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Inspection on 22/11/05 for Edensor Nursing and Residential Home

Also see our care home review for Edensor Nursing and Residential Home for more information

This inspection was carried out on 22nd November 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Edensor provides a welcoming, homely and pleasantly decorated environment. Staff are friendly and work hard to meet residents` needs. Those spoken with said they found staff very caring and helpful and said they were well looked after. However there were not enough staff during the lunch period to fully meet the dependency needs of residents. The standard of food, mostly cooked on site is good and nutritious. Residents said they enjoyed the meals that were provided. The home is well supported by the local GP practice and district nursing service and their health needs are generally well met, although problems in communication had evidently resulted in some delays in referral to GPs.

What has improved since the last inspection?

Since the last inspection the home has been refurbished and lighting provided in residents` rooms and repairs undertaken to mend a leaking roof. Call bells were provided in all rooms and the laundry wall and flooring replaced. A fire safety audit of the premises had been undertaken, an action plan developed that was in the process of being implemented. Action had been taken to ensure all residents had an assessment and plan of care and mobility plans improved to provide detailed instruction. Staff had received training on the moving and handling instructors course, advanced diabetes, pressure ulcer identification and prevention, single assessment process awareness, basic awareness of diabetes, abuse in vulnerable adults, deep vein thrombosis, pain management, health and safety and management of epilepsy in the elderly.

What the care home could do better:

There is a lack of leadership and management. The interim management arrangements do not provide staff with an appropriate level of support and supervision. Whilst staff were observed to be caring and aimed to meet residents needs in a dignified way, staffing levels were too low to meet the personal, nutritional and social care needs of residents and dignity was sometimes compromised. There was a lack of monitoring and review of residents needs` with some considerable delay between reviews. Accident records were not recorded as required and follow up risk assessments were not undertaken following incidents. The activities programme in not sufficiently developed to meet the social/therapeutic needs of all residents including those with a dementia. Appropriate procedures were in place for managing residents` monies, however staff did not always adhere to them. There are some health and safety risks to the premises that were evident: one radiator in a resident`s en-suite was not guarded, a wardrobe was not secured safely, thermostatically controlled valves were not provided in all residents` rooms and a fire exit had no magnetic fittings. There is a separate visitors room for residents to meet with their visitors in private, but this had not been made available to relatives spoken with. There were no staff hand washing facilities in some en-suites and foot operated bins were not available for disposal. Tablets of soap were evidently being used communally, posing a risk of infection. Some staff had a poor understanding of English and were not clear on health and safety requirements.

CARE HOMES FOR OLDER PEOPLE Edensor Nursing and Residential Home 3 - 9 Orwell Road Clacton on Sea Essex CO15 1PR Lead Inspector Diana Green Unannounced Inspection 22nd November 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 Edensor Nursing and Residential Home DS0000015322.V268294.R01.S.doc Version 5.0 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. Edensor Nursing and Residential Home DS0000015322.V268294.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Edensor Nursing and Residential Home Address 3 - 9 Orwell Road Clacton on Sea Essex CO15 1PR 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) 01255 423317 01255 423347 Elder (UK) Limited Manager post vacant Care Home 66 Category(ies) of Dementia (26), Mental Disorder, excluding registration, with number learning disability or dementia - over 65 years of of places age (46), Physical disability over 65 years of age (26) Edensor Nursing and Residential Home DS0000015322.V268294.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Persons of either sex aged 40 years and over, who require nursing care by reason of dementia (not to exceed 26 persons) Persons of either sex, aged 65 years and over, who require care by reason of a mental disorder, excluding learning disability or dementia (not to exceed 46 persons) Persons of either sex, aged 65 years and over, who require nursing care by reason of a physical disability (not to exceed 26 persons) 11th May 2005 Date of last inspection Brief Description of the Service: Edensor provides nursing and personal care with accommodation for younger people with dementia and older people with mental illness and/or physical disabilities. Edensor is owned by a private organisation named Elder (UK) Ltd. The home is located in a residential area within walking distance from the centre of Clacton upon Sea.The home was opened in 2002 and consists of a three-storey building.There are 34 single bedrooms and 16 double bedrooms. There is a passenger lift. The home has gardens to the front of the property and a secure courtyard garden that is accessible to wheelchair users. Edensor is accessible by road and rail and the nearest station is in Clacton on Sea. Parking is available in the small car park and adjacent road. Edensor Nursing and Residential Home DS0000015322.V268294.