Inspection on 16/05/05 for Edgecumbe Lodge Rest Home for the Elderly

This inspection was carried out on 16th May 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Edgecumbe Lodge Rest Home for... 18/08/06

Edgecumbe Lodge Rest Home for... 17/01/06

Edgecumbe Lodge Rest Home for... 25/02/05

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

CARE HOMES FOR OLDER PEOPLE Edgecumbe Lodge 35 Overnhill Road, Downend, South Gloucestershire BS16 5DS Lead Inspector Odette Coveney Unannounced 16th May 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Edgecumbe Lodge D56 D05 S62860 Edgecumbe Lodge V227427 160505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Edgecumbe Lodge Address 35 Overnhill Road Downend South Gloucestershire BS16 5DS, 01179 568856 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) williamsardar@hotmail.com Mr William Sardar Mr Wiliam Sardar Care Home for Older People 20 Category(ies) of D(E) Drug dependence over 65 x 4 registration, with number OP Old age x 20 of places Edgecumbe Lodge D56 D05 S62860 Edgecumbe Lodge V227427 160505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: May accommodate 20 service users aged 65 and over requiring personal care only May accommodate 4 service users aged 65 and over for Dementia care. Date of last inspection 25/02/05 Announced Brief Description of the Service: Edgecumbe Lodge is situated in an established residential area in the south of South Gloucestershire. It is approximately half a mile from the shopping areas of Staple Hill and Downend where doctor’s surgeries, post offices, banks, library, shops and other facilities exist. There are bus routes on roads at either end of Overnhill Road that take you into Bristol. The home is a large, detached Victorian house on four floors. Despite adaptation for its present use, many features of the original period remain and enhance the sensitively planned alterations. Full use is made of the basement/garden level area and of the top of the attic. Service users living here are Older People with some physical frailties. There is a passenger lift accessing all but the top floor, which has a stair lift to it. The stair lift is for the use of visitors and the occasional use of service users. It is the policy of the home not to accommodate those with limited mobility in this area of the home. There are well laid out, mature gardens which are well tended throughout the year. The exterior and interior of the property are in good repair, pleasantly decorated and comfortably furnished. Edgecumbe Lodge D56 D05 S62860 Edgecumbe Lodge V227427 160505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection conducted as part of the annual inspection process to examine the care provided, and monitor the progress in relation to the six requirements and four recommendations from the last inspection that was conducted in February 2005. It should be noted that two requirements in relation to staff training were reviewed and although these have not been met they are still within the allocated timescale for action. The inspector arrived at the home at 8.30 am and the inspection took place over eight hours. The inspector returned to examine further records on May 18th. During the process 12 residents, seven care staff and both of the registered providers were spoken with. The inspector looked around some of the building and examined records. The Commission for Social Care Inspection has produced a leaflet for those living in care establishments entitled ‘Is the care you need the care you get?’; the inspector gave out a number of these to residents living at the home, a copy of this was also put on the home’s notice board. What the service does well: What has improved since the last inspection? The home has ensured that all resident’s have been issued with a written and costed statement of the terms and conditions of their placement at Edgecumbe Lodge. Edgecumbe Lodge D56 D05 S62860 Edgecumbe Lodge V227427 160505 Stage 4.doc Version 1.30 Page 6 What they could do better: In order to ensure that the resident’s living at Edgecumbe Lodge are protected the home must adhere to robust recruitment and selection of staff to include ensuring that a CRB (Criminal Records Bureau) and POVA (protection of Vulnerable Adults list) check is carried out. An Immediate requirement notice was left at the home in respect of this on the day of the inspection. To ensure that resident’s are supported by staff that are aware of their roles and responsibilities and to promote effective communication within the home staff must receive regular, recorded supervision meetings. To effectively meet the needs of residents care plans must be reviewed on a monthly basis and the summary of the care plan must indicate that all areas of the plan have been evaluated and changes recorded. To ensure the protection of resident’s and staff against the risk of fire attention must be paid to the fire door identified during the inspection. The safety of residents and staff awareness of their responsibility in relation to medication errors would be much improved if the home incorporated within the medication policy the action for staff in the event of an error or omission. Risks to staff could be minimised if the home monitored, by recording accidents. Resident’s would benefit from being supported by a