Inspection on 19/12/05 for Edendale Residential Care Home

This inspection was carried out on 19th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Edendale Residential Care Home 31/07/07

Edendale Residential Care Home 19/06/06

Edendale Residential Care Home 15/06/05

Edendale Residential Care Home 21/01/05

Edendale Residential Care Home 28/07/04

Similar services:

1 Marten Road

Daubeney House

Three Gables

Deepdene Care Centre

Aldwick House

49 Glendale

Ferndale Residential Care Home

David Gresham House

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

CARE HOMES FOR OLDER PEOPLE Edendale 5-6 The Green St Leonards-on-sea East Sussex TN38 0SY Lead Inspector Mrs Sally Gill Unannounced Inspection 19th December 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Edendale DS0000021092.V274379.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Edendale DS0000021092.V274379.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Edendale Address 5-6 The Green St Leonards-on-sea East Sussex TN38 0SY 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) 01424 429908 Mr Glynn Fettiplace Mrs Andrea Fettiplace Mr Glynn Fettiplace Care Home 31 Category(ies) of Dementia (31), Mental disorder, excluding registration, with number learning disability or dementia (31) of places Edendale DS0000021092.V274379.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The minimum age of service users on admission will be fifty five years (55). The maximum number of residents to be accommodated is thirty one (31). 15th June 2005 Date of last inspection Brief Description of the Service: Edendale is registered to provide accommodation for up to 31 people of 55 years old and over suffering from dementia or mental illness and admits people with low to high dependency needs. The premise is two large separate detached properties situated in St Leonards. It has 13 single rooms and nine doubles situated on three floors all have a wash hand basin. Residents in one house have the use of a ground floor lounge and a dining room and first floor smaller lounge/diner. In the other house residents have use of a ground floor lounge and dining room and a second floor smaller lounge and dining area. Smoking is allowed in each house in the designated area. The home has a secure rear garden accessed by steps with seating and lawn area for residents to enjoy. Car parking is available to the front of the houses. The buildings are located a five minute walk from the nearest shops and is on a bus route with a bus stop just outside the home. The home currently has 27 residents. Edendale DS0000021092.V274379.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place on Monday, 19th December 2005 between 10.10am and 4.30pm. Additional time was spent in preparation and report writing. During the inspection the Inspector spoke to eight residents both in company and in private and met/briefly spoke to six others. Also, she spoke to the senior carer on duty and the handyman. The Registered Managers/Owners were not on duty at the time of the inspection and the Inspector spoke to one Registered Manager/Owner (Mrs A Fettiplace) by telephone whilst at the home regarding concerns highlighted during the inspection. Feedback from residents during the inspection confirmed that they are all satisfied with their care at Edendale. Comments included “I have a nice room”, “its clean”, “the food is very good and I am quite particular but I can always chose something I like for instance today I’m having curry”, “ the food is pretty good”, “the staff are nice”, “I have no complaints”, “we like the staff they don’t make a lot of fuss but care”, “its free and easy here” and “its well run”. The Inspector examined various records including care plans, risk assessments, doctors book, monthly reports, Medication Administration Record (MAR) charts, menus, adult protection, whistle blowing and complaints procedure, and the fire safety logbook, accident book, staff recruitment and induction documents, and health and safety records. The complaints log could not be located at the time of the inspection. The senior staff member assisting with the inspection did not have access to resident’s finances or training statistics. The Inspector accessed parts of the building including all lounges and dining rooms, bathrooms and toilets, kitchens, the office and several resident’s bedrooms. After discussion during the inspection those that live at Edendale will be referred to in this report as residents. The Inspector would like to thank both residents and staff who assisted during the inspection. As this report only covers only some of the key standards it should be read in conjunction with the previous inspection report. Edendale DS0000021092.V274379.R01.S.doc Version 5.1 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Staff recruitment procedures must be reviewed immediately to safeguard residents. Residents are at risk from shortfalls in the medication system, fire safety procedures and the lack of a radiator guard. To ensure the good health of resident’s improvements must be made to infection control and all risks must be assessed. Improvements are required to care records. Records must be complete and stored/recorded confidentially and in line with regulations. Edendale DS0000021092.V274379.R01.S.doc Version 5.1 Page 7 The quality of life could be much enhanced by suitable formats for resident’s information. The lock on a bathroom door should be repaired to ensure residents dignity. To ensure residents safety storage of cleaning materials, hot water safety valves and a bedroom carpet require attention. Food hygiene should be improved to ensure residents health. A record of food should also be maintained. The adult protection/whistle blowing policy requires review in order that residents are fully protected. Residents and all visitors to the home must be aware of how to complain within the home. Residents must benefit from a team of staff trained and competent in sufficient numbers. There should be a formal quality assurance system in place within the home. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Edendale DS0000021092.V274379.R01.S.doc Version 5.1 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 Edendale DS0000021092.V274379.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None inspected on this occasion EVIDENCE: Edendale DS0000021092.V274379.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 There is little evidence that residents assessed needs and risks are reviewed and the information is still up to date. Resident’s health care needs are met. There are major shortfalls in the medication system, which could pose a risk to residents. There are minor shortfalls in maintaining resident’s privacy and dignity. EVIDENCE: Care plans were seen to contain good detail regarding residents assessed needs however the assessment and/or the monthly reports do not evidence that the information with the assessment is reviewed and still current. Risk assessments are in place for behaviour and falls but these are not dated and again do not evidence review. The risk assessments must contain all relevant risks such as tissue viability and other individual risks highlighted during the inspection including the portable heater, self-administration of medicines, handling and storage of cleaning materials. A communal book is currently used for recording health information. In order to maintain the confidentiality of resident’s records and meet legal requirements changes are required to the way these are recorded. Edendale DS0000021092.V274379.R01.S.doc Version 5.1 Page 11 Health care needs are met and currently GP’s, the District Nurse, CPN and the continence advisor support the home. A chiropodist visits the home six weekly. Although the residents weight was recorded in the care assessment and the Inspector advised that residents are weighed there is no record of this in their care plan to enable the monitoring of any loss or gain. The Inspector viewed the medication system within the home and was pleased to see that the majority of residents have been transferred to a monitored dosage system to avoid re-dispensing medicines. This system needs to be expanded to include all residents. Other concerns that need addressing include the medication policy should include areas such as homely remedies, over the counter medicines, self administration or part self administration and arrangements for medicines in the event of a death of a resident. There must be a clear step-by-step written procedure for staff to follow for medication administration including recording and controlled drugs, ordering and returns of medicines and storage. There must be risk assessments for selfadministration or part self-administration and storing medicines/creams in resident’s bedrooms. Any medication prescribed as and when required should have clear written instruction for staff as what it is for, how and when it should be administered including any maximum/minimum quantities and any authorisation that is required by staff before it can be administered. There should be a signature list of staff competent to administer medication. It is strongly recommended that the home obtain and refer to the Royal Pharmaceutical Society’s “The Administration and Control of Medicines in Care Homes”. Staff should undertake medication training that reflects the standards. Other shortfalls in the medication system include controlled drugs must have two signatures on the MAR chart and good practice would be to use a bound book for administration of a controlled drug. The MAR charts should detail a full audit trial of all medication that comes into and leaves the home, which is currently not the practice. MAR charts should reflect up to date medication for each resident. Any eye drops should be dated when opened to ensure they are only used in the recommended period. Medication coming into the home is currently not logged on the MAR chart and there is no record of returns either therefore there is no audit trail of medication entering and leaving the home. All medicines must be stored securely and any storage unit should not draw attention to the fact that medicines are stored here. The storage area must be clean with sufficient work surface. All medicines apart from those that require refrigeration must be stored below 25 degree C. All medicines no longer required must be return to the pharmacist and not disposed of any other way. Staff were observed to have adopted the practice of using named pots and bulk dispensing which is consider bad practice, the use of any pots is not considered good practice. Staff should be taking the medication to each Edendale DS0000021092.V274379.R01.S.doc Version 5.1 Page 12 individual resident using a safe method of transport and administering medication directly from the blister pack/bottle to the resident wherever possible checking all details in the process. This may on occasion for the convenience of the resident involve a pot but this practice would be carried out in front of the resident. The staff member should observe the medication being taken unless