Inspection on 06/06/06 for Eden Place

This inspection was carried out on 6th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Eden Place 03/11/05

Eden Place 05/05/05

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 Warwickshire CV32 7RH Lead Inspector Jackie Howe Key Unannounced Inspection 6th June 2006 09:15 Eden Place DS0000004306.V299402.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Eden Place DS0000004306.V299402.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Eden Place DS0000004306.V299402.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eden Place Address 1 Vicarage Road Lillington Leamington Spa Warwickshire CV32 7RH 01926 313227 01926 887333 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) Eden Place Limited Richard Mark Bloomer Care Home 24 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (24) of places Eden Place DS0000004306.V299402.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may admit and continue to care for residents over the age of 65 provided they do not require full physical nursing care and that their needs can be met by the home. The home may only admit residents over 49 years old. Richard Bloomer (Registered Manager) must achieve his Registered Managers Award by 1st January 2007. Eden Place may also care for the person named in the application for variation dated 10 May 2006 3rd November 2005 2. 3. Date of last inspection 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 over half of service users are over 65 years. Wheelchair access is from the car park. There is a new lift which has recently been installed in 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. Range of fees: £ 765 per week Eden Place DS0000004306.V299402.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first inspection of the inspection year 2006/07 and was unannounced. It was carried out between 9:15am and 5:30pm. All of the ‘key standards’ were inspected focusing on the outcome for residents of life in the home. The manager was present through out the day, and the inspector was able to tour the home, and spend time speaking with residents, relatives and staff. The inspector ate lunch with the residents and was able to observe care practices, and how staff interacted with residents in the home. During the inspection care plans were read, and records including staff files, policies and procedures, health and safety / environmental checks and risk assessments were accessed. Prior to the inspection a copy of a quality assurance audit, which had been undertaken with residents and visitors to the home, was forwarded to the commission. Comments received and reflections of the service from this have been used as part of the inspection process. What the service does well: Improvements in the service noted at the previous inspection in November, have been maintained, and further improvements made. A major reason for this is the hard work of the manager, who has introduced good standards and practices, as well as the commitment of his team. Positive comments reflected in the last report about the attitude of the staff, and approachable style of the manager, are still relevant. The redecoration programme continues to improve the appearance of the home, and residents spoken with confirmed that they appreciated the improvements being made. ‘ I love my room and was able to choose the colour’. The home’s policy with regard to introductory visits is very thorough, and residents are given an opportunity to stay for a meal, view their room and on a separate occasion spend a night in the home before making a decision to stay there. Eden Place DS0000004306.V299402.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The home is currently well below the National Minimum Standards for staff to attain an NVQ qualification. The manager is aware of this and has shown a commitment to improve. Some staff are due to be registered on an NVQ programme. Staff would benefit from more training in specific mental health conditions, and in person centred care training. Eden Place DS0000004306.V299402.R01.S.doc Version 5.2 Page 7 An initial quality assurance review has been undertaken with residents in the home. The manager needs now to build on this to demonstrate to all interested parties changes that are to be, and are currently being made, and how residents will be able to participate in this process. Gaps in administration of medication were found during the inspection. A regular audit should be undertaken by the manager to ensure that residents are receiving all medicines prescribed to them, and reasons for not taking medication is recorded on the MAR chart. 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 DS0000004306.V299402.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Eden Place DS0000004306.V299402.R01.S.doc Version 5.2 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 the following standard(s): 1, 2, 4, 5 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the home. Prospective residents have the information and are given sufficient opportunity through visits to make a decision about the home. Their needs are assessed and an individual contract given. EVIDENCE: Since the last inspection the Statement of Purpose has been reviewed to demonstrate the changes required. Admissions to the home are only agreed if the resident and the staff feel that the home is the right environment, and staff have the appropriate skills to meet their needs. A relative of a resident spoken with confirmed that her mother had received an assessment, and that she had been able to visit and choose the home. During the inspection, the home was preparing for the admission of a younger adult for whom a variation to the registration has been agreed. Eden Place DS0000004306.V299402.R01.S.doc Version 5.2 Page 10 