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Inspection on 23/06/06 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 23rd 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 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 homely and pleasantly decorated environment. Those residents spoken with said they found staff very caring and helpful and said they were well looked after. The standard of food, mostly cooked on site is good and nutritious. The home is well supported by the local GP practice and district nursing service. There is good monitoring of health care needs. Most feedback from relatives indicated that they found the home clean, personal care needs were met and the food was very good. One relative said they had found the deputy manager and staff very helpful.

What has improved since the last inspection?

A new full-time manager has been appointed to the home. The deputy manager post has developed and provides good support to the manager. Good progress has been made to raise standards of care and improve care planning. Action had been taken to address most requirements made following the unannounced inspection of medication on 6/02/06.The refurbishment of the premises has been completed and action taken to address any required action following the fire risk assessment of the premises, including the provision of fire exits doors with magnetic fittings. Staffing levels during the day were deployed appropriately and met the needs of residents. However there is a need to ensure they are also sufficient during the night, taking into account residents` dependency needs and the layout of the building. Accident records were recorded as required and follow up risk assessments were undertaken following incidents. Appropriate procedures were in place for managing residents` monies that were well adhered to.

What the care home could do better:

There were some health and safety risks to the premises that were evident including a lack of thermostatically controlled valves in residents` rooms. The laundry ventilation is not adequate, meaning that the exterior door is left open, enabling residents to access the room where COSHH items are stored in unlocked facilities. The interior door to the laundry was also found unlocked. COSHH items were also stored in an unlocked cupboard on the first floor of the premises. An external gate was left unlocked enabling vulnerable residents to exit the home without notice. External clinical waste bins were also found unlocked. The fishpond in the lounge poses a risk to residents and should be considered for removal. Water drinking dispensers on the first and second floor of the home are not in use and are a potential risk to residents and staff where they protrude from the wall.

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 23rd June 2006 09:50 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.V302697.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 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.V302697.R01.S.doc Version 5.2 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.V302697.R01.S.doc Version 5.2 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) 22nd November 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. The fees range from £260.00 -£565.00 weekly. Additional costs apply for chiropody, toiletries, hairdressing and newspapers. This information was provided to the CSCI on 19/05/06. Edensor Nursing and Residential Home DS0000015322.V302697.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection that took place on the 23/06/06, lasting 6.5 hours. Two inspectors undertook the inspection. The inspection process included: discussions with the recently appointed manager, deputy manager, administrator, three 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, the sluiceroom 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-seven standards were covered, and eight requirements made including two repeat requirements and five recommendations. The manager, deputy manager and staff were welcoming and helpful throughout the inspection. What the service does well: What has improved since the last inspection? A new full-time manager has been appointed to the home. The deputy manager post has developed and provides good support to the manager. Good progress has been made to raise standards of care and improve care planning. Action had been taken to address most requirements made following the unannounced inspection of medication on 6/02/06.The refurbishment of the premises has been completed and action taken to address any required action Edensor Nursing and Residential Home DS0000015322.V302697.R01.S.doc Version 5.2 Page 6 following the fire risk assessment of the premises, including the provision of fire exits doors with magnetic fittings. Staffing levels during the day were deployed appropriately and met the needs of residents. However there is a need to ensure they are also sufficient during the night, taking into account residents’ dependency needs and the layout of the building. Accident records were recorded as required and follow up risk assessments were undertaken following incidents. Appropriate procedures were in place for managing residents’ monies that were well adhered to. 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.V302697.R01.S.doc Version 5.2 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.V302697.R01.S.doc Version 5.2 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a site visit to the service. Assessments had improved but did not reflect social care needs adequately. This home does not provide intermediate care. EVIDENCE: Assessment documentation had been improved. The initial assessment included a nursing needs assessment, a mental health assessment and a risk assessment sheet. However it did not contain information on the prospective residents’ social background, or the leisure pursuits they undertook before needing care. Edensor Nursing and Residential Home DS0000015322.V302697.R01.S.doc Version 5.2 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, 9, 11 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit to the service. Improvements were evident in care planning and healthcare that assured residents their needs would be met, but attention to the environment was needed to uphold residents’ privacy and dignity. EVIDENCE: Observation of the staff with the residents, demonstrated an unhurried and pleasant attitude to the residents throughout this visit. Four