Inspection on 17/01/06 for Edgecumbe Lodge Rest Home for the Elderly

This inspection was carried out on 17th January 2006.

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... 16/05/05

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

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Edgecombe Lodge Rest Home for the Elderly 35 Overnhill Road Downend South Glos BS16 5DS Lead Inspector Odette Coveney Announced Inspection 17th January 2006 09:30 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 Edgecombe Lodge Rest Home for the Elderly DS0000062860.V270696.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. Edgecombe Lodge Rest Home for the Elderly DS0000062860.V270696.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Edgecombe Lodge Rest Home for the Elderly Address 35 Overnhill Road Downend South Glos BS16 5DS 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) 0117 9568856 Mr William Sardar Mrs Nargis William Sardar Mr William Sardar Care Home 20 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (20) of places Edgecombe Lodge Rest Home for the Elderly DS0000062860.V270696.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 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. 16th May 2005 Date of last inspection 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 doctors 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. Resident’s 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. The former garage/workshop is a large well equipped day room, with tea making facilities and a toilet, so making the unit self contained. Edgecombe Lodge Rest Home for the Elderly DS0000062860.V270696.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced 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 six recommendations from the last inspection that was conducted in May 2005. Prior to the inspection the inspector received a completed pre inspection questionnaire, which provided information about the establishment, policies and procedures, management and staffing arrangements. There was information about those receiving a service at the home. Information was also provided about healthcare and visiting professionals. Twenty-One comments cards were received prior to the inspection, information provided within these has been shared with the manager and have also been incorporated within this report. The inspection took place over eight hours. During the process twelve residents, two staff a visitor and the registered provider were spoken with. The inspector looked around both buildings and a number of records were examined. What the service does well: What has improved since the last inspection? Residents care plans are being reviewed on a monthly basis and the summary of the care plan indicates that all areas of the plan have been evaluated and changes recorded. Residents at the home are better protected and safer now that attention has been given to a fire door, which was not closing fully and also now that emergency lighting is being checked on a consistent basis. There is a clearer Edgecombe Lodge Rest Home for the Elderly DS0000062860.V270696.R01.S.doc Version 5.0 Page 6 understanding of medication administration now that the home have incorporated within their medication policy what staff must do in the event of errors or omission. Improvements in the recording of accidents has been made now that the home have purchased an accident book in order that incidents may be recorded and evaluated. The home is now a safer and more pleasant place to live for resident’s as there is monitoring of maintenance work carried out in the home. The use of a book to record maintenance issues has assisted with this and aids communication. The manager was be able to demonstrate that he and the staff team were aware of the policies and procedures in place at the home as a system has been implemented to demonstrate that staff were aware of these documents and their responsibility to work within the guidelines set by these. To ensure that resident’s are supported by staff that are aware of their roles and responsibilities and also to promote effective communication within the home the manager has arranged that staff receive regular, recorded supervision meetings. 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. Evidence of this for those staff members identified during the inspection must be forwarded to the Commission. Resident’s would benefit from being supported by a knowledgeable workforce if staff have three paid days training each year. This would assist with personal development. In order to identify areas of need the home should conduct an audit of staff training. The home would be a better and safer environment for residents to live in and for the staff who support them if all areas of the house are kept free from offensive odours, if staff received sufficient fire safety instruction, if evidence were provided of the testing of portable electrical appliance testing and also if a risk assessment in respect of the use of the stair lift was completed. Safety for the residents would be improved if the manager’s checklist of room maintenance and safety included that the emergency call bells for residents were checked. Record keeping if information held about residents would be improved if photographs of all residents were held at the home and if the home sought and recorded the wishes and choices of individual’s in the event of their death and if consideration were given to the consistent recording of visiting health professionals and/or appointments. Edgecombe Lodge Rest Home for the Elderly DS0000062860.V270696.R01.S.doc Version 5.0 Page 7 The home would better record that the health need of individuals are being met if a consistent approach in the recording of resident’s medical contacts/appointments were maintained. 