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on the 22/11/05, lasting 6 hours. Two inspectors undertook the inspection. The inspection process included: discussions with the proprietor, five staff, five service users, two relatives and feedback from health and social work professionals; a tour of the premises including a sample of residents’ rooms, bathrooms, communal areas and the laundry; and inspection of a sample of policies and records (including any records of notifications or complaints sent to the CSCI since the last inspection). Twenty standards were covered, and nineteen requirements made including four repeat requirements and two recommendations. The proprietor and staff were welcoming and helpful throughout the inspection. What the service does well: What has improved since the last inspection? Since the last inspection the home has been refurbished and lighting provided in residents’ rooms and repairs undertaken to mend a leaking roof. Call bells were provided in all rooms and the laundry wall and flooring replaced. A fire safety audit of the premises had been undertaken, an action plan developed that was in the process of being implemented. Action had been taken to ensure all residents had an assessment and plan of care and mobility plans improved to provide detailed instruction. Staff had received training on the moving and handling instructors course, advanced diabetes, pressure ulcer identification and prevention, single assessment process awareness, basic awareness of diabetes, abuse in vulnerable adults, deep vein thrombosis, pain management, health and safety and management of epilepsy in the elderly. Edensor Nursing and Residential Home DS0000015322.V268294.R01.S.doc Version 5.0 Page 6 What they could do better: 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. Edensor Nursing and Residential Home DS0000015322.V268294.R01.S.doc Version 5.0 Page 7 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 Edensor Nursing and Residential Home DS0000015322.V268294.R01.S.doc Version 5.0 Page 8 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): 3&6 Assessment of residents is not sufficiently robust to identify all residents’ needs. Without a detailed assessment there is no assurance their needs can be met. This home does not provide intermediate care. EVIDENCE: The homes pre- admission assessment was sampled for three residents recently admitted to the home. One covered all of the areas identified under the standard apart from social activities/interests. One made no reference to foot-care or oral health and there was no record of weight on admission. The level of detail in the assessment was also too brief to enable care plans to be appropriately developed. This home does not provide intermediate care. Edensor Nursing and Residential Home DS0000015322.V268294.R01.S.doc Version 5.0 Page 9 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, 10 Residents have good access to health care services but problems in communication and poor record keeping results in late referrals to GPs that compromise their wellbeing. Further staff training and attention to address premises issues are needed to assure residents they are respected and their right to privacy is upheld. EVIDENCE: Three care plans were sampled and whilst linked to the pre-admission assessment did not cover all identified needs and did not provide staff with clear instructions on how to meet residents’ needs. One resident identified on the risk assessment as being of high risk of developing pressure sores had a pressure-relieving mattress in place but there was no care plan for prevention of pressure sores evident. A turning chart was in use that also included a record for food and fluid but this indicated that they were not being turned at the specified times. Discussion with two residents indicated that they were generally happy with the support that they were receiving at the home, however one resident spoken with was quite derogatory in their comments on the home, these comments were discussed further with the proprietor, who was able to clarify Edensor Nursing and Residential Home DS0000015322.V268294.R01.S.doc Version 5.0 Page 10 the issues raised by the resident. Care plans were not all regularly reviewed with some reviewed at three monthly intervals and some risk assessments not reviewed since 20/05/02. The home has a contract with a local general practitioner who attends the home twice weekly and on request. Some concern was raised by the home in relation to the ‘out of hours’ access for GP support. From the records inspected it was evident that monitoring of health needs was inconsistent and referrals were not always made promptly to GPs as needed. One resident identified as having lost