care plans were reviewed during the site visit; they had improved considerably since the last inspection. The new deputy manager was in the process of updating all the residents’ care plans to a very good standard. The newly written plans were detailed; well written and had a user-friendly layout; they contained a wide range of risk assessments and good daily records. The range of risk assessments included falls; individual accident; moving & handling; pressure sore; infection; nutrition and other general risks of living in a care home. All risk assessments and care plans had been reviewed regularly. One care plan reviewed was of a resident who had suffered a number of falls. All had been Edensor Nursing and Residential Home DS0000015322.V302697.R01.S.doc Version 5.2 Page 10 appropriately reported, detailed in the care plan and changes made as necessary. There were also plans for the deputy manager to work with the trained staff to make sure that all care plans are rewritten and reviewed for all residents regularly. The records confirmed evidence of good monitoring of health care needs with prompt referral to GPs and health care professionals and appropriate follow up action being taken. The home had a contract with a local general practitioner who attended the home twice weekly and on request. There was evidence of access to outpatient services, dental, chiropody and eye tests annually. District nurses and community psychiatric nurses attended as relevant. Positive feedback was received from a community psychiatric nurse who was undertaking reviews of residents’ needs. Medication procedures had improved and a number of the issues from the random inspection of 6th February 2006 had been addressed. All MAR sheets reviewed were correct. There is no evidence of over prescribing or overstocking of medication throughout the home. There was a current staff signature list at the front of each medication administration records file. The resident’s photograph was on the divider between each medication administration record. The medication fridge was now being properly monitored and temperatures were seen to be within required limits. However the temperature of the medication room was still giving cause for concern. The temperatures were taken twice daily and consistently showed temperatures above 25oC. The home had recently commenced a new discarded medicine collection service contract from a national waste disposal firm. Medication reviews were undertaken by the GP’s at least every six months, but often sooner as needs dictate. Homely medicines had been reviewed and all GP’s had signed the agreed list for their patients who were resident in the home. Temazepam was being recorded in an exercise book but the deputy manager was planning to start recording all administrations in the newly purchased Controlled Drug book. Some prescribed creams were still not being signed for when administered by the registered nurses. Discontinued medications were appropriately crossed off, but had not been signed, or dated, by the member of staff discontinuing them. Staff were observed to knock before entering residents’ rooms and to be respectful towards them. However there were a number of issues regarding the environment that did not uphold residents’ dignity. Numerous signs were observed on walls in residents’ rooms next to windows to remind staff to close and lock. Mobile screens rather than curtains were provided in double rooms. One resident’s room had a large pane of frosted glass in the door with no internal curtain to cover and maintain dignity when lights in the room are on. Resident files contained a form detailing the residents’, or their relatives’ wishes, in the event of the resident’s deteriorating condition, or death, but not all were completed. The deputy manager was concerned that asking these type of questions was sensitive and could not be undertaken during initial assessment of the resident, or immediately on admission. Edensor Nursing and Residential Home DS0000015322.V302697.R01.S.doc Version 5.2 Page 11 Edensor Nursing and Residential Home DS0000015322.V302697.R01.S.doc Version 5.2 Page 12 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 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit to the service. The social activities offered at the home enhanced the daily lives of some residents but there is a need for further development to ensure all residents have opportunities that meet their needs and preferences. The home provided residents with a well-balanced and nutritious diet. Action had been taken to ensure residents received sensitive and timely assistance. EVIDENCE: The activities coordinator had recently left the home and activities had been taken over by one of the care assistants, who had been the residents’ choice. The residents were very pleased with the activities he was organising; there was a wide range of activities offered including one-to-one sessions; activities within the home divided between the different units; activities outside the home in small groups and bought in entertainment. The care assistant is currently filling in a tick list form of what each resident takes part in. The forms also contain information on participation by the resident, resident interaction during the session; resident engagement in the activity; their physical ability to undertake the activity; memory recall of activity; if it helps or hinders their mood/well-being. The inspector discussed further training for the care assistant in activities for the elderly infirm and those with deteriorating mental Edensor Nursing and Residential Home DS0000015322.V302697.R01.S.doc Version 5.2 Page 13 conditions. There were regular religious services held at the home, but residents could also attend a place of worship if this is their choice. All residents have a named key worker. The key worker is responsible to the named nurse for each resident and makes sure that they have enough toiletries and their clothing is properly labelled and maintained. Residents who are able to go out of the home are taken shopping by their individual key workers as necessary. Visitors were always welcome at the home and a number were welcomed during the site visit. The new acting manager already appeared to have a good rapport with the visitors on the day. At the time of this inspection the administrator, who had only been in post since January 2006, did not know which residents were on the electoral register. She agreed to check this