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. Edgecombe Lodge Rest Home for the Elderly DS0000062860.V270696.R01.S.doc Version 5.0 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Edgecombe Lodge Rest Home for the Elderly DS0000062860.V270696.R01.S.doc Version 5.0 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4, 5 Information is provided to residents in order that they are aware of their rights and responsibilities. No one is admitted to the home without having their needs assessed and that they have been assured that these will be met. EVIDENCE: The home has a clear comprehensive statement of purpose in place at the home and this provides sufficient information for prospective residents and their relatives about the services and facilities provided at the home. Mr Sardar confirmed that this document, along with the brochure for the home is given to individuals prior to their admission to the home. Mr Sardar was aware that should the registration status of the home change that this document would then require amendment. The admission process for the most recent individual into the home was discussed with the registered manager. Mr Sardar was very clear and had a consistent approach about the home’s admission procedure and whom the home is able to provide a service for. Clear policies about the homes admission Edgecombe Lodge Rest Home for the Elderly DS0000062860.V270696.R01.S.doc Version 5.0 Page 10 procedure are also in place, this records that individuals are given the opportunity to visit the home prior to admission and when admitted have a months trial to ensure the placement is an appropriate one. In place were assessments that had been completed by the placing care manager prior to individuals being admitted to the home. The assessment completed by Mr Sardar when he visited an individual at their home. The inspector also saw that Mr Sardar had completed the care plan for this individual in anticipation and preparation for their admission into the home. The inspector also saw review notes involving a meeting with the resident, their family, the placing care manager and a representative from the home confirming the placement was an appropriate one and that the home were able to meet the needs of the individual. The person most recently admitted to the home told the inspector that had chosen Edgecombe Lodge as their friend was also living at the home. They also said ‘it took a while for me to settle as I had lived at my previous home for many, many years, the staff and the manager here have helped me to settle in and make this my home’ ‘I am happy here, I feel safe and well looked after’. A visitor to the home said that Mr Sardar had visited their relative prior to their admission to the home and that since admission into the home their relative’s health had improved and stabilised, that staff were approachable and friendly. Edgecombe Lodge Rest Home for the Elderly DS0000062860.V270696.R01.S.doc Version 5.0 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 the following standard(s): 7, 8, 9, 10, 11 Individual’s health, medication, personal and social needs are well met, responded to and reviewed on an ongoing basis. However improvement is required within health care records and also within records of what individuals would want at the end of their life. Resident’s are treated with respect with their rights to privacy being upheld. EVIDENCE: Following an examination of care plans at the previous inspection it was found that not all of the care plans in place had been reviewed; some had not been reviewed for over two months. A requirement was made that 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. At this inspection there was clear information within care records that evidenced that individuals are supported by staff in order to make decisions about their lives, that they have been given appropriate assistance and that support had been tailored to the needs of the individuals in order that they can make an informed decision. It was clear that where able individuals had been consulted and their input within assessment processes had been recorded in care records. Each person’s plan sets out the in detail the action which needs Edgecombe Lodge Rest Home for the Elderly DS0000062860.V270696.R01.S.doc Version 5.0 Page 12 to be taken by staff to ensure that all aspects of health, personal and social care needs of residents are met, records were seen to be detailed. Staff knowledge on individual’s expectation’s and support was sound and care plans are reviewed and updated on a regular monthly basis. Mr Sardar has developed ‘clinical pathway’ records for those residents living at the home who have an increased level of support and health care need. This works in partnership with an individual’s care plan and ensures that any additional healthcare needs are identified and met. Fluid, meal intake and weight charts are maintained at the home for those resident’s who require additional nutritional monitoring in this area. There was a record of visits to the doctor and other primary healthcare support including consultants to evidence that advice is sought when necessary from specialists. The inspector saw that support is also accessed from specialist services, when required, examples of this includes district nursing services, hospital out patients, chiropody and dentist, demonstrating a ‘multi disciplinary’ approach. Evidence of this was up to date and sufficiently detailed within individuals daily records, however it is recommended that a consistent approach to the recording of medical appointments and visits is undertaken. The home also has in place a ‘clients medical sheet record’ however these were not being fully utilised. There are residents at the home who are supported by district nurses; they complete a care plan outlining the health support they are providing. Full medication administration, practices and recording were not reviewed at this inspection as these were found to be satisfactory at the previous inspection. The home has in place a clear medication policy. A recommendation was made at the last inspection that this policy should include what to do in the event of errors or omissions. This had been completed and clear information had been added to the policy, the guidelines for staff as to what they were to do in this event had been well written. Since the last inspection the home have supported two residents at the home with their terminal care. The home has in place a clear care of the dying policy. This provides information and guidance to staff in how to support residents at the end of their life. A staff member spoke with empathy on how they supported the residents and said that supporting people at this time ‘was an honour’. Upon a review of information held it was found that the home did not have information from all of the residents as to what their wishes were in the event of the end of their life. It was recommended that the home to seek and record the wishes and choices for residents in the event of their death. Edgecombe Lodge Rest Home for the Elderly DS0000062860.V270696.