weight prior to admission had nutritional intake recorded but there had been no weight recorded since their admission two months ago. A second resident had no weight recorded on admission. The daily progress records included a statement that one resident had a pressure sore but there was no care plan or evidence this had been treated. The daily progress records also made reference to an accident three weeks previously but this had not been recorded in the accident records and no risk assessment had been undertaken afterwards to evidence that the risk had been minimised. One resident had a hearing impairment and had been referred to the audiology clinic and provided with a hearing aid but had refused to wear it. However this had not been explained to the family who were experiencing considerable difficulty in understanding the resident. Staff were observed to treat residents with respect and to call them by their preferred name. However some were observed not to knock prior to entering residents’ rooms. Relatives also raised concerns that they had not been offered a room to see their loved one in private. Edensor Nursing and Residential Home DS0000015322.V268294.R01.S.doc Version 5.0 Page 11 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, 15 Staffing levels are too low for the dependency needs of residents. This and a lack of cover for the activities coordinator results in limited activities provided with no consistent therapeutic programme to meet the needs of residents with dementia. The home provides residents with a well-balanced and nutritious diet but there are not enough staff to ensure residents receive sensitive and timely assistance. This is reflected in the institutionalised environment evident in some areas during meals. EVIDENCE: Care staff undertake activities with residents individually and as a group. However there is no annual leave or sickness cover provided for the activity coordinator and there are too few care staff to provide social/therapeutic activities without compromising residents’ personal care needs. No physical exercise sessions were provided although residents were observed to be encouraged to walk with assistance where needed. The menu was displayed for residents’ information and their choice discussed daily with them. Residents were observed to eat their meals in either of three communal rooms with arrangements for some to eat later as they chose. Some residents were able to eat independently and those who were able said they found the food very good. However there were too few staff during the lu Edensor Nursing and Residential Home DS0000015322.V268294.R01.S.doc Version 5.0 Page 12 period to provide assistance to the high proportion of residents who required assistance with eating or supervision, resulting in some residents having to wait to receive assistance although their food had already been served and other residents being required to wait to receive attention to personal care needs. Edensor Nursing and Residential Home DS0000015322.V268294.R01.S.doc Version 5.0 Page 13 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 The home has appropriate complaint procedures that have usually been adhered to but there is evidence that some residents/relatives are not aware of them and therefore do not know how to make a complaint. The home’s protection of vulnerable adults procedure had not been personalised to the home. Without clear procedures there is a risk that residents may not be protected from abuse. EVIDENCE: Edensor Nursing and Residential Home DS0000015322.V268294.R01.S.doc Version 5.0 Page 14 The service user was asked if they were aware of the homes complaint procedure, to which they replied no. OP 16 (2 Edensor Nursing and Residential Home DS0000015322.V268294.R01.S.doc Version 5.0 Page 15 The home had a complaints procedure that included the timescales within which complainants can expect a response and advised them of their right to refer to the CSCI at any stage. One complaint was under investigation. The manager said there had been no other complaints since the previous inspection. Some residents spoken with said they were not aware of the complaints procedure. Edensor had a whistle blowing procedure place for staff guidance. The Essex Guidelines on the Protection of Vulnerable Adults (POVA) was available. A revised procedure had been obtained but this required personalising to the home. There had been no allegations of abuse. Edensor Nursing and Residential Home DS0000015322.V268294.R01.S.doc Version 5.0 Page 16 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, 25, 26 The recent refurbishment has provided residents with a pleasant environment but attention is still required to ensure all areas of the home are free from hazards. EVIDENCE: The home had been refurbished, new carpets fitted and some new furniture installed. Garden areas had been tidied and were now safe. A regular maintenance programme was in place with records maintained. A fire safety audit had been undertaken and an action plan developed that was in the process of being actioned. The proprietor stated that heating in residents’ rooms was now thermostatically controlled, however during a tour of the premises each of the rooms inspected had no thermostatic controls fitted to