knowledgeable workforce if staff have three paid days training each year. This would assist the personal development and in order to identify areas of need the home should conduct an audit of staff training already completed. The manager would be able to demonstrate that he and the staff team were aware of the policies and procedures in place at the home and that they were current if they were dated and signed by the manager and if a system was implemented to demonstrate that staff were aware of these documents and their responsibility to work within the guidelines set by these. The home would be a better environment for residents to live in and staff who support them to work in if all areas of the house are kept clean and free from offensive odours. The home would be a safer and more pleasant place to live for resident’s if there was monitoring of maintenance work carried out in the home. The use of a book to record maintenance issues would assist with this and aid communication about these and issues in the home. Edgecumbe Lodge D56 D05 S62860 Edgecumbe Lodge V227427 160505 Stage 4.doc Version 1.30 Page 7 Service user and staff would be protected in the event of an emergency if lighting was checked on a regular monthly basis, and this check must be recorded. 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. Edgecumbe Lodge D56 D05 S62860 Edgecumbe Lodge V227427 160505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Edgecumbe Lodge D56 D05 S62860 Edgecumbe Lodge V227427 160505 Stage 4.doc Version 1.30 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 standard(s) 1, 2, 3, 4, 5. Information is available to residents and their representatives about the home and the admission processes provide adequate safeguards for all. EVIDENCE: There are currently two vacancies at the home, these vacancies would be in a shared room. The home have in place a comprehensive, up to date statement of purpose and a resident’s guide that provides prospective residents and their relatives with sufficient information on the services and facilities provided at Edgecumbe Lodge in order to make an informed choice of whether the home is able to meet their needs. A resident was admitted to the home three days prior to the inspection, in place was an assessment that had been completed by the manager prior to the individual being admitted to the home and a care plan had commenced recording areas of identified need. Also in place was a health needs assessment and a hospital transfer assessment providing additional information in order to direct and guide staff. The inspector saw that staff had Edgecumbe Lodge D56 D05 S62860 Edgecumbe Lodge V227427 160505 Stage 4.doc Version 1.30 Page 10 maintained clear records on the wellbeing of the individual recently admitted to the home, their level of support and how they had settled at the home. Mr Sardar demonstrated a clear understanding of the admission process, he told the inspector about the criteria for the home and that the admission is tailored to the specific needs of the individual. Mr Sardar told the inspector that individuals are able to visit the home prior to their admission and that he visits them prior to them entering the home. The inspector saw that resident’s have been issued with a written and costed copy of the terms and conditions of their placement, these documents provide clear information for resident’s on their rights, the document outlines the admission process, the aims and objectives of the home, information about fees and additional charges along with how individuals are able to complain. Edgecumbe Lodge D56 D05 S62860 Edgecumbe Lodge V227427 160505 Stage 4.doc Version 1.30 Page 11 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 standard(s) 7,8,9 The healthcare and medication needs of resident’s are well met and relationships between residents and staff are well established, however, the care planning system in place does not adequately provide the information that staff need in order to satisfactorily meet the needs and choices of residents. EVIDENCE: Each resident had in place a care plan assessment booklet, within these are recorded all areas of daily living, personal, emotional and social needs plus information to direct staff in order to ensure these needs are met. Not all of the care plans in place had been recently reviewed, some had not been reviewed for over two months, care plans must be reviewed on a monthly basis and the summary of the care plan must indicate that all areas of the plan have been evaluated and changes recorded. The staff present demonstrated an enthusiastic and sensitive approach to the resident’s and were observed interacting and supporting resident’s in their preferred routines. Staff when spoken with were fully conversant with how individuals at the home were supported Edgecumbe Lodge D56 D05 S62860 Edgecumbe Lodge V227427 160505 Stage 4.doc Version 1.30 Page 12 Medication systems were not reviewed at this inspection, however a recommendation was made at the previous inspection that the safety of residents and staff awareness of their responsibility in relation to medication errors would be much improved if the home incorporated within their medication policy what to do in the event of an error or omission, this will be reviewed at the next inspection. All of the