Inspection on 05/05/05 for Eden Place

This inspection was carried out on 5th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Eden Place 06/06/06

Eden Place 03/11/05

Eden Place 20/09/04

Eden Place 29/04/04

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Eden Place 1 Vicarage Road Lillington Leamington Spa CV32 7RH Lead Inspector Justine Poulton Unannounced 05 May 2005 08:45 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 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 Stationary 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. Eden Place E53 S4306 Eden Place v224512 050505 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Eden Place Address 1 Vicarage Road Lillington Leamington Spa CV32 7RH 01926 313227 01926 887333 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Eden Place Limited N 24 Category(ies) of MD 24 registration, with number of places Eden Place E53 S4306 Eden Place v224512 050505 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 20 September 2004 Brief Description of the Service: Eden Place is a spacious Edwardian Town House, situated in Lillington, Leamington Spa. The home accommodates 24 Service Users with enduring mental health problems. It is staffed 24 hours a day by a team of qualified nurses and nursing assistants. Currently a quarter of service users are over 75 years and two-thirds are over 65 years of age. Wheelchair access is from the car park. There are no lifts available within the home. The Home is within easy reach of local amenities including shops, churches, libraries and the local bus route. The Home was established in 1984 and is a building of three storeys, a basement and extension, known as “The Lodge”. There are 22 bedrooms including two double bedrooms. There is a medium sized, private, sheltered garden. Eden Place E53 S4306 Eden Place v224512 050505 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on a weekday and was carried out from 8:45am until 17:35pm. The manager, residents and staff co-operated fully with the inspection. A total of 17 standards were inspected on this occasion of which 14 had shortfalls. A number of requirements have also been carried forward from the previous report for this home, as they were either not met or not inspected on this occasion. All of the residents were at home for all or part of the day. A number were spoken with informally, whilst two residents chose to speak with the inspector on an individual basis. Four members of staff spoke to the inspector as a group. One relative who was visiting the home on the day of the inspection was also spoken with. In addition to this records, files and policies and procedures were also inspected. The home has recently undergone a change of manager, with the new manager only being in post since March 2005. At the time of writing this report an application for the managers registration with the Commission for Social Care Inspection had not been received. The inspector would like to thank the manager, residents and staff for their cooperation and hospitality during the inspection. What the service does well: The atmosphere in the home was relaxed during the inspection, with residents appearing happy and comfortable with the staff on duty. Staff appeared to be none intrusive, treating the residents with respect. Permission was sought from residents before the inspector was shown their bedrooms, with a number choosing to allow the manager to show the inspector their rooms. The home has two lounges that provide the residents with a choice of whether to sit with smokers or non-smokers. Two dining rooms are also available, again providing residents with a choice of where to take their meals. The inspector ate lunch during the inspection, which was tasty and well presented. Residents spoken with during lunch said that they enjoy the food that is provided, as it is generally plentiful and nice. Medication storage and procedures for administering medication are satisfactory, with qualified nurses responsible for the monitoring and administration of medication. Regular medication reviews are carried out. Staff spoken with were familiar with residents care needs, and were able to highlight the care and support needed on an individual basis. Eden Place E53 S4306 Eden Place v224512 050505 stage 4.doc Version 1.30 Page 6 Information contained within the staff files examined confirmed that staff recruitment procedures are safe for new staff appointed to the home, with references, Criminal Records Bureau checks and Pova checks being carried out as required. What has improved since the last inspection? What they could do better: Evidence was not available to confirm that a number of requirements from the previous inspection of this home which took place on 20th September 2004 have been actioned. Work is required urgently to ensure that these requirements are addressed within the new timescales stated in this report. The home is large and