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15 Resident’s lifestyle matches their expectations and preferences and satisfies their social and recreational interests and needs. Residents are supported to exercise choice and control over their lives. EVIDENCE: The visitor’s book confirmed that there are a number of visitors to the home who visit on a regular basis. A visitor to the home said that they are always made welcome and that staff spoken with were pleasant. Prior to the inspection ten comment cards were received from relatives and visitors to the home. Comments on these were ‘an excellent care home, very friendly and clean. Always able to talk to you if you have any concerns’, ‘my mother is very happy at the home and is cared for in an excellent manner’ ‘the owners and staff are always friendly and helpful and the atmosphere at the home is always homely’. A staff member said that resident’s routines at the home are flexible and that residents are encouraged to make choices and decisions about their life. The staff member said that residents can chose what to eat, where to eat, what to wear, who to see, when to get up and when to go to bed and that residents routines are usually what they used to do before they moved into Edgecombe Lodge although they do change on a day to day basis, it was dependent on the needs and wishes of those living at the home. Edgecombe Lodge Rest Home for the Elderly DS0000062860.V270696.R01.S.doc Version 5.0 Page 14 A record of scheduled activities that take place at the home is on display with activities taking place four afternoons a week. Residents confirmed that they enjoyed participating in these sessions and also enjoyed it when entertainers came to perform at the home. Residents said they enjoyed board games and quizzes and going for walks in the local area. Lunch being served during the inspection was roast chicken, mixed vegetables and potatoes with yogurt for dessert. The inspector was invited to join the residents for lunch. The meal was very tasty and residents said that they enjoyed the meals at the home, that alternatives were offered and that the menu was varied. Edgecombe Lodge Rest Home for the Elderly DS0000062860.V270696.R01.S.doc Version 5.0 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Residents are confident that their complaints would be listened to and taken seriously and staff demonstrated a clear understanding in this area with clear policies and procedures in place. Those living at the home are protected from the potential of abuse due to staff training and understanding in this area. EVIDENCE: The home has in place procedures for responding to suspicion or evidence of abuse or neglect to ensure the safety and protection of individuals. Residents at the home told the inspector they had no complaints and that if they had any concerns they would speak to the manager or staff. One of the residents said that they had complained in the past and the situation had been dealt with appropriately. The inspector saw that there had been complaints made in the home; the information seen showed that the manager had dealt with the situation in a professional and effective manner The Commission for Social Care Inspection has received notification of incidents that have affected individual’s wellbeing at the home, the information provided shows that individuals had been supported in an appropriate manner. Mrs Sardar said that all staff has received protection of vulnerable adult training. Edgecombe Lodge Rest Home for the Elderly DS0000062860.V270696.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, 20, 22, 23, 24, 25, 26 The relationships between staff and those living at the home are good, and this creates a warm, supportive, homely environment, which promotes a good quality of life for the individuals living at Edgecumbe Lodge. Arrangements must be made to ensure that areas of the home are hygienic, odour and risk free. EVIDENCE: Edgecombe Lodge is a residential care home for older people located within the residential area of Downend. The home is a large detached house with accommodation provided over three floors. The home is within close proximity to local amenities and shops. Mr Sardar has requested to convert the manager’s office into bedroom accommodation for one resident and the office would then be re-located. An application to change the registration of the home in order that the home can increase their bed numbers from 20 to 21. Edgecombe Lodge Rest Home for the Elderly DS0000062860.V270696.R01.S.doc Version 5.0 Page 17 Resident’s bedrooms are appropriately furnished with residents being encouraged to bring in personal effects in order to make their room more ‘homely’. Rooms seen had appropriate furniture and fittings with photographs, plants, pictures and ornaments enhancing these rooms. A resident said that they had brought in their bed from home, another said they had brought personal items in order to make themselves feel more at home. Emergency call bells are provided in individual’s room in order that they can request additional assistance. At the previous inspection it was noted that a residents room had a carpet in need of cleaning and the room also had a strong odour. This room was revisited at this inspection; the carpet was clean however there was still an odour in this room. It is recommended that the home to eliminate the source of odour