residents are registered with a general practitioner; evidence was in care records to confirm that residents are supported with their primary healthcare needs such as optician, audiology and chiropody. One of the residents is visited on a number of occasions during the week by the district nurse; all of the residents that wanted to, have had a flu vaccination. There are no residents living at the home that require pressure area care. One of the resident’s told the inspector they were having difficulty in reading and that the home had recently arranged for them to have their eyesight checked by the optician who would visit them at the home. Another resident told the inspector they have digestive problems and that staff at the home had been very caring and supportive to them and that they had seen the doctor on a number of occasions to remedy this. All of the resident’s are allocated a key worker, staff spoken with had a clear understanding of their role and responsibilities, one staff member was very clear that it was important to treat each person as an individual and that Edgecumbe Lodge is the resident’s home. During the inspection resident’s were supported with their personal and intimate care, the inspector observed that these tasks were undertaken discreetly and in privacy. Resident’s spoken with told the inspector that if they wanted to speak with someone in private they would see them in their own room. Edgecumbe Lodge D56 D05 S62860 Edgecumbe Lodge V227427 160505 Stage 4.doc Version 1.30 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 standard(s) 12, 13, 14, 15. The meals in the home are good offering both choice and variety along with catering for special dietary needs. Activities are arranged and provided at the home one a regular basis. EVIDENCE: The home was able to demonstrate that daily living routines and activities provided are flexible and varied to suit resident’s preferences and capacities. Resident’s spoken with gave the inspector examples of their own preferred routines and choices they had made as part of daily living in the home. At the time of the inspection resident’s were seen participating in a number of activities, in the morning a number of individuals enjoyed participating in a musical movement group, in the afternoon the inspector joined resident’s in the day centre annex, all resident’s of which were undertaking various craft activities such as embroidery, knitting and tapestries. The residents told the inspector they enjoyed the social aspect of getting together and the reward for completing an article they were making. Resident’s told the inspector they enjoyed activities at the home on a daily basis, examples given included bingo, quizzes and weekly entertainers visiting and performing at the home. The inspector saw that the notice board confirmed the range of activities that take place within the home. Edgecumbe Lodge D56 D05 S62860 Edgecumbe Lodge V227427 160505 Stage 4.doc Version 1.30 Page 14 The inspector noted that there were a number of videos, books, board games and music available for resident’s use. Two of the resident’s told the inspector they enjoy a daily walk in the local area. One of the resident’s told the inspector that the previous day they had visited Clevedon with their family and how much they had enjoyed their day. The home does have a mini bus for the resident’s use however Mr Sardar said that this had not been used for some time as some maintenance of the vehicle is required, he said that he anticipates the vehicle will be fit for use in time for the warmer weather. Mr Sardar said that taxi tokens had been requested from South Gloucestershire Council for all of the resident’s for their personal use. One of the staff members commented that one of the regular entertainers to the home no longer visits the home, resident’s were asked if they wished to comment on this, all of the resident’s asked were unaware that this had stopped and commented that they were happy with the quality and the frequency of the entertainment and the activities provided. The visitors book evidenced that there a number of frequent visitors to the home, who visit on a regular basis. Residents told the inspector that their visitors were always made welcome and that they were an important part of their life. The inspector noted that meals were unrushed and relaxed. There was positive interaction between staff and resident’s. Resident’s were seen enjoying their lunch on the day of the inspection this meal was lamb chops, peas, carrots and potatoes served with homemade sponge and custard. Resident’s commented favourably on the ‘lovely’ food and said that there was always plenty of it!. One of the resident’s told the inspector of their special diet that the home caters for, that they are happy with what is provided for them. The cook told the inspector that supplies were always available and that menus were changed seasonally. The kitchen was seen to be clean and tidy, foods stored in the fridge were covered. Both the fridge and the freezers were seen to be well stocked with a variety of foods. Edgecumbe Lodge D56 D05 S62860 Edgecumbe Lodge V227427 160505 Stage 4.doc Version 1.30 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 standard(s) 16, 18 Complaints are handled objectively and residents are confident that their