It was clear that the manager has undertaken a thorough assessment, and personal needs are being taken into consideration. An opportunity had been given for the resident to spend part of the day in the home, to view the facilities and a suitable bedroom, which was then redecorated, and a nighttime stay was planned for. Consideration is being given to personal tastes and an agreement has been made about the things that are coming into the home such as musical instruments and CD’s. A ‘life style’ assessment details needs with regard to leisure and occupational needs. The assessment was found to be thorough and detailed, with risks clearly identified. The Community Psychiatric Nurse (CPN) also completed an assessment, and this is also very detailed and gives clear medical information and care requirements. The inspector also saw a copy of the contract, this contains terms conditions and the range of fees. Eden Place DS0000004306.V299402.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome group is good. This judgement was made using available evidence including a visit to the home. Care plans are developed with residents, and reviewed to reflect changing needs. Residents are encouraged to take positive risks. EVIDENCE: Each resident has an individual care plan, which has been agreed with him or her, and includes health and personal care needs and risk assessments linked to lifestyle choices. A ‘Life style form’ is used and built on during the time spent in the home to record all past, present and future aspirations. The lifestyle form is also sent to social workers for completion prior to admission. Staff interviewed, demonstrated that they have the necessary skills to develop a care plan, which works for the individual. One member of staff interviewed said that one of the positive things about working in the home was that care plans were designed to ‘ offer choice and a chance for residents to live their life as they want’. Eden Place DS0000004306.V299402.R01.S.doc Version 5.2 Page 12 Care plans read showed that reviews are being held with residents and their relatives. One relative spoken with confirmed that she was aware of the care plan, attends the review meeting with the staff and the social worker, and receives a copy of the review. Risk assessments are particularly well documented on a ‘risk identity sheet’ and these are regularly reviewed. Positive risk taking is encouraged and supported. During the inspection residents were noted to be coming and going from the home, using local shops and leading their own lifestyle, supported by the staff. Care plans are the specific responsibility of the qualified staff and are monitored by the manager and his deputy. Care staff are also encouraged to make an input and pass on relevant information as required. Eden Place DS0000004306.V299402.R01.S.doc Version 5.2 Page 13 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 the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the home. Residents are able to enjoy a full and enjoyable lifestyle, and receive a healthy diet with choices available. EVIDENCE: The employment of an additional activities carer, and the availability of a mini bus have improved the home’s ability to offer a full range of activities. It is hoped by the manager to be able to offer increased flexibility of this and build in more trips at the weekend. On the day of the inspection activities such as bingo and then a musical / dance session were happening in the home, whist another group of went out to the local park in the minibus. Eden Place DS0000004306.V299402.R01.S.doc Version 5.2 Page 14 An aroma therapist has been employed on a trial basis to focus on residents with high anxiety levels. Staff and residents also spoke positively about the holiday, which is currently being planned for the summer, and the ‘cinema evenings’, which are enjoyed along with the obligatory choc-ices and popcorn! More trips are also being planned for the summer. The inspector ate lunch with residents from the home. Due to refurbishment, one of the dining areas is currently taking place in a lounge and corridor, which makes things a little cramped. This is only a temporary measure and it is hoped things will be back to normal as soon as possible. Most of the residents spoken with were aware of the reasons for change; one said that she was unaware of what was going on. ‘They don’t tell you what is going on, I have to ask’. Staff were observed serving the meal in a courteous and friendly way. Choices were offered as to the different vegetables available. The mealtime was a very social occasion, residents chatted amongst themselves and to the staff. One of the residents from the satellite homes joined one of the tables for lunch and was welcomed by the rest of the group. The menu on the day of the inspection was shepherds pie, fresh cabbage and carrots, green beans, with a choice of trifle or yoghurt for desert and this was displayed on a board in the dining room. There was no obvious choice of main meal available, but everyone on the table agreed it was a ‘lovely dinner’ and all agreed that if they had not liked what was on offer, that an alternative would be available. The cook on duty said she knew the residents’ likes and dislikes very well, and a ‘likes list’ is kept. The tea choice for that day is offered on the same afternoon. The tea for that day was fish cakes, but one resident was heard to be immediately offered fish fingers, as the cook was aware of her dislike for fish cakes. The manager said that the quality assurance questionnaire undertaken has thrown up a few issues about the food provision, which he is currently addressing. Residents are offered egg and bacon at breakfast, but a number would prefer this for tea occasionally. The manager is also exploring a