their room with a tray of tea at 7am’ and ‘likes to have a cup and saucer’ were noted in the care plans that were looked at. Choices in respect of night care were also seen to be recorded and adhered to such as: ‘does not want to be checked on at night. [Name] knows how to use the buzzer if assistance is required’. During the inspection, visitors were observed coming to the home at various times and a number of residents were seen to be going ‘out-and-about’ as they chose. Daily notes also provided evidence of regular contact with friends and family. General observations throughout the inspection included: ● ● ● ● ● ● ● ● A very relaxed and jovial atmosphere. Residents chatting to each other and to staff. Residents sitting in various areas of the Home, according to their choice. Peaceful ‘piped’ music in areas such as reception, toilets and hallways – at an appropriate volume. Staff appeared to be very friendly and cheerful, continually chatting with residents. A resident going out to the local shop, with a staff member, to buy some flowers for the Home. One resident being asked: “Do you want to go for a walk [name]? One of the girls(staff) will go with you.” A game of skittles being played by a number of residents and staff in the afternoon. St Edmunds DS0000027497.V378426.R01.S.doc Version 5.3 Page 17 One person was noted to live at St Edmunds on a permanent basis but likes to go back to their own home during the daytime. It was evident from observations and information in the care plans that people are able to pursue their hobbies and interests which were noted to include going out for a walk or on mobility scooter, going to the local hairdresser, going to the pub, playing cards, playing dominoes, bingo, gardening, reading and horse racing. Some of the activities provided by the staff at St Edmunds were seen to include walks, Nintendo WII, skittles, Yesteryear, music, flower arranging and external entertainers. From the staff files and supervision notes looked at, there was clear evidence that the manager and provider expect very high ‘hotel like’ standards of service and care from the staff. Some examples of the areas that were seen to be covered during induction and supervision were as follows: Reception: Emotional: Beverages: Trays: Meals: Care Observations: …has a very good manner… …listens to what residents say… …always asks what people want and advises if it is something they shouldn’t have (i.e. due to diabetes)… …well presented… …waitresses well… …asked [resident] to wash what they could manage first and offered then to help with the rest… …explained to [resident] what they were doing first before washing… In respect of meals and mealtimes, the standards were again observed to be extremely high in respect of the food and the environment. The dining room had a genuine quality hotel/restaurant feel to it, all the tables were laid professionally with linen cloths and nice quality crockery etc was seen to be used. Each of the dining tables had a small vase of flowers and people appeared happy and relaxed, sitting where and with whom they chose. It was noted that the chef has been at St Edmunds for fifteen years and also ran the kitchen when the Home was a hotel. St Edmunds DS0000027497.V378426.R01.S.doc Version 5.3 Page 18 Special requirements, such as for people with diabetes, were seen to be catered for and it was noted that one person now needs to have their food pureed. The menus were seen to offer alternatives for main meals, vegetables (i.e. chips, mashed or boiled potatoes) and desserts. St Edmunds DS0000027497.V378426.R01.S.doc Version 5.3 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People using the service experience good quality outcomes in this area. Residents and their families and friends know their complaints will be listened to, taken seriously and acted upon. Residents are protected from abuse. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The Home was seen to have a very clear and accessible complaints and grievance procedure, which is included in the Service User Guide and a summary is on display in the reception area (although the new details for the Care Quality Commission do need to be updated). The complaints book was seen, although it was confirmed that no formal complaints have been received. A high number of compliments were noted to have been received. Some of the residents were chatted with during the inspection and all said they are very happy at St Edmunds. Staff records showed that staff have been trained in adult protection and the manager and proprietor confirmed that they are fully aware of the procedures in this area. St Edmunds DS0000027497.V378426.R01.S.doc Version 5.3 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 & 26 People using the service experience excellent quality outcomes in this area. St Edmunds provides a clean, safe and well-maintained environment for the people living there and the indoor and outdoor communal facilities are safe and comfortable. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: A tour of the premises was carried out as part of this inspection and St Edmunds was found to be clean, homely and free from offensive odours. The communal areas were warm and inviting and the standard of furnishing and décor was very good throughout. St Edmunds DS0000027497.V378426.R01.S.doc Version 5.3 Page 21 It was noted and observed that there are two cleaners for the Home on a daily basis, including weekends, who also carry out their work to a very high standard. Observations confirmed that many people have specialist equipment such as wheelchairs, walking frames, mobility scooters etc, which help them maintain their independence. The communal toilet and bathroom areas were seen to be, again, of a very high standard and included chair hoist, whirlpool bath, ornaments and pictures, giving them a luxurious and homely feel. Hand rails and slopes were noted throughout the home, for ease of access and all the hallways were seen to be nicely decorated with added touches such as ornaments, plants, pictures and ‘occasional’ seating areas – including a telephone and chair in a quiet area, which is stated to be available for use