concerns will be taken seriously, listened to and actioned. The home does have in place some measures to ensure that residents are protected from abuse, these need to be improved upon in order to ensure the safety of resident’s. EVIDENCE: Information on how to make a complaint was seen on display in a communal area of the home. The home has in place an Adult Protection Policy and also a copy of South Gloucestershire’s Protection of Vulnerable Adults Policy; staff spoken with were conversant with it’s contents and of the significance to them within their role. The inspector viewed the complaints logbook; there were no recorded entries. No resident’s at the home are on the protection of vulnerable adults list. No areas of concern were recorded on care documentation. All of the resident’s user’ spoke favourable of the care and attention they receive from staff. Relationships with the new providers are being established and resident’s spoke of Mr and Mrs Sardar’s kindness and of they time they spend talking to them and getting to know how they feel. The registered provider has contacted the Commission for Social Care Inspection to inform of incidents that have affected the wellbeing and safety of those living at the home. Edgecumbe Lodge D56 D05 S62860 Edgecumbe Lodge V227427 160505 Stage 4.doc Version 1.30 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 standard(s) 19, 20, 23, 24, 25, 26 The quality of furnishings and fittings in the home is good. An overall a warm comfortable environment has been created ensuring individuals needs are met, however, arrangements must be made to ensure that areas of the home are hygienic, odour and risk free. EVIDENCE: The home is well furnished and maintained to a standard that creates a comfortable ambience. All areas of the home are accessible and have ramps and rails to the front and rear of the property, there is a lift to the first floor of the home and a stair lift to the first and second floor. Overall a warm, comfortable environment has been created ensuring individuals needs are met, using good quality furnishings however more effort must be made to ensure that all areas of the home are hygienic and odour Edgecumbe Lodge D56 D05 S62860 Edgecumbe Lodge V227427 160505 Stage 4.doc Version 1.30 Page 17 free. A partial tour of the premises found that all communal areas of the home were clean, tidy and odour free, however this was not the case in individuals private rooms, one resident’s room had a strong smell of urine and staining was evident on the bedroom carpet. Mr Sardar said that he was aware of the carpet and he that had discussions in order to arrange for this to be replaced. The home has an array of comfortable spaces for shared use, resident’s were seen relaxing and making full use of these areas. The home has an extensive garden to the rear of the property, these were seen to be well tended. Mr Sardar told the inspector of the future plans to fill in the unused swimming pool to create a large flower bed. A gardener visits the home every two weeks to maintain the area. There are a number of toilet, washing and bathing facilities provided at the home that are available for resident’s use, these are within close proximately to service users private accommodation. The numbers of facilities available are sufficient for the numbers of resident’s accommodated at the home. Edgecumbe Lodge D56 D05 S62860 Edgecumbe Lodge V227427 160505 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29, 30 Whilst the morale of staff is low the service to the resident’s has not suffered however, the recent decline in recruitment leaves resident’s potentially at risk. EVIDENCE: The inspector examined the employment documents for the two most recently appointed staff members; both had completed application forms in place, however for one of the staff members there were two written references, for the other there were none, neither of the staff members had a criminal records bureau check in place, Mr Sardar was reminded that the home must adhere to robust recruitment and selection of staff, to include that all staff must have in place a satisfactory criminal records bureau check and POVA check. Since the last inspection two staff members have left, during the inspection another staff member gave notice to leave telling the inspector that they did not feel as if they were trusted and were unhappy with issues in relation to their contract, pay and that they believed that relations between the Sardar’s and herself had broken down to the point that it would be difficult for her to continue working at the home. In order to prioritise areas of personal development and to equip staff with the knowledge and skills in order to perform their jobs effectively staff must receive a minimum of three days paid training per year and the home should undertake an audit of staff training and development. The manager would be able to demonstrate that he and the staff team were aware of the policies and procedures in place at the home and that they were current if they were dated and signed by the manager and if a system was Edgecumbe Lodge D56 D05 S62860 Edgecumbe Lodge V227427 160505 Stage 4.doc Version 1.30 Page 19 implemented to demonstrate that staff were aware of these documents and their responsibility to work within the guidelines set by