a risk assessment is in place, which states otherwise. Once the resident has been observed taking the medication then the MAR chart should be signed. This practice will result in the MAR charts evidencing a true account of medication administration, which again at present is not the case. An oxygen cylinder was observed in a lounge although the Inspector informed this is normally kept in the resident’s bedroom. The home must handle and store oxygen in line with BOC guidance. Residents confirmed that their privacy is maintained whilst staff undertake personal care and they are able to choose to spend time alone if they wish. However improvement needed to ensure privacy and dignity are maintained include the lock on one bathroom door was broken and should be repaired, one resident was temporarily occupying a room with another residents name on the bedroom door and furniture. Edendale DS0000021092.V274379.R01.S.doc Version 5.1 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Residents confirmed that routines are flexible, they benefit from activities although choice and control could be improved within their day-to-day life. It is apparent that resident maintain contact with families and friends. Residents enjoy a varied menu. EVIDENCE: Records did not reflect activities residents are offered or participate in. Although the senior carer said that lists of residents undertaking organised activities have been given to the Registered Manager. In house activities include listening to music, radio or tapes, daily newspapers and magazines and watching television. Some residents are able to go out independently shopping and visiting friends; staff also take other residents for walks. Outside entertainment also comes into the home including a music man singing and playing a keyboard; a Nostalgia group singing and they bring in instruments for residents to play, a music and movement session is held each week. The hairdresser visits every two weeks. Seasonal activities include visiting carol singers and a Christmas meal out. Several residents talked about the contact, which is maintained with families and friends. A volunteer visits the home twice a week to spend time talking to residents. Edendale DS0000021092.V274379.R01.S.doc Version 5.1 Page 14 Menus rotate six weekly although there is no choice residents confirmed that alternatives are available. The cook is aware of likes and dislikes and an alternative that the resident would like is cooked. On the day of the inspection no resident could inform the Inspector of what was for lunch. It is recommended that perhaps a menu board could be used to inform residents; this could also be used as a re-orientation and activities board to aid choice and control. The cook was not working and one of the care staff was cooking. The meal looked appetising and residents confirmed, “It tastes good and is hot”. Residents can chose where to eat their meals some choosing to eat in their rooms. Although there is a record of the main meal and of suppers the alternatives are not recorded and must be. To help exercise choice and control over resident’s lives they should benefit from picture/signage of their own rooms and around the home (toilets/bathrooms). The practice of keeping residents toiletries ‘safe’ must be reviewed and the restriction only in place where necessary, following a risk assessment. The importance of a re-orientation board was also discussed which should be introduced and include information such as day, date, menu, today’s activity etc. Edendale DS0000021092.V274379.R01.S.doc Version 5.1 Page 15 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 There is no clear procedure within the home for complaints or how to handle and record them. Some of the homes procedures/records leave the residents at risk from harm and abuse. EVIDENCE: The homes complaints procedure is not displayed within the home. The complaints procedure displayed is that of the local Social Services department. Staff could not find a complaints procedure for the home, which showed how complaints would be dealt with in the home including timescales and the name and address of the Commission. The complaints log could also not be found. After checking staff files it became evident that staff were working in the home without proper and full recruitment checks having been carried out leaving the residents at risk. See standard 29 for further details. The last accident recorded (October 2005) was not recorded fully. Accidents that were recorded did not require further investigation. Accident reports must be stored in line with confidentiality and Date Protection Act 1998. See also standard 38. The Inspector viewed the Adult Protection and whistle blowing policy, which does not show who and where to report abuse outside of the home. The home must be working in line with the East Sussex, Brighton and Hove Multi-Agency Adult Protection Guidelines and needs to identify the relevant Social Services Edendale DS0000021092.V274379.R01.S.doc Version 5.1 Page 16 Department. In addition the name and address of the Commission should be added, as this would be a reportable incident under the Care Homes Regulation 37. The homes practices regarding resident’s monies, personal allowance and savings could not be inspected, as the Registered Managers were not present. Edendale DS0000021092.V274379.