following the site visit and would ensure that all are on for the next election. The menus observed were balanced and nutritious. Residents spoken with said they enjoyed the food at the home and there was always plenty to eat and drink. Staffing levels were appropriate to meet the needs of residents who required assistance with eating. The lunchtime meal comprised beef hot pot with fresh cabbage and carrots with alternatives provided. Care plans and nutritional records inspected detailed weight monitoring and action taken as needed. Edensor Nursing and Residential Home DS0000015322.V302697.R01.S.doc Version 5.2 Page 14 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, 17,18 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit to the service. Residents have access to a robust, effective complaints procedure, are protected from abuse. Action is needed to ensure all residents have their legal rights protected. EVIDENCE: 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. The procedure was included in the statement of purpose and displayed in the entrance of the home. The manager said that in the future, she planned to document all issues of concern and the action taken. There was evidence that all concerns and complaints had been fully investigated and appropriate action taken. Action was agreed to ensure all residents were registered on the electoral roll. Arrangements were in place for residents to access advocacy services. Several residents had advocates arranged on their behalf and some attended the local advocacy drop in centre. Edensor had a whistle blowing procedure place for staff guidance. The Essex Guidelines on the Protection of Vulnerable Adults (POVA) was available. The revised procedure previously obtained still required personalising to the home. However staff spoken with, were clear on the procedures to be followed in the event of any allegations. There had been three allegations of abuse since the previous inspection regarding personal care, monies and medication, which Edensor Nursing and Residential Home DS0000015322.V302697.R01.S.doc Version 5.2 Page 15 had been unsubstantiated for personal care and medication and unresolved for monies. No further action was taken for monies due to lack of evidence and in line with the residents’ wishes. Edensor Nursing and Residential Home DS0000015322.V302697.R01.S.doc Version 5.2 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, 20, 22, 24, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a site visit to the service. The home was clean, well furnished and generally well maintained but daily monitoring and action was needed to reduce health and safety risks and improve the environment for residents. EVIDENCE: The recent refurbishment of the home had been completed and new carpeting provided throughout the main areas. The deputy manager said that mobile dignity screens were used but as this could not be guaranteed, advice was given to either remove glass or ensure appropriate covering/curtains were in place. The large open fishpond in lounge poses a risk to residents and as most residents who are seated cannot view it, gives little pleasure. The home had a large lounge with a smoking room adjacent. There are two dining rooms and a small lounge on the ground floor. Wheelchairs were observed obstructing the use of the only pay phone in home. The deputy Edensor Nursing and Residential Home DS0000015322.V302697.R01.S.doc Version 5.2 Page 17 admitted that they had no other mobile phones, but residents could use the office phone if wished to. Some en-suite room lights were not working and wall lights had no bulbs. In the Middle House’ upstairs ‘lobby’ there was no light outside rooms some rooms and the area was very dark even for someone with good eyesight. This was brought to the attention of the acting manager who was advised to do a complete walk around of home regarding lights and maintenance. Drinking water dispensers on upper hallways posed a risk to residents and staff as they ‘stick out’ just as you turn out of stairwell. Neither were in use and were in need of a clean if they were to be reactivated. Window restrictors were in place but they were ‘crude’ and unsightly. (Piece of chain screwed to window and frame.) The home had grab rails, ramps, hoist and other mobility equipment to meet the needs of residents. However an ‘out of date’ blue moving & handling strap was observed hanging on wall in the shower. The manager later added that it had not been there a couple of days previously meaning it had most probably been used in those few days. Individual rooms were furnished as appropriate and some had small personal items of furniture, pictures etc.. However one room had two doors and neither were lockable. Only mobile screens were available in double rooms, which is not adequate to ensure residents’ privacy and dignity is upheld. The home was clean and hygienic with staff hand-washing facilities provided. However hoist slings and cot bumpers were in a dirty condition and there was a malodorous smell emanating from the shower on the ground floor. External clinical waste bins were also found unlocked. The laundry door was found unoccupied and unlocked with a large amount of CoSHH products present. The laundry backdoor is the only ventilation in the laundry in the summer consequently it is left open. Residents are able to walk out of the lounge, along path and enter the laundry. A small shed next to the path was observed to have cleaning products visible through a window, which was made of loose Perspex and could be easily removed. Edensor Nursing and Residential Home DS0000015322.V302697.R01.S.doc Version 5.2 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, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit to the service. Staff in the home are trained, skilled and in sufficient numbers to fill the aims of the home and meet the changing needs of residents during the day. However night staffing levels are low for the layout of the building and to provide assurance that residents’ needs are appropriately met. EVIDENCE: There were 61 residents. A new manager had recently been appointed and was supported by a deputy manager. Both were present throughout the inspection. Staffing levels comprised: AM: 2 registered nurses and 8 care staff PM: 1 registered nurse and 7 care staff NIGHT: 1 registered nurse and 3 care assistants. Observation during the inspection indicated that staffing levels were appropriate to meet the dependency