at no extra charge. A number of residents have arranged to have their own telephone facilities in their bedrooms and settle the bill themselves. It was confirmed and observed that residents are able to have their own possessions around them and personalise their rooms. All residents have their own room with a colour television and en-suite toilet. There are also three double rooms, which are suitable for ‘couples’. Residents are welcome to have and use their own linen and towels, which will be laundered by the staff at St Edmunds, although the Home can also supply this, again in ‘hotel’ style. No serious safety hazards were noted during the inspection, although a couple of recommendations have been made in respect of the stair carpet near the reception and maintenance store-room. St Edmunds DS0000027497.V378426.R01.S.doc Version 5.3 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People using the service experience good quality outcomes in this area. St Edmunds has robust recruitment policies and practices, the staff have a good mix of skills and they are trained and competent, which ensures residents’ are in safe hands at all times. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Observations, discussions and the records looked at during the inspection confirmed that there continue to be sufficient numbers of staff on duty at all times. Personnel files were looked at in detail for three staff members and these were seen to contain records of induction and training, references, identification, application, employment contracts and supervision notes. In accordance with a previous requirement the staff files were seen to contain evidence that POVA 1st checks and Enhanced Criminal Records Bureau (CRB) St Edmunds DS0000027497.V378426.R01.S.doc Version 5.3 Page 23 Disclosures have been obtained for staff prior to starting work at St Edmunds. At least two written references were seen to be in the staff files and the proprietor confirmed that they had recently not commenced employment for one prospective member of staff, due to lack of references – despite their apparent suitability in all other areas. The training records confirmed that staff continue to receive regular and appropriate training and updates in areas such as first aid, fire safety, moving and handling, health and safety, medication, food hygiene, infection control, Control Of Substances Hazardous to Health (COSHH), continence awareness, and adult protection. Each member of staff is also supervised well and completes a good quality induction process upon commencement of their employment at St Edmunds. It was confirmed that appraisals are currently being carried out with each staff member and should be completed within the next few weeks. St Edmunds DS0000027497.V378426.R01.S.doc Version 5.3 Page 24 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 & 38 People using the service experience excellent quality outcomes in this area. St Edmunds is a well run home and benefits from competent day-to-day management by the manager and proprietor, who genuinely have the residents’ best interests at heart. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Discussions and evidence seen during this inspection confirmed that the proprietor actively manages the Home in conjunction with the registered St Edmunds DS0000027497.V378426.R01.S.doc Version 5.3 Page 25 manager, which enables the previous requirement to be regarded as having been met. The proprietor confirmed and provided evidence, by way of diary entries, shift plans and rotas that she visits the Home every day, works two full days on managerial tasks and two days doing the catering. The manager and proprietor confirmed that, as the manager also has specific ‘management’ time allocated on the rota, St Edmunds is consistently and effectively managed. The proprietor confirmed that she also lives next door to the Home and can be ‘called on’ at any time if she is needed. The Service User Guide was also seen to confirm this. The proprietor and manager were both observed to be very approachable in respect of staff, residents and visitors. As mentioned in the previous (Staffing) section, staff are receiving regular supervision sessions and appraisals are currently being undertaken. Some of the residents’ financial records were checked at random and found to be accurate, safe and well organised. The procedure is that any money held on behalf of residents is locked in the safe but available immediately upon request. Each resident has an individual folder, containing a purse/wallet, receipts and a record of all money in or out, which is signed by two staff members. Staff and residents meetings were also noted to be held formally on a regular basis and the results of the last Quality Audit were seen to be very positive. The proprietor confirmed that this year’s Quality Audit is in the process of being completed. Both proprietors generally take responsibility for health, safety and maintenance within the Home and all the records looked were found to be complete and up to date. Servicing records were seen for areas such as fire alarms, fire extinguishers, boilers, gas appliances and passenger lifts. Servicing of the hoists was seen to have been arranged, with an appointment recorded in the diary. Appropriate risk assessments in respect of health and safety were also seen to be in place, confirming that confirming the health and welfare of service users and staff continues to be promoted and protected. St Edmunds DS0000027497.V378426.R01.S.doc Version 5.3 Page 26 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 3 3 3 3 4 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 4 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 4 4 3 3 4 4 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 4 4 4 X 3 3 4 3 St Edmunds DS0000027497.V378426.R01.S.doc Version 5.3 Page 27 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. 2. 3. 4. Refer to Standard OP7 OP16 OP19 Good Practice Recommendations OP19 St Edmunds DS0000027497.V378426.R01.S.doc Version 5.3 Page 28 Care Quality Commission East Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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