institutionalised, requiring considerable refurbishment and redecoration to bring it up to the required standard. Although work has been commenced on this, a written programme of refurbishment is not available, and would benefit the home in prioritising the areas in most need of work. All residents would benefit from updated clearly defined and laid out files that contain accurate care plans and risk assessments. As well as containing information regarding care needs, these must also include information regarding residents social and leisure activities and aspirations. The home must ensure that comprehensive nursing needs or assessment documentation is available for all residents. Contracts between the home and each individual resident must also be in place. In order to enable staff to spend time supporting residents with their chosen activities, cleaning duties currently allocated to nursing assistants must be reallocated to cleaning staff. The home must ensure that sufficient domestic staff are employed to undertake the cleaning, as on the day of the inspection the dining room in particular was dirty. Eden Place E53 S4306 Eden Place v224512 050505 stage 4.doc Version 1.30 Page 7 Although staff training records were in place, they were disorganised and haphazard, making it difficult to determine what training had been undertaken by whom and when. Clear individual training records would greatly assist the manager in ensuring that staff training is up to date. Staff spoken with advised that they would appreciate training in Mental Health Issues. Staff supervision has not been carried out in line with the National Minimum Standard of a minimum of six times per year. The manager must ensure that this is commenced and maintained. Although the home manages the health and safety of residents and staff as far as is applicable, fire safety procedures were not in line with the required standards and require addressing. 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. Eden Place E53 S4306 Eden Place v224512 050505 stage 4.doc Version 1.30 Page 8 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 Standards Statutory Requirements Identified During the Inspection Eden Place E53 S4306 Eden Place v224512 050505 stage 4.doc Version 1.30 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 and 5. Pre admission assessment documentation is limited and does not ensure that their individual aspirations and needs are assessed. The lack of individual written contracts between the resident and the home leaves the residents in a potentially vulnerable position. EVIDENCE: Evidence was available of Nursing Needs Reports written by the previous care provider being in place for some residents. Care plans are compiled using information contained within this report. The Nursing Needs Report was missing from one file examined and could not be located at the time of the inspection. The homes initial assessment form has been completed by the manager for one newer resident to the home. This has been compiled using information found in the Nursing Needs report, and by accessing records at the previous placement. This documentation was not available in all of the files examined. It is recommended that this document be completed for all of the residents in the home as a starting point for the compilation of appropriate care plans. Placement contracts between the placing authority, the home and the resident were available, as was a signed terms of residency agreement. These do not meet the outcome of standard five however. A blank contract between the home and the resident was available within the service user guide, which has yet to be issued to residents. Eden Place E53 S4306 Eden Place v224512 050505 stage 4.doc Version 1.30 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6and 9. Residents needs are met by informed staff using comprehensive care planning documentation, however it is not clear to what extent the residents themselves have been involved in compiling and reviewing their care plans. Some risk assessments have not been reviewed or updated to safely ensure that staff have the current information to meet the resident’s needs. EVIDENCE: Residents’ files examined contained care plans that covered a wide range of needs. These have been compiled by the home utilising pre admission information available and information gained since the resident moved into the home. Examples of the plans in place include personal hygiene, physical health, mental health, smoking and death and dying. All of the plans examined had the date they were written on them. The manager advised that care plans are reviewed on a monthly basis and updated as necessary. This was confirmed by staff spoken with. It was not clear whether residents are involved in the planning and review of their care plans. This must be confirmed. The manager advised that the home is in the process of updating all of the residents’ files to the format of those