more person centred approach to food, where a resident who would like something different for a meal would be offered an opportunity to go to the butcher, buy a piece of steak for example, and have it cooked. Improvements to the kitchen as identified in the last report have been made and measures have been undertaken to limit access to anyone other than catering staff or identified people, by the provision of a clearing trolley to hold used crockery and cutlery which can then be wheeled into the kitchen. Eden Place DS0000004306.V299402.R01.S.doc Version 5.2 Page 15 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 the following standard(s): 18, 19, 20 The quality in this outcome group is adequate. This judgement has been made using available evidence including a visit to the home. Residents receive appropriate personal support, and have their health care needs met. Medication administration records do not always record that residents have received their prescribed medicines. EVIDENCE: Following the last inspection, a book has been introduced to record all health care appointments, when they are due, if they were attended, or if residents choose not to go. This information is also transferred to the care plan. There is evidence that residents are attending appointments and residents confirmed that they were able to see their GP as well as a chiropodist, dentist, optician and have audio examination. The manager is hoping to organise for a GP ‘surgery’ to be held in the home, to free up the time of the staff escorting residents to some appointments. Eden Place DS0000004306.V299402.R01.S.doc Version 5.2 Page 16 Many of the residents in the home are still under the care of a Consultant Psychiatrist and some experience signs of acute distress and anxiety. A system to identify triggers to this happening is used by staff with an early warning signs risk assessment. A resident who has recently experienced an acute medical problem was seen to be handled sensitively by the staff and to be kept informed appropriately. Systems for the management and administration of medicines were checked during the inspection. The home currently uses a local chemist, and all routine medicines are in special ‘blister types’ packs, with some occasional use or short-term medicines kept in boxes. Staff currently collect all prescriptions, which are for 28-day cycles from the doctors surgery, and take them to the chemist for dispensing. The chemist visits the home approximately every 3 months to look at stock controls and procedures. Photocopies of prescriptions are held in the home, and it is recommended that these be kept in the MAR sheet folder, so that staff have easy access, and an opportunity to monitor medication administered against the prescription. Stock cupboards were seen to be clean and tidy and not overstocked. Controlled drugs are kept in appropriate cupboards and records maintained and recorded in a CD register. Records checked on the day of the inspection were found to be correct. Letters from residents’ GPs regarding the use of homely remedies such as paracetamol are kept on file, and thorough procedures are kept. Medications discontinued by the doctor are signed and dated. Medication Administration Records (MAR) were found to have a few omissions. One resident’s records showed that he had not received any of his medication on one day, with no explanation of why. Bottles of liquid medicines did not have a date of opening recorded on them. Eden Place DS0000004306.V299402.R01.S.doc Version 5.2 Page 17 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 the following standard(s): 22, 23 The quality in this outcome group is good. This judgement has been made using available evidence including a visit to the home. Systems currently in place in the home protect residents from potential abusive situations, and their views about the home and the life they lead is listened to. EVIDENCE: Staff undertook a thorough quality audit earlier this year. The results of this have been collated, but the consultation process with all residents and their relatives have not yet been completed. Most residents spoken with during the inspection confirmed that they had contributed to the survey and many felt consulted, although some said they would like more information. A relative who acts as an advocate for her mother said that she felt both informed and consulted. Residents meetings are held regularly in the home, and the manager would like to extend this to a further involvement with friends and families. The home has a complaints procedure which is clearly written and is known and understood by staff and residents. This was confirmed within the quality audit and by relatives spoken with. Each resident receives a copy within the Service Users Guide. Whilst complaints are recorded and investigated, the manager said that the audit had shown that not all relatives felt there was sufficient feedback given on the outcome of complaints, and he hopes to address this in the next year. Eden Place DS0000004306.V299402.R01.S.doc Version 5.2 Page 18 The home’s Policies and procedures to protect residents are clear. Training in the Protection of Vulnerable Adults (POVA) has been attended by the majority of staff. Those who have not attended are aware of the policies and procedures in the home. There have not been any referrals made to social services under POVA. Staff spoken with were aware of the home’s ‘whistle blowing’ policy. The home has a copy of the Department of Health ‘No Secrets’ document and the Warwickshire multi agency policy on adult protection. Information sent under regulation 37 of the Care Standards Act, which informs the commission of serious events in the home or serious injury, illness or harm to residents has been sent appropriately as