them. The inspector was told by staff that their had been some anxieties amongst the team as there have been some problems with the new payroll system and new staff contracts of employment. Staff confirmed that a number of individual and team meetings had been held with Mr and Mrs Sardar to resolve outstanding issues, however these remain unresolved. Mr Sardar told the inspector that he had sought legal advice in order to ensure he was giving staff correct information, he also told the inspector that a meeting had been arranged to take place on 17th May 2005, with an employment solicitor to look at staff contracts, a further meeting would then take place to consult with staff. Edgecumbe Lodge D56 D05 S62860 Edgecumbe Lodge V227427 160505 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 36, 37, 38. Mr and Mrs Sardar aim to provide a good quality service run in the best interest of the resident’s within a safe environment. EVIDENCE: Mr and Mrs Sardar told the inspector that all of those living at the home are treated as individual’s with individual needs and wishes, however they viewed all of those living and working at the home as part of one family working together. Mr Sardar was aware of some staff concerns and is committed to resolving issues to the satisfaction of those concerned ensuring continuity of care for the resident’s. The inspector observed the manager interacting with resident’s and staff; he addressed people in an appropriate manner with the correct use of voice tone and language and was caring in his approach. Edgecumbe Lodge D56 D05 S62860 Edgecumbe Lodge V227427 160505 Stage 4.doc Version 1.30 Page 21 To aid effective communication and to ensure that staff are fully aware of their role and responsibilities it is required that staff receive regular, recorded supervision. To ensure that fire safety within the home is maintained attention must be given to the fire door identified within the inspection. The home must ensure that staff receive sufficient fire safety instruction to ensure the safety of all living and working at the home. A requirement was made at the previous inspection that the homes must complete a fire risk assessment, there was no evidence to suggest that this has been completed, this requirement must be met in order to ensure that all areas have been appropriately assessed. Health and safety recording methods would be better improved if the home purchased a book to record staff accidents. The home has a maintenance record book, however it is not always clear when repairs have been undertaken, therefore it is recommended in order to aid communication and monitor maintenance within the home it is recommended that the manager record when contractors have been contacted and when issues have been resolved. Both resident’s and staff commented that both Mr and Mrs Sardar were very pleasant. One resident commented that Mr Sardar was very kind and listened to them with concerns and worries they have. Staff responded promptly to the call bell system. Edgecumbe Lodge D56 D05 S62860 Edgecumbe Lodge V227427 160505 Stage 4.doc Version 1.30 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 2 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 3 x 3 2 x 2 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 2 x x x 2 x 2 Edgecumbe Lodge D56 D05 S62860 Edgecumbe Lodge V227427 160505 Stage 4.doc Version 1.30 Page 23 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. 4. 5. 6. 7. Standard OP 37 OP 38 OP 7 OP 36 OP 38 OP 30 Regulation 19(b) Requirement Timescale for action 17/05/05 31/05/05 16/06/05 16/09/05 17/06/05 25/02/06 No staff are to commence employment untill a satisfactory police check has been obtained 23(4) Attention to be given to repair fire door at the top of the stairs. 15 Care plans must be reviewed at a minimum every month. 18(2) Staff to formal recorded supervision; six times per year. 23(4)(c)(ii Emergency lighting must be ) checked on a monthly basis, this must be recorded. 18(1)(c) Staff must a minimum of three days paid training per year. 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 OP 30 OP 36 Good Practice Recommendations The home to undertake an audit of staff training and in order to identify training needs. Policies and proceedures within the home to be dated and signed by the manager and a system implemented to demonstrate that staff have an awareness of their role and responsibility in this area. D56 D05 S62860 Edgecumbe Lodge V227427 160505 Stage 4.doc Version 1.30 Page 24 Edgecumbe Lodge 3. 4. 5. 6. OP38 OP 9 OP 38 OP 23 To purchase a book in order to record staff accidents. The home to incorporate within the medication policy what to do in the event of errors or omisssions. The manager to record when contractors have been contacted and repairs undertaken. The home to eliminate source of odour in room and clean carpet, if stains unable to be cleaned carpet to be replaced. Edgecumbe Lodge D56 D05 S62860 Edgecumbe Lodge V227427 160505 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection 300 Aztec West Almondsbury South Glos BS32 4RG 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 Edgecumbe Lodge D56 D05 S62860 Edgecumbe Lodge V227427 160505 Stage 4.doc Version 1.30 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. 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