in room. Mr Sardar said that that the home strive to maintain levels of hygiene within the home, this will be further reviewed at the next inspection. The home has in place a number of aids and adaptations in order that residents have in place the specialist equipment in order to support them and to maintain their independence. Those seen included; pressure-relieving equipment, ramps/rails, toileting aids, aids for mobility, a stair lift, sensory impairment and bath aids. Risk assessments are in place for supporting residents within a number of areas of their care. In order to ensure the safety of the residents is it required that a risk assessment must be completed re the use of the stair lift. The home has a maintenance record book, however it was found at the last inspection that this record was not always clear when repairs have been undertaken, therefore it was 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. Evidence was seen to show that the home is well maintained. The manager has a monthly audit checklist which records what areas are checked for safety, it was recommended that the manager’s checklist include a section to demonstrate that emergency call bells are also checked. Edgecombe Lodge Rest Home for the Elderly DS0000062860.V270696.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, 29, 30 Residents are not fully protected by the homes recruitment and selection practices. Staff have not received sufficient training. EVIDENCE: The recruitment and selection documents for the three most recent staff members were reviewed at this inspection, all had in place completed application forms, two references, copies of identification documents, a copy of their job description and evidence of training undertaken and professional qualifications, however although the home have applied for a protection of vulnerable adults check and a criminal records bureau check evidence was not in place that clearance had been received. 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. Evidence of this must be forwarded to the Commission It was recommended at the previous inspection that in order to demonstrate that accidents are dealt with appropriately it was recommended that the home purchase a book in order to record staff accidents. This has been purchased with incidents being well recorded. A requirement was made at the last inspection that staff must a minimum of three days paid training per year. A review of five staff member’s records evidenced that this has not been undertaken. It is essential that staff receive sufficient appropriate training in order that they are able to fully undertake the duties and responsibilities of this role. The requirement will remain and will Edgecombe Lodge Rest Home for the Elderly DS0000062860.V270696.R01.S.doc Version 5.0 Page 19 again be reviewed at the next inspection. The inspector saw that all staff are currently undertaking infection control training, this training has been purchased as part of a package of training that also includes health and safety, legislation, risk assessment and diet and nutrition. These are ‘distance’ learning packages and incorporate an assessment of staff understanding. A recommendation was made at the previous inspection that the home to undertake an audit of staff training and in order to identify training needs. This had not yet been completed. Mr Sardar was aware of the benefits of this audit and was able to explain how this would be undertaken. This will be reviewed at the next inspection to the home. The significance of a National Vocational Qualification is well promoted at the home with one staff member who had achieved a qualification at level three, promoting independence. Mr and Mrs Sardar are both qualified nurses with Mr Sardar currently undertaking a registered managers award. Mrs Sardar is currently undertaking an assessor’s award for this process supporting two candidates in the home. There is also four staff that has achieved an NVQ at level two. Progress in this area will be further reviewed at the next inspection. Each individual has a key worker to support them with the manager being involved with the overall monitoring of individual care. It was clear that staff have developed relationships with individual’s and have worked together with them and others in order to identify the needs of a resident and then support the person in achieving their goals and future aspirations. There was information in individual care plans these provided information to guide staff to the appropriate level of support that individuals require. Clear job descriptions are also given to staff, these outline individual’s roles, responsibilities and what is expected of them. Residents who were asked were able to tell the inspector who their key worker was and spoke positively about the relationships, which had been established, and the support, which is given to them. The atmosphere at the home at the time of the inspection was calm and relaxed with individual’s looking clearly at ease and ‘at home’. Comments received from residents at the home about the staff included ‘the staff here are very good’, ‘staff here are so thoughtful and kind’. Five comment cards were received from resident’s prior to the inspection, all said that they felt well cared for. Edgecombe Lodge Rest Home for the Elderly DS0000062860.V270696.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, 32, 33, 36, 37, 38 The registered manager at Edgecombe Lodge is also the registered provider. Mr Sardar is qualified, skilled and experienced. The manager ensures an open and inclusive atmosphere is present in the home, which is run in the best interest of those living at the home. Health and safety of those living and working at the home is generally well managed however improvements are needed in respect of fire training for staff. EVIDENCE: Mr Sardar is both the registered manager and the responsible individual for the home and is supported with the management of the home by his wife Nargis who is also a qualified nurse. Mr. William Sardar has achieved the following professional qualifications: • MSC Nursing; Diploma in Higher education. 