examined on the day of the inspection. Work has commenced on ensuring that residents have appropriate risk assessments in place. A risk assessment identification sheet has been compiled Eden Place E53 S4306 Eden Place v224512 050505 stage 4.doc Version 1.30 Page 11 that identifies whether an area is considered to be high, medium or low risk. Risk assessments are then generated accordingly. For example smoking was identified as a medium risk in one file examined and personal care in another. Detailed risk assessments were in place with review dates six months from the date of writing. It was advised that this format for risk assessment is not in place for all of the residents as yet, therefore this is required. Eden Place E53 S4306 Eden Place v224512 050505 stage 4.doc Version 1.30 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) x No standards in this section were inspected on this occasion. The key standards 12, 13, 15, 16 and 17 will be inspected at the next inspection of this home. EVIDENCE: Eden Place E53 S4306 Eden Place v224512 050505 stage 4.doc Version 1.30 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,20. Residents’ personal care needs are identified and met. Most residents’ healthcare needs are identified and monitored with routine and specialist appointments being arranged as necessary. Medication is managed safely. Residents have signed medication consent forms. EVIDENCE: Care plans were available within the residents files examined that provided comprehensive and detailed information regarding the individual personal care and support needs of the residents, however it was not clear from the care plan documentation, where the information had been obtained from. A recorded reference to the origination of the information within each care plan is required. In discussion staff spoken with were able to identify the care and support needs of residents. Record sheets were also available within the files examined for routine health appointments such as the dentist, optician and chiropodist as well as more specialist appointments with consultants, or well woman clinics for example. In one file examined no appointments were recorded. Confirmation that all residents are offered routine health care appointments is required. The manager advised that updating the care plans into the format seen is a work in progress for all service users, and is not in place in all of the files as yet. Eden Place E53 S4306 Eden Place v224512 050505 stage 4.doc Version 1.30 Page 14 Medication is stored in a locked cupboard in the Nursing office within the home. It is supplied by a local pharmacy in blister packs, which are accompanied by printed medication administration record sheets. Any medication that cannot be supplied in a blister pack is also stored securely within this cupboard. Prescribed controlled drugs that are required by residents are stored appropriately in a locked cupboard within a locked cupboard. Accurate recording was in place for this medication. Qualified nurses are responsible for administering medication. Prescribed medication administration records examined during the inspection provided no cause for concern at this time. It was noted during the inspection that some residents are administered pain relief or laxative medication on an ‘as necessary’ basis. This medication is not prescribed and is administered as a homely remedy. Signed consent to medication was available within the files examined, and evidence of regular medication reviews was in place. Eden Place E53 S4306 Eden Place v224512 050505 stage 4.doc Version 1.30 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 The home has a complaints procedure in place, however it was difficult to ascertain whether the residents knew about it and were able to use it effectively. EVIDENCE: The home has a complaints procedure in place, which is located in the nurses office. A copy of the procedure was also on the wall in the main hallway of the home. Residents do not have their own copy, however, it is in the Service User Guide, which has yet to be given to residents. It was unclear on the day of the inspection as to whether residents know about the complaints procedure or feel able to complain about issues that are of concern to them, however those spoken with stated that they were generally happy living in the home. It was not possible to determine whether the home has received any complaints since the last inspection, as, although the manager stated that a complaints log was in place, it was not able to be located at the time of the inspection. Eden Place E53 S4306 Eden Place v224512 050505 stage 4.doc Version 1.30 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25,28 and 30. The home is large and institutionalised, with a large number of residents living together in a group. A major part of the environment is shabby and worn, with specific areas in need of thorough cleaning. Two bedrooms are shared, with the