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 26 Improvements are required to ensure that the environment is safe and hygienic for residents. The resident are benefiting from an environment, which is comfortable and spacious with on going maintenance work carried out. EVIDENCE: The home is clean, warm, spacious, comfortable and homely. There is on going maintenance to maintain the environment. The home is in keeping with local properties and the grounds are safe, well maintained and accessible to residents. The Inspector was advised that radiator guards have been fitted however one toilet had a hot radiator with no guard which is a risk to residents. The Inspector viewed the fire safety logbook, which evidenced that the alarms had not been tested to the required frequencies and that not all call points were randomly tested. The fire extinguishers should be visually checked monthly and recorded. The Fire Safety Officer must be contacted for Edendale DS0000021092.V274379.R01.S.doc Version 5.1 Page 18 guidance in relation to fire safety and the front door, which is kept locked. The door at the top of the stairs (fire door) must be kept closed or fitted with an appropriate closure. Records of the servicing of fire equipment were not available for inspection. Generally the home appeared to be clean although one freezer requires cleaning and defrosting. However there must be liquid soap, paper towels (or equivalent) and pedal bins in all the communal toilets and bathrooms. Currently because resident’s toiletries are kept ‘safe’ there is no soap or towel on some entire floors of the home should any resident wish to use the toilet. The clinical waste bin must be a pedal bin not open. Good practice would be the double bagging of clinical waste. One bedroom had an offensive odour, which was discussed with the senior carer and must be addressed. All commodes must have pot lids and those that are rusty must be repaired/replaced. The bathroom chairs must be readily cleanable and the mouldy bathmats and highlighted toilet seat must be replaced. The leaking pipe work in a bathroom and the broken toilet roll holders must be repaired. See previous standard regarding signage around the home to meet the needs of residents Edendale DS0000021092.V274379.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29, 30 Appropriate checks have not been carried out prior to staff working in the home, which leaves the residents at risk of harm and abuse. Residents should benefit from a staff team, which undertakes induction/foundation training to Skills for Care specification and can evidence staff competency. EVIDENCE: The Inspector viewed two staffs’ documents, which are held in communal file and not individually. This highlighted that staff are being recruited without proper checks being completed. One sheet of A4 paper is the application form and also doubles as an interview form. There is no space for the previous employment record required by the regulations, addresses of references are not asked for nor does it state that one of these must be the previous employer. These documents were also not signed by the employee. One employee had one written reference and the other had none. There was no evidence of a CRB disclosure in place. The Inspector telephone the Registered Manager/Owner (Mrs Fettiplace) to inform her that staff must not work in the home unless two written references have been obtained and an enhanced disclosure is in place with immediate effect. The home should check the regulations to see also what information must be held at the Care Home in relation to staff and adjust their records as necessary. Any volunteers should also under go a thorough recruitment procedure, which would include a disclosure. Edendale DS0000021092.V274379.R01.S.doc Version 5.1 Page 20 Staff confirmed that they have not received a copy of the GSCC code of conduct and practice, which they should. The Inspector and senior member of care staff discussed the homes inductiontraining programme. The induction programme does not meet the Skills for Care specification, which they should. The revised Skills for Care induction standards, which will replace the current induction/foundation standards, were discussed. The home should obtain a copy of these, as at present they cannot evidence that their induction meets the specification of Skills for Care. The home also needs to be able to evidence the competency of staff undertaking induction as in future this evidence will go with staff when joining a new employer. Edendale DS0000021092.V274379.R01.S.doc Version 5.1 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 37, 38 Improvements to records, policies and procedures are required to safe guard residents. Residents do not benefit from an effective quality assurance system where their views are heard. To ensure residents health and safety are protected improvement must be made. EVIDENCE: All feedback from residents was positive throughout the inspection. However the requirement to have a formal quality assurance system in place where residents, relatives, professionals and others involved in the home are asked their views on the service remains outstanding. Improvements are required to records as stated previously in this report (medication, fire safety, record of food, activities, review of care plans and risk assessments, additional risk assessments, recruitment, accident reports). The Edendale DS0000021092.V274379.R01.S.doc Version 5.1 Page 22 day-to-day reports written by staff regarding resident’s health are recorded in a communal book. The system used to record information particularly sensitive information about residents should be reviewed to ensure individual confidentiality is maintained. Personal resident information must