required. Recruitment procedures to ensure that staff employed are of suitable character to work with vulnerable people, are robust. Eden Place DS0000004306.V299402.R01.S.doc Version 5.2 Page 19 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 the following standard(s): 24, 25, 26, 28, 30 The quality outcome for this group is adequate. This judgement has been made using available evidence as well as a visit to the home. Improvements have been made, and more are planned, to give residents who live in the home an environment, which is homely, comfortable and suits their needs and lifestyle. EVIDENCE: The inspector toured the home with the manager. It is obvious from looking around, that the home has undergone significant improvement, and more is planned. Residents and relatives spoken with were complimentary about the changes. ‘It’s so much nicer now’. There is a choice of communal space; a smoker’s lounge is at the front of the building with two further lounges and two dining areas. Rooms have been redecorated with new flooring and curtains, to be bright and cheerful. Fixtures are age appropriate. Eden Place DS0000004306.V299402.R01.S.doc Version 5.2 Page 20 Personal rooms are large and spacious. There are still two shared rooms in the home, but it is planned that these are phased out eventually. Bedrooms are currently being redecorated, and residents are being consulted over the decoration. Rooms have been adapted to lifestyle and contain TV’s, DVD players, fitness weights, personal items and pictures / photos. All residents are able to have a key to their room, but there are not currently lockable facilities within the room. Along with the new kitchen facilities and lift, new windows have been provided in part of the home, with more yet to be done. The maintenance person is providing the majority of the work, and was seen to have good discussions with the manager about appropriate floorings, colours etc. As in any home undergoing refurbishment, a certain amount of inconvenience is having to be put up with, by both staff and residents, but staff are working hard to make it as comfortable as possible. Outside the back of the home, debris is being stored for removal; old sinks, boxes and general rubbish, which could constitute health and safety risk, as residents use the back of the home. These should be removed as soon as possible and suitable storage such as a skip, acquired. The laundry of the home is situated down in the basement, which is rather dark and dingy and access is down rather steep steps, which the manager said were risk assessed. The laundry is adequately equipped, as residents in the home do not have nursing needs, so equipment is more domestic in style. Staff spoken with, had not attended training in infection control, and were unaware of the infection control policy. Advice if required on infection control issues is sought from the hospital, or GP. Staff were observed wearing protective clothing in the kitchen, serving meals and undertaking personal care. Some work is being undertaken in the garden areas, plants have been put in and some pavement slabs are being provided. In the middle of the home accessed by some patio doors is an alternative seating area. Access through these doors is currently slightly restricted due to dining tables being there on a temporary basis. This should be monitored to ensure that access to the outside is not blocked and cause an accident. The manager hopes to provide more seating in other areas of the home, as there are a significant number of residents who smoke, and require comfortable and safe outside provision. Eden Place DS0000004306.V299402.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 Quality in this outcome group is good. This judgement was made using available evidence including a visit to the home. Residents in this home receive care and support from staff who are competent to undertake the role, and are protected by sound recruitment procedures. EVIDENCE: The staffing structure of the home is currently adequate to meet the needs of the residents in the home. The manager is supernumerary to the care staff and the deputy manager has some time ‘off rota’ to undertake her responsibilities. The home has a mixture of both qualified nurses and nursing assistants, as well as cooks, housekeeping and maintenance staff and an administrator. Additional staff have been employed to undertake activities and to drive the minibus. The manager hopes to provide a placement in the future to student nurses, who will be mentored by staff in the home, but will be supernumerary to the rota. Eden Place DS0000004306.V299402.R01.S.doc Version 5.2 Page 22 Staff spoken with spoke positively about the home and the staff who work there. Induction into the home is thorough, and staff are mentored and trained and supported by more senior colleagues. One member of staff said that there was a good shift system in place and a good core of permanent staff. ‘Everyone knows what their roles are, and working towards the same goals’. Staff meetings are held monthly, and the times are alternated to allow for night staff. Training is provided by an external consultant, and staff spoken with confirmed that they had received training in most mandatory areas, but there were sometimes courses missed, and records indicate that a number of staff have not received training in health and safety. The home would benefit from the purchase of training resources so that staff that miss a course, can catch up at a convenient time. The number of staff to have attained NVQ awards are below the required standard. 