remainder being single bedroom accommodation. The majority of bedrooms do not currently meet individual needs. Residents share two lounges, and two dining rooms. EVIDENCE: The home is spread over three floors, which are only accessible, by stairs. The manager stated that he hopes to have a lift installed in the not to distant future, and was able to show the inspector information in relation to this. A vast majority of the home is shabby, worn and in need of redecoration and refurbishment. Some work has been undertaken with regards to this as three bedrooms have been redecorated since the last inspection, one was in the process of being redecorated on the day of the inspection and a bathroom was in the process of being refurbished. A written plan for redecoration and refurbishment was not available. On a tour of the home it was noted that a number of bedrooms had particularly unpleasant odours, a toilet seat in a Eden Place E53 S4306 Eden Place v224512 050505 stage 4.doc Version 1.30 Page 17 ground floor shower room required replacing, a smoke detector in a linen cupboard by room 30 required replacing, a number of carpets in bedrooms, hallways and the smoking lounge require replacing, and curtains require rehanging where they have come loose. Residents’ health, well-being and dignity are impeded by the poor environment, which will only serve to impact on their self-perceived aspirations. Residents have the choice of two lounges for their use. One is a smoking lounge that has a large industrial looking extractor fan, whilst the second is smaller and quieter for non-smoking residents. On the day of the inspection the inspector noted that the floor in the dining room in particular was dirty, especially under the radiator covers. An area in the dining room where the residents can make themselves drinks was also dirty. Eden Place E53 S4306 Eden Place v224512 050505 stage 4.doc Version 1.30 Page 18 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34, 35 and 36. Staff have been recruited to work in the home in line with current good practice that safeguards residents. The lack of staff supervision and clear training records however leaves residents vulnerable to potential risk to their health and well-being. EVIDENCE: All of the staff files examined contained details of Criminal Records Bureau checks. The home pays the Registered Nursing Home Association to obtain the checks for them. One member of staff recently recruited to the home also has a POVA check in place. There were two written references in the majority of files examined, along with copies of identification documents such as driving licences or birth certificates, application forms and terms and conditions, however not all of these documents were available within all of the files. Very little evidence was available of staff receiving formal recorded supervision a minimum of 6 times per year. This was confirmed by both the staff spoken with and the manager. Some training records were available but they were disorganised and haphazard. It was difficult to determine what training had been undertaken by staff and when, especially in relation to mandatory training. Staff spoken with advised that they had undertaken little training recently. When asked what they would appreciate training in, they advised that they would find training in Mental Health Issues beneficial. Eden Place E53 S4306 Eden Place v224512 050505 stage 4.doc Version 1.30 Page 19 The manager and staff spoken with advised that the nursing assistants have a responsibility for undertaking domestic cleaning tasks throughout the day, even though the home employs cleaning staff. Staff advised that they feel that this takes them away from the residents and leaves them with little time to support them with social activities both in house and in the community. Concern was expressed by staff spoken with during the inspection about the number of Registered General Nurses (RGN) that are being employed by the home as opposed to Registered Mental Health Nurses (RMN) who have the required experience and qualifications to support the specialist needs of the residents. Eden Place E53 S4306 Eden Place v224512 050505 stage 4.doc Version 1.30 Page 20 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,41 and 42. The home has a new manager in post, making it difficult to determine whether it is well run at this inspection. Residents’ records are stored securely. The health and safety of residents and staff is maintained with the exception of fire safety, hygiene and staff training. EVIDENCE: At the time of the inspection the manager of the home was relatively new in post. He advised that he had been spending his time familiarising himself with the management of the home, and had already started to implement new procedures and ways of recording information. At the time of writing this report the manager had yet to apply to the Commission for Social Care Inspection for registration. Residents’ records and files are stored in a lockable cabinet in the nurses’ office. Work has been commenced to condense the amount of information stored into one easily accessible file per resident that can easily be tracked through the daily records in the Kardex, care plan reviews and medication records. The home has a procedures manual in place, however this was not inspected on this occasion. Health and safety within the Eden Place E53 S4306 Eden Place v224512 050505 stage 4.doc Version 1.30 Page 21 home is delegated to the maintenance man who was able to provide evidence that of all of the routine checks and tests required by law are carried out at the required intervals. The exception to this is in relation to fire safety. Records for the testing of fire alarms and emergency lighting was sporadic, the last fire drill was recorded as having been carried out in March 2004 and the fire risk assessment needs reviewing urgently, as this places residents and staff at potential risk. Eden Place E53 S4306 Eden Place v224512 050505 stage 4.doc Version 1.30 Page 22 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 2 x x 2 Standard No 22 23 ENVIRONMENT Score 2 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 2 x x 3 x x Standard No 11 12 13 14 15 16 17 x x x x x x x Standard No 31 32 33 34 35 36 Score 2 x x 2 2 1 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Eden Place Score 3 2 3 x Standard No 37 38 39 40 41 42 43 Score x x x x 3 2 x E53 S4306 Eden Place v224512 050505 stage 4.doc Version 1.30 Page 23 YES Are there any outstanding requirements from the last inspection? 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 1 Regulation 4 Requirement Timescale for action 31/12/04 2. 3. 2 3 14(1)(a)( b)(c) 16 4. 5 13 The Responsible Person must: Consider the aims and objectives of the home and demonstrate how the home will provde appropriate services to both younger and older adults, and discuss with commissioning agencies how appropriate services to both service user groups can be achieved. NOT INSPECTED ON THIS OCCASION. (31/12/04) Pre admission information for 30/06/05 new residents must be avaialble within their service user files. The Responsible Person must 31/12/04 extend the assessment and planning process to include personal development, education, occupation, and leisure needs and aspirations of service users. These aaspects of care should be part of the assessment and contract process prior to placement in the home. NOT INSPECTED ON THIS OCCASION. (31/12/04) Residents must be provided with 08/07/05 individual contracts that detail all of information as listed within Standard 5. Version 1.30 Eden Place E53 S4306 Eden Place v224512 050505 stage 4.doc Page 24 5. 5 5 6. 6 16 7. 7 15(2)(b) 8. 9 13(4) 9. 10. 6, 19 11 14(1) 16 11. 12 16 The Responsible Person must inform each service user in their service user guide of the financial arrangements made in respect of the amount and method of payment of fees, personal contribution to fees (if any) and amount and method of payment of personal allowances. NOT INSPECTED ON THIS OCCASION. (31/12/04) The Responsible Person must ensure that the personal development, education, occupation, and leisure needs and aspirations of service users are included in ongoing reviews with the service user and the placing health and social services. ( 31/01/05) Work has commenced on this requirement. Evidence to confirm that residents are involved in the review of their care plans must be provided. Comprehensive risk assessment documentation must be in place for all residents. (31/12/04) CARRIED FROM THE LAST INSPECTION. A recorded reference as to the origination of the information within care plans is required. The Responsible Person must provide all service users with opportunities and support to develop and maintain social, emotional, communication and living skills by ensuring their needs and preferences are assessed, and by providing opportunities that are planned, monitored and evaluated. NOT INSPECTED ON THIS OCCASION. (31/01/05) The Responsible Person must ensure assessment of service users is undertaken to identify 31/12/04 31/01/05 08/07/05 30/09/05 31/08/05 31/01/05 (31/01/05) Eden Place E53 S4306 Eden Place v224512 050505 stage 4.doc Version 1.30 Page 25 12. 13 16(2)(m) 13. 19 13(1)(b) 14. 21 15 15. 20 12(1) 13(2) 16. 22 22(2) 17. 18. 