not be entered into the communal logbooks in accordance with the regulations and the Data Protection Act 1998. The home must check their records against the regulation schedules as there are shortfalls in resident and staff records required to be held at the home. Some of the homes policies and procedures require review as previous stated in this report (medication, adult protection and whistle blowing). Statistics for staff training were not available however some staff have recently undertaken fire safety training. Given the findings of the inspection and discussions with staff further staff should be trained in fire safety, food hygiene, manual handling, first aid and infection control, this training must also be kept up to date. A person qualified in first aid must also be on duty at all times. Cleaning materials must be handled and stored in line with COSHH regulations and not left unattended in the hallway. See also standard 19 for fire safety. See also standard 18 for accidents and recording. See standard 30 for induction training. See standard 10 regarding the handling and storage of oxygen. Edendale DS0000021092.V274379.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 2 X X X X X X 1 STAFFING Standard No Score 27 X 28 X 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 1 X X X 1 1 Edendale DS0000021092.V274379.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 15(1) Requirement The service needs to ensure that the care plans in existence match the criteria and cover the topics set out in Standard 7, this is particularly relevant to the activities offered within the service, and will help to identify which service users participate in which activity and how often they do this (previous timescale of 01/08/05 not met) Risk assessments must contain all risks, be dated and evidence review Care plans must evidence that information is up to date and reviewed The service follows the recommendations as set out by the pharmacy inspector (previous timescale of 01/09/05 not met) The home shall make safe arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the home DS0000021092.V274379.R01.S.doc Timescale for action 19/02/06 2 3 4 OP8OP7 OP8OP7 OP9 13(4) 15(2) 13(2) 19/02/06 19/02/06 19/02/06 5 OP9 13(2) 19/02/06 Edendale Version 5.1 Page 25 6 OP10OP14 12(2)(4) 7 8 OP16 OP18OP29 22 19 9 10 11 OP18OP29 OP38OP19 OP38OP19 19 23(4) 23(4) 12 OP19 23(2) 13 14 OP25 OP38OP26 13(4) 13(3) 16(2) j, k 13(3) 16(2) j, k 13(3) 16(2) j 13(3) 16(2) j 16(2) j, k 16(2) j 24(1)(a) (b)(2) 15 16 17 OP38OP26 OP38OP26 OP26 18 19 20 OP26 OP38OP26 OP33 The practice of keeping residents toiletries ‘safe’ must be reviewed and the restriction only in place where necessary, following a risk assessment The home must have its own complaints procedure which is accessible to residents/visitors The home must follow a robust recruitment procedure which meets the regulations Immediately Staff working must be in accordance with CRB guidance Immediately Maintain adequate fire safety (testing equipment, door closure) Contact the Fire Safety Officer for guidance in relation to the locking of the front door and fire safety The leaking pipe work in a bathroom, the bathroom lock and the broken toilet roll holders must be repaired Radiators must be safeguarded where is a risk to residents There must be liquid soap, paper towels (or equivalent) and pedal bins in all the communal toilets and bathrooms The clinical waste bin must be a pedal bin The rusty commodes must be repaired/replaced, bathroom chairs must be readily cleanable The mouldy bathmats, highlighted toilet seat and the missing commode pot lids replaced The highlighted bedroom must be free from offensive odours The freezer must be clean and regularly defrosted The service must implement an effective quality assurance and DS0000021092.V274379.R01.S.doc 19/02/06 19/02/06 19/12/05 19/12/05 20/12/05 04/01/06 19/01/06 19/02/06 05/01/06 26/12/05 19/02/06 19/01/06 19/01/06 26/12/05 31/03/06 Edendale Version 5.1 Page 26 21 OP37 17 Schedules 2,3,4 18(1) 22 OP38 23 OP38 13(4) monitoring system that meets the requirements set out in this standard (previous timescale of 01/09/05 not met) Maintain adequate, effective and efficient records required by regulation for the protection of all Sufficient numbers of staff trained in (and up to date) fire safety, food hygiene, manual handling, first aid and infection control Cleaning materials must be handled and stored in line with COSHH regulations 31/03/06 31/03/06 26/12/05 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 4 5 6 7 8 Refer to Standard OP9 OP9 OP9 OP12OP14 OP10OP22 OP14 OP18 OP29 OP30 Good Practice Recommendations Obtain and work to the Royal Pharmaceutical Society’s “The Administration and Control of Medicines in Care Homes” Staff should undertake medication training that reflects the standards Handling and store oxygen in line with BOC guidance A orientation board should be introduced and include information such as day, date, menu, today’s activity etc. Implement picture/signage of residents own rooms and around the home (toilets/bathrooms The homes adult protection/whistle blowing policy must show where to report abuse outside of the home (names and address) All staff should received a copy of the GSCC code of conduct and practice The induction programme should meet the Skills for Care specification and evidence competency Edendale DS0000021092.V274379.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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. 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