the radiators. The laundry floor and wall tiles had now been replaced as required at the previous inspection. Staff hand-washing facilities (liquid soap and paper towels) were not present in all residents’ en-suites. Tablets of soap were left in bathrooms and were evidently being used communally, posing a risk of Edensor Nursing and Residential Home DS0000015322.V268294.R01.S.doc Version 5.0 Page 17 infection. Foot operated pedal bins were not present for disposal of waste in all clinical areas. Edensor Nursing and Residential Home DS0000015322.V268294.R01.S.doc Version 5.0 Page 18 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): 27 & 30 Staffing levels are too low to appropriately meet the dependency needs of residents and the layout of the building. This results in residents having to wait to receive assistance with eating and personal care. The recruitment processes are generally satisfactory but attention is needed to ensure evidence of fitness for the job and a recent photograph are obtained. There has been substantial investment in staff training. A competency framework needs to be developed and staff assessed to ensure they have benefited from the training and are now competent in the identified areas. EVIDENCE: There were 62 residents of which 27 required nursing care. The manager was on long-term leave and interim management arrangements were in place, comprising a manager from another home attending 2 days per week supported by a deputy manager. Neither were present but the proprietor was in attendance throughout the inspection. Staffing levels comprised 2 registered nurses and 10 care staff. Observation during the inspection and particularly at mealtimes indicated that staffing levels were not adequate to appropriately meet for the dependency needs of residents (see standard 15). The personal files of two recently appointed staff were inspected. One had no recent photograph of identity and neither had evidence that the person is physically and mentally fit for the role that they are to perform. Edensor Nursing and Residential Home DS0000015322.V268294.R01.S.doc Version 5.0 Page 19 Sampling of the homes training records indicated that the following training has taken place since the last inspection: • Moving and handling instructors course x 6 staff 31/5/05 • Advanced diabetes, level one x 4 staff 3 10/5/05 • Pressure ulcer identification and prevention x 4 staff 8/6/05 • Single assessment process awareness x 4 staff 8/6/05 • Basic awareness of diabetes x 3 staff 1/7/05 • Abuse in vulnerable adults x 6 staff 5/7/05 • Deep vein thrombosis x 12 staff 26/7/05 • Pain management x 10 staff 8/8/05 • Health and safety x 12 staff 24/8/05 • Management of epilepsy in the elderly x 9 staff 6/9/05 • Risk assessment x 8 staff 4/10/05 Evidence indicated that access to staff training at the home was generally good. Edensor Nursing and Residential Home DS0000015322.V268294.R01.S.doc Version 5.0 Page 20 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): 31, 33, 35 & 38 There is a lack of leadership, guidance and direction for staff to ensure residents receive consistently good quality care. This results in some practices that do not promote and safeguard the health, safety and welfare of residents or staff. The quality assurance programme has commenced but further development is needed to establish an annual plan for the home. Edensor has the required systems and procedures in place for management of residents’ monies. However unless these are strictly adhered to, residents or their relatives cannot be assured their finances are safeguarded. Health and safety procedures are in place but practices are not well monitored, placing residents and staff at risk of harm. EVIDENCE: Since the former manager left, interim management arrangements had been put in place. This comprised a manager from another home in attendance two days per week supported by a full-time deputy manager. Neither were present Edensor Nursing and Residential Home DS0000015322.V268294.R01.S.doc Version 5.0 Page 21 but the proprietor was in attendance. It was evident from feedback from some social care staff and some health and safety practices i.e. poor and recording of accidents and a lack of follow up following incidents that the current arrangements were not sufficiently robust. The quality assurance system was in early development. A residents’ questionnaire had been developed that was planned for distribution to residents. Minutes were provided of a recent residents’ meeting, held primarily to introduce the acting manager, where views of residents were also recorded and action planned to address any issues identified. Visits required under regulation 26 had been undertaken and reports sent to the CSCI. Service user’s monies were sampled. Appropriate procedures were in place with receipts held for expenditure. However these were not always adhered to as one was incorrect and a member of staff confirmed they had removed money for payment without making a record and confirming the withdrawal by signature. All other records were confirmed as correct. Accident records now comply with legislation, but staff had not been using them in accordance with Data Protection Act. Several records were incomplete and risk assessments had not been