22 24, 25 22(8), Schedule 4(11) 23(2)(d) areas they want to pursue in terms of training, education, employment and taking part in fulfilling activities and that the assessments and activities undertaken are monitored and evaluated. NOT INSPECTED ON THIS OCCASION. (31/01/05) The Responsible Person must ensure leisure and activity programmes are developed for all each service user, including accessing and participating in local amenities if they wish. The programmes should include 1:1 activities as well as group activities inside and outside the home. Activities undertaken by service users should be documented, monitored and evaluated.NOT INSPECTED ON THIS OCCASION. (31/01/05) Confirmation that all residents are offered routine health care appointments at the appropriate intervals is required. The Responsible Person must ensure the wishes of service users regarding terminal care and death are documented in their care plans. NOT INSPECTED ON THIS OCCASION. (31/01/05) A policy for the administration of homely remedies to residents must be compiled that includes details of how this is to be documented. The manager must ensure that residents have an appropriate means of making complaints that that is appropariate to their needs and comfortable for them to use. A written complaints record must be in place. All areas of the home must be clean and hygeinic. 31/01/05 08/07/05 31/12/04 30/09/05 31/08/05 31/07/05 08/07/05 Page 26 Eden Place E53 S4306 Eden Place v224512 050505 stage 4.doc Version 1.30 19. 24 16, 23 20. 24 16, 23 21. 26 16, 23 22. 27 16, 23 23. 24. 31 33 18(1)(a) 18(1)(a) The Responsible Person must ensure the environment meets the standards requied including: Beds and mattresses, Bedroom furniture, Furniture and fittings in the lounge and lodge, Bedroom lighting, floor covering and wall covering. Furniture, fixtures and fittings that are broken, especially those as detailed in the body of this report, damaged, soiled, stained, worn or have holes or cigarette burns in them must be replaced, repaired or cleaned. THIS REQUIREMENT IS ONGOING. (31/03/05) The Responsible Person must provide a written copy of the of the redecoration and refurbishment programme to CSCI. The programme must prioritiseareas in greatest need to be refurbished / redecorated and the items to be replaced. It must also specify the timescales and systems in place to monitor progress against the programme. CARIED FORWARD FROM THE LAST INSPECTION. (31/12/04) The Responsible Person must continue the refurbishment programme of service users bedrooms until all meet the required standard. CARRIED FORWARD FROM THE LAST INSPECTION. (31/03/05) The Responsible Person must continue the refurbishment prgramme of service users toilet and bathroom facilities until all meet the required standard. NOT INSPECTED ON THIS OCCASION. Nuring Assistants must cease undertaking cleaning duties. The home must ensure that it employs enough cleaning staff to 31/08/05 08/07/05 30/09/05 31/03/05 30/06/05 30/06/05 Page 27 Eden Place E53 S4306 Eden Place v224512 050505 stage 4.doc Version 1.30 25. 33 18 26. 33 18 27. 34 19(4) 28. 35 18(1)(a) 29. 36 18(2) 30. 37 undertake all of the cleaning duties, without having to rely on care staff. The Responsible Person must: Review and set care staffing levels in conjunction with reassesment of service users needs to ensure there are sufficient staff to meet the mental, physical and social needs of all service users. Keep staffing levels under review and ensure additional staff are provided in the event of service users needs increasing. CARRIED FORWARD FORM THE LAST INSPECTION. (15/12/04) The Responsible Person must develop and implement policies for care staff that prohibits family members or others in close personal relationships working together. NOT INSPECTED ON THIS OCCASION. (31/12/04) The Responsible Person must ensure that all staff files contain the information and documents as listed in Schedule 2 of the Care Homes Regulations 2001. CARRIED FORWARD FROM THE LAST INSPECTION. (31/07/04) Staff training records must be audited, and an appropriate method of monitoring staff training be implemeted that shows at a glance what training has been undertaken, and when. Staff must be provided with formal recorded supervision a minimum of six times per year by a senior staff member that has been received training in providing effective supervision. The manager of the home must apply to the Commission for Social Care Inspection for Registration. 30/06/05 31/12/04 31/08/05 30/09/05 31/07/05 31/07/05 Eden Place E53 S4306 Eden Place v224512 050505 stage 4.doc Version 1.30 Page 28 31. 42 23(4) 32. 42 23(4) The manager must ensure that routine checks of fire alarms and emergency lighting is carried out at on a weekly and monthly basis as necessary. The Fire Risk Assessment for the home must be reviewed urgently. 30/06/05 30/06/05 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. Refer to Standard 2 Good Practice Recommendations It is recommended that the manager complete the homes initial assessment form for all residents as a good practice baseline for compiling care plans. Eden Place E53 S4306 Eden Place v224512 050505 stage 4.doc Version 1.30 Page 29 Commission for Social Care Inspection Imperial Court Holly Walk Leamington Spa CV32 4YB National Enquiry Line: 0845 015 0120 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 Eden Place E53 S4306 Eden Place v224512 050505 stage 4.doc Version 1.30 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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