needs of residents. However staffing levels during the night appeared low for the dependency of residents and the layout of the building and will continue to be monitored. There were no registered mental health nurses and the manager confirmed that efforts were being made to recruit nurses with mental health experience. Ancillary staff included an administrator, 1 activities coordinator, 1 cook, 1 kitchen assistant, 1 maintenance person, 1 laundry assistant and 3 domestic staff. Edensor Nursing and Residential Home DS0000015322.V302697.R01.S.doc Version 5.2 Page 19 There were 8 care assistants with NVQ level 2, which is less than 50 of care staff employed. The information provided by the home indicated that staff from overseas were qualified nurses in their country of origin. The recruitment files for five care staff were inspected. All had the appropriate checks undertaken (2 satisfactory references, CRB disclosures, health declaration), with exception of two staff who had transferred from another home within the organisation. The manager was advised to ensure copies of their files were transferred to the home together with a reference from their previous manager. The home had a training programme in place. In the previous twelve months, training had been provided in moving and handling, COSHH (Control of Substances Hazardous to Health), continence care, first aid, health and safety, pain management, diabetes awareness, deep vein thrombosis, protection of vulnerable adults and caring for the elderly. Fire safety training, and further moving and handling training was also planned for the next few weeks. Edensor Nursing and Residential Home DS0000015322.V302697.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit to the service. The management of the home is more stable providing confidence to staff, residents and their relatives that it will be run in their best interests. Health and safety procedures are in place but close monitoring of practices is needed to prevent residents being placed at risk of harm. EVIDENCE: A new acting manager started at the home on 12/6/06. She had managed and owned care homes in the past. A history of the service was discussed with the new manager along with information about the commission’s new inspection processes. Relatives spoken with said they found the manager very approachable. The deputy manager had been in post since February 2006, having moved from one of the other homes in the group. The last two Edensor Nursing and Residential Home DS0000015322.V302697.R01.S.doc Version 5.2 Page 21 unfinished complaints to the home were discussed to highlight the work that needs to be done in the home to rectify the problems. Quality assurance programme had been implemented with distribution of residents’ questionnaires. The outcome of this exercise was yet to be collated from which to develop an annual plan for the home. Visits required under regulation 26 had been undertaken and reports sent to the CSCI. The home had appropriate procedures in place for the safe storage of residents’ monies. Four service user’s monies were sampled. All had receipts held for expenditure and records were confirmed by signature. The procedures were well adhered to and amounts held were confirmed as correct. Improvements were noted in the recording and follow up of accidents/incidents, with risk assessments undertaken following 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 had been actioned. However the following issues were identified: • • • • • There was an open hole in shower room floor that posed a risk to residents and staff. Window restrictors were in place but they were ‘crude’ and unsightly. (Piece of chain screwed to window and frame). Items subject to COSHH requirements were stored in unlocked facilities. External clinical waste bins were unlocked. An exterior gate was unlocked, enabling residents who may be at risk to leave the premises unseen. Edensor Nursing and Residential Home DS0000015322.V302697.R01.S.doc Version 5.2 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 3 8 3 9 2 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 2 18 3 2 3 x 3 x 2 x 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X x 2 Edensor Nursing and Residential Home DS0000015322.V302697.R01.S.doc Version 5.2 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 Standard OP9 Regulation 13(2) Requirement The registered person must ensure that medicines are stored in strict accordance with the manufacturer’s recommendations. The purchase of an air conditioning unit should be considered. This is a repeat requirement The registered person must ensure that prescribed creams are signed for by the person who has administered the cream. This is a repeat requirement The registered person must ensure that discontinued medicines are signed and dated by the person recording the discontinuation. The registered person must ensure that action is taken to remove signs instructing staff and replace or provide curtains to glass screens on doors in residents’ rooms. The registered person must ensure all resident’s rooms have locks. The registered person must ensure that the premises are DS0000015322.V302697.R01.S.doc Timescale for action 30/07/06 2 OP9 13(2) 30/07/06 3 OP9 13(2) 30/07/06 4 OP10 12(4)(a) 31/08/06 5 6 OP10 OP19 12(4)(a) 13(4) 31/08/06 30/07/06 Edensor Nursing and Residential Home Version 5.2 Page 24 7 OP26 13(3) 8 OP38 13(4) 9. OP38 13(4) & 13(5) safe and secure and gates are locked. The registered person must ensure all equipment including hoist slings and bed rail protectors are kept clean. The registered person must ensure storage of COSHH items and external clinical waste bins are kept locked. The registered person must ensure moving & handling equipment meets with recommended safe practice. Out of date equipment must be disposed of. 30/07/06 30/07/06 30/07/06 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 Refer to Standard OP3 OP17 OP24 OP28 OP38 Good Practice Recommendations Include residents’ lifestyle and social care needs in their assessment. Ensure that residents are registered on the electoral register. Ensure that heating can be controlled in all residents rooms. Ensure 50 care staff have NVQ level 2. Review ventilation to the laundry room. Edensor Nursing and Residential Home DS0000015322.V302697.R01.S.doc Version 5.2 Page 25 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.V302697.R01.S.doc Version 5.2 Page 26 - 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!