undertaken following recorded accidents. The home had a health and safety policy and appropriate procedures in place and in the main these were adhered to. A fire risk assessment of the premises had been undertaken and requirement/recommendations were in the process of being actioned. However the following issues were identified: • The fire exit on the first floor, leading to the external fire escape and steel steps was not fitted with a magnetic door release, and subsequently posed a potential serious risk to service users health and well being-it was later confirmed that this had been addressed. • Accident records were incomplete with no time of accident recorded and no evidence of a risk assessment of the premises having been undertaken following those sampled. • One wardrobe was not secured to the wall posing a risk to residents. • Laundry staff were unable to confirm their understanding of COSSH requirements. Edensor Nursing and Residential Home DS0000015322.V268294.R01.S.doc Version 5.0 Page 22 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 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 x 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 x 14 x 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x 3 x 2 2 STAFFING Standard No Score 27 2 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 2 x x 2 Edensor Nursing and Residential Home DS0000015322.V268294.R01.S.doc Version 5.0 Page 23 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 2 Standard OP3 OP7 Regulation 15(1) 15(2) Requirement The registered person must ensure that assessments include more detail of residents needs. The registered person must ensure that residents care plans and risk assessments are regularly reviewed. The registered person must ensure that care plans include all identified needs including tissue viability and social care. The registered person must ensure that appropriate action is taken where residents’ unexplained weight loss is identified. This is a repeat requirement The registered person must ensure that accidents are recorded as required and a follow up risk assessment is undertaken to include the environment. CSCI must be notified of serious injuries/incidents. The registered person must ensure that there is no delay in residents being referred to GPs. DS0000015322.V268294.R01.S.doc Timescale for action 28/02/06 31/01/06 3 OP8OP7 15(1) 28/02/06 4 OP38OP8 12(1) 31/01/06 5 OP8 13(4) 14(2) 37 31/01/06 6 OP8 13(1) & 13(6) 31/01/06 Edensor Nursing and Residential Home Version 5.0 Page 24 7 8 9 OP13OP10 OP10 OP12 10 OP27OP15 11 12 OP25 OP26 13 OP29 14 OP30 15 OP33 16 OP33 12(4)(a) & The registered person must 23(2)(i) ensure that residents are able to meet their visitors in private. 12(4)(a) The registered person must ensure that staff knock before entering residents’ rooms. 16(20(m) The registered person must & 16(2)(n) ensure that a comprehensive social and therapeutic programme is developed to meet all residents’ needs including those with dementia. 18(1) The registered person must ensure that there are adequate numbers of staff on duty to ensure residents do not have to wait to receive assistance with eating or personal care. 23(2)(p) The registered person must ensure that heating can be controlled in residents’ rooms. 13(3) The registered person must ensure that liquid soap & paper towels are provided for staff hand washing and tablets of soap are not used communally. 19 The registered person must ensure that a recent photograph of staff and evidence they are fit for the job is obtained prior to their appointment. 12(1) & The registered person must 18(1) ensure that the induction programme is developed to NTO specification. This requirement has been brought forward as the standard was not inspected. 24 The registered person must ensure the quality assurance system is further developed to include an internal annual audit and anonymous residents questionnaires. This is a repeat requirement 18(2) The registered person must ensure that supervision records are developed to fully meet the DS0000015322.V268294.R01.S.doc 31/01/06 31/01/06 31/03/06 31/01/06 28/02/06 31/01/06 31/01/06 31/01/06 31/03/06 31/03/06 Edensor Nursing and Residential Home Version 5.0 Page 25 17 OP35 17(2) Schedule 4 (9) 17(1)(a) Schedule 3(j) 18(1)(c) 18 OP38 19 OP38 standard. This requirement has been brought forward as the standard was not inspected. The registered person must 31/01/06 ensure that accurate records are maintained for residents’ monies. The registered person must 31/01/06 ensure that accident records are recorded as required and are used in accordance with the Data Protection Act 1998. The registered person must 31/01/06 ensure that laundry staff are ware of COSHH requirements. 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 Refer to Standard OP3 OP31 Good Practice Recommendations The registered person should ensure that assessment include social care needs, hobbies and interests. The registered person should ensure that a full-time manager is appointed to the home. Edensor Nursing and Residential Home DS0000015322.V268294.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Edensor Nursing and Residential Home DS0000015322.V268294.R01.S.doc Version 5.0 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!