2002. Edgecombe Lodge Rest Home for the Elderly DS0000062860.V270696.R01.S.doc Version 5.0 Page 21 • • • • Diploma Module (anaesthetic & recovery). 1999. BSC Nursing (psychology). 1994. BSCN (teaching/learning). 1993. Certificate in nurse anaesthetic. 1971 and a Diploma in general nursing. Mr Sardar is currently in the process of undertaking his registered managers award in care. Mr Sardar and his wife were very open to the inspection process and appear committed to meeting the National Minimum Standards and in providing a good quality service for those living at the home. A requirement was made at the previous inspection that attention must be given to repair the fire door at the top of the stairs. The inspector saw that this had been undertaken and the door was seen to be in good working order. It was also required at the previous inspection that staff must ensure that emergency lighting is checked that is working on a monthly basis, The fire logbook at this inspection showed that this was now being undertaken on a weekly basis, therefore meeting the minimum standard in this area. Other weekly and monthly checks of fire equipment had been undertaken as required. However the inspector was concerned to find that staff have not received sufficient fire safety instruction. It is required that night staff must receive instruction every three months and other staff must receive instruction every six months. The manager was able to provided evidence for the maintenance servicing of the passenger lift and the stair lift. Mr Sardar had a tool in which to test for the electrical safety of portable electrical appliances however there was no evidence in place to show that this had been undertaken, it is required that evidence that portable electrical appliances have been checked is provided to demonstrate that items are safe for both resident’s and staff use. In July last year the home undertook a quality assurance audit of services and facilities provided within the home. This audit was completed in the form of questionnaires, which were given to residents and visitors. The questionnaire recorded high levels of satisfaction. The information seen corresponded with information given to the inspector by residents comment cards that had been forwarded to the inspector prior to the inspection also recorded that those living at the home were satisfied with the support they received. The inspector viewed the organisational policies and procedures in place at the home, these are robust and provide sufficient information in order to direct and guide staff practice. The policies seen were appropriate to the service provided at the home. A recommendation was made at the previous inspection that the policies and procedures 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. The inspector saw that the home have developed a process of ensuring that staff understand these Edgecombe Lodge Rest Home for the Elderly DS0000062860.V270696.R01.S.doc Version 5.0 Page 22 documents. Supervision records also confirmed that staff responsibilities are discussed. In order to aid effective communication and to ensure that staff are fully aware of their role and responsibilities it was required at the previous inspection that staff receive regular, recorded supervision. A review of five staff records confirmed that this has being taking place at the home. Records showed that staff have received regular one to one meetings with Mrs Sardar with appropriate subjects being discussed. Mrs Sardar confirmed that staff are given a copy of the supervision meeting notes and said that the supervision process had been ‘very positive, an opportunity for both parties to provide feedback and information sharing’ Individuals records and home records are secure, up to date and in good order and are kept secure, however there are not photographs of all residents in place. It is required that these must be in place in order to safeguard the welfare of the resident’s. It was noted at the previous inspection that staff morale at the home was low, this was not apparent when talking with those staff members on duty at the time of the inspection. Edgecombe Lodge Rest Home for the Elderly DS0000062860.V270696.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X 2 2 3 3 3 STAFFING Standard No Score 27 3 28 X 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 3 1 1 Edgecombe Lodge Rest Home for the Elderly DS0000062860.V270696.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. 4. 5. 6. 7. Standard OP37 OP38 OP37 OP22 OP37 OP30 OP38 Regulation 19(b) 23(4)d 19(b) 13(4) 17(1)a 18(1)(c) 23(2)c Requirement No staff are to commence employment until a satisfactory police check has been obtained Staff must receive sufficient fire instruction. Evidence of CRB clearance to be forwarded to CSCI Risk assessment must be completed re the use of the stair lift. Photographs of all residents must be in place. Staff must a minimum of three days paid training per year. Evidence must be provided of portable electrical appliance testing. Timescale for action 18/01/06 18/03/06 18/01/06 18/02/06 18/03/06 18/02/06 18/02/06 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. Refer to Standard OP30 Good Practice Recommendations The home to undertake an audit of staff training and in DS0000062860.V270696.R01.S.doc Version 5.0 Page 25 Edgecombe Lodge Rest Home for the Elderly 2. 3. 4. 5. OP23 OP11 OP10 OP22 order to identify training needs. The home to eliminate source of odour in room. The home to seek and record the wishes and choices for residents in the event of their death. Consideration to be given to a consistent approach to the recording of visiting health professionals and/or appointments. Managers check list to incorporate that emergency call bells are checked. Edgecombe Lodge Rest Home for the Elderly DS0000062860.V270696.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Bristol North LO 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 Edgecombe Lodge Rest Home for the Elderly DS0000062860.V270696.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!