1 member of staff has now been registered, with 3 or 4 more to register in September. The manager said that he knew there was work to be done in training the staff, and hoped to be focusing on providing a plan and training on specific medical conditions. A supervision programme for staff is in place and a supervision policy is being developed. Staff confirmed that they were supervised in their role, and that there is a clearly defined structure of which senior member of staff, supervises other staff. Records seen confirm that staff are appropriately supervised. Residents and relatives spoke well of the staff group ‘This staff group are really good, they tell you what is going on, let me know when the doctor is coming, and will ring and let me know’. Eden Place DS0000004306.V299402.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 42. The quality in this outcome group is good. This judgement has been made using available evidence including a visit to the home. The registered manager is competent to run the home, and residents benefit from the policies, procedures and ethos of the home, which has their safety and best interests at heart. EVIDENCE: The manager of the home is now registered with the commission and is undertaking his NVQ level 4 Registered managers award, which he feels is progressing well and will be completed within the timescales set. The manager and his senior team appear to have a good working relationship, and there was evidence of good communication. Eden Place DS0000004306.V299402.R01.S.doc Version 5.2 Page 24 The manager receives regular supervision in his role from both his line manager, and the training consultant. His ‘aims and objectives’ for discussion include staffing levels, clinical supervision, finance and time management, staff training and accountability. The manager said that he felt well supported by his line manager, and staff said that the directors of the company were ‘very proactive’ and willing to invest in the home. Staff spoke highly of the manager saying that they felt positive that the home was ‘on the up’. ‘The manager is excellent, very approachable, the door is always open and they listen to us’. ‘The manager is always willing to listen to different ways of doing things and has got the best interests of the residents at heart’. As previously referred to in the report a quality assurance survey has recently been undertaken. A few residents and some relatives said that they would benefit from more communication and involvement. The manager feels that there is more to be developed in this area of management of the home, and is keen to look at ways to increase both resident and relative involvement. The home is currently undergoing refurbishment and improvement. The manager demonstrated that both he and the maintenance staff are aware of the health and safety needs of residents. Some concerns were raised during the inspection with regard to uneven flooring both in and outside to home, and the lack of storage for equipment, but the manager was aware of these issues. Training for staff in health and safety needs updating, and whilst there was evidence that the majority of staff have attended fire safety training, evidence that staff have attended a drill was not available for inspection. A fire inspection was undertaken earlier this year, and the home has a fire risk assessment, which is reviewed annually. Eden Place DS0000004306.V299402.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 Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 3 X X 2 X Eden Place DS0000004306.V299402.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. 1. Standard YA20 Regulation 13 Requirement The Medicine Administration Record (MAR) chart must be completed to record all the drugs administered and if not administered, a reason for not doing so. Staff drug audits before and after a medicine round must be undertaken on a regular basis to assess nursing staff competence in medicine management and appropriate action must be taken when audits identify that the medicines are not administered as prescribed. The date that all liquid medicines in bottles are opened must be written clearly on the bottle, so that the date for discarding such medicine is known. The registered manager must ensure that all rubbish and items removed from rooms being refurbished, are safely stored and removed from the premises as soon as is possible. The registered manager must ensure that all rubbish and items removed from rooms being refurbished are safely stored and removed from the premises as soon as is possible. DS0000004306.V299402.R01.S.doc Timescale for action 30/06/06 2. YA20 13 30/06/06 3. YA20 13 30/06/06 4. YA24 23 14/07/06 5. YA42 12 31/07/06 Eden Place Version 5.2 Page 27 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 YA25 YA26 YA32 Good Practice Recommendations The plans for refurbishment should continue as planned and all shared bedrooms should be phased out as soon as is practicable. Lockable storage space for medication, money and valuables should be available within individual bedrooms. The inspector recommends that a training matrix be kept to record all training achieved by staff and when refreshers are due. A training plan to identify the training needs of the staff group linked to the needs of the residents and supervision is needed. The inspector recommends that due to the lay out of the building and client group, and especially during the refurbishment, that regular fire drills be undertaken to supplement the training already received by staff. Uneven flooring both flagstones outside the home, and matting in corridors, should be repaired to avoid trip hazards for staff and residents. 4. YA42 5. YA42 Eden Place DS0000004306.V299402.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Leamington Spa Office 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 DS0000004306.V299402.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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