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Inspection on 25/05/05 for Edgeview Nursing Home

Also see our care home review for Edgeview Nursing Home for more information

This inspection was carried out on 25th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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

The Home is extremely well organised, with a committed care management team, combining daily, short-term and long-term aims and objectives. Great emphasis goes into involving the residents and their families in the process of care, ensuring a highly personal approach to meeting individual needs. Nursing care is of a high standard with many on a one-to-one dependency contact with named nurses and keyworkers. Assessment procedures and care planning is of an excellent standard, offering detailed information on each resident`s progress the meeting of objectives. The support services all contribute to the team approach, and are recognised by the management for their efforts. Maintenance of good staffing levels, staff training and supervision are well established in safeguarding the interests of residents. Overall the attitude in meeting clinical and organisational demands is commendable, with forward thinking, planning and application contributing to an excellent service.

What has improved since the last inspection?

Each requirement and recommendation made through Inspection has been complied with. There have been very positive moves in establishing a firm socialisation and activities process, resulting in an atmosphere of creativity and energy, that was impressive.

What the care home could do better:

To maintain the very high standards achieved, constant vigilance is needed. The main area of concern is to ensure that fire lectures are maintained twice a year for all staff.

CARE HOME ADULTS 18-65 Edgeview The Compa Comber Road Kinver, Nr Stourbridge Staffordshire, DY7 6HT Lead Inspector Keith Jones Announced 25 May 2005 09:00 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Edgeview E53-E09 S22324 EDGEVIEW V209013 250505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Edgeview Address The Compa Comber Road Kniver Nr Stourbridge, Staffordshire DY7 6HT 01384 872804 01384 878980 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) Mrs Jane Heslop Edgeview Homes Limited Mrs Julia Ann Jasper Care Home 24 Category(ies) of MD - 24 registration, with number LD - 24 of places LD (E) - 1 Edgeview E53-E09 S22324 EDGEVIEW V209013 250505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 03/02/2005 Brief Description of the Service: Edgeview caters for twenty-four adults (18 – 65 yrs) with learning disabilities, including those with challenging behaviours and persons of a similar age range suffering mental ill health, which require twenty-four hour nursing care. It does not admit persons detained under the provisions of mental health legislation.There are sixteen service users in the main house; three more independent service users in the bungalow and five service users in the newly refurbished stable block annex.Edgeview aims to provide a home environment that will afford service users greater security, choice, independence and a good quality of life. This is achieved by maintaining a relaxed, friendly atmosphere with staff who appreciate that they are there to cater for their individual needs in a home environment, while maximising the services that the Home can offer to the service users.Edgeview is located in a residential area of Kinver, approximately one mile from the village centre in an area of outstanding natural beauty. Road links to nearby Stourbridge and Wolverhampton are good, with regular services. Edgeview E53-E09 S22324 EDGEVIEW V209013 250505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection was conducted with the provider, operations manager and the care manager. The inspector also had the full cooperation and contribution of all staff, service users and relatives present. There were no outstanding requirements or recommendations. A tour of the home allowed free access to all areas of the Home and open discussion with service users, relatives and staff. There were 24 service users in residence. There followed a sample review of administrative procedures, practices and records. Four service users were randomly selected for case tracking to inspect all aspect of their care at Edgeview, from referral to the present time. There followed a report feedback in which the inspector offered an evaluation of the inspection, indicating those requirements and recommendations resulting from the inspection. What the service does well: The Home is extremely well organised, with a committed care management team, combining daily, short-term and long-term aims and objectives. Great emphasis goes into involving the residents and their families in the process of care, ensuring a highly personal approach to meeting individual needs. Nursing care is of a high standard with many on a one-to-one dependency contact with named nurses and keyworkers. Assessment procedures and care planning is of an excellent standard, offering detailed information on each resident’s progress the meeting of objectives. The support services all contribute to the team approach, and are recognised by the management for their efforts. Maintenance of good staffing levels, staff training and supervision are well established in safeguarding the interests of residents. Overall the attitude in meeting clinical and organisational demands is commendable, with forward thinking, planning and application contributing to an excellent service. Edgeview E53-E09 S22324 EDGEVIEW V209013 250505 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? 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. Edgeview E53-E09 S22324 EDGEVIEW V209013 250505 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Edgeview E53-E09 S22324 EDGEVIEW V209013 250505 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4and 5 The managers have reviewed and updated the Statement of Purpose to offer a comprehensive, yet user-friendly information package that serves to clarify the aims and objectives, facilities and services, and the staff who they will be meeting. Pre- admission assessment is conducted by the senior team of nurses or care manager at the point of referral, with a full multi-disciplinary and a community assessment. The assessor provides advice to potential service users as to the suitability of the home in meeting their needs. This includes a visit or short stay to get used to the Home environment. The contract offered is clear in outlining the terms and conditions of residency and care. EVIDENCE: During the course of the inspection there was ample opportunity to sit and talk with residents, staff and a couple of visitors. It was evident that much care had been taken in involving residents and family in the admission process. A recent new resident expressed his pleasure at the easiness of fitting in, and the general friendliness around. The Statement of Purpose was examined and found to provide a very informative description of Edgeview’s aims and the way it operated. Edgeview E53-E09 S22324 EDGEVIEW V209013 250505 Stage 4.doc Version 1.30 Page 9 The contract of residence was unchanged, offering clear terms of reference of residence. Examination of resident’s care records and plans clearly demonstrated the extensive efforts to see through the pre-admission and admission procedures and assessments. Each record showed the attention to individuality and their unique needs. Evidence was seen of that assessment process being applied following admission and in continuing care. Edgeview E53-E09 S22324 EDGEVIEW V209013 250505 Stage 4.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,8,9 and 10 Residents spoken to were keen to show the extent of independence and the degree of involvement in their care, a ‘partnership of care’ approach. This focused on positive behaviour, ability and willingness of the individual, showing that service users freely make decisions about their life in the home. Residents were also seen to be supported by their key workers and the management to take risks as part of an independent lifestyle in the home. Edgeview E53-E09 S22324 EDGEVIEW V209013 250505 Stage 4.doc Version 1.30 Page 11 EVIDENCE: Care plans were examined and found to offer an excellent record of daily living, which were comprehensive, and included a provider assessment; a person centred plan, a health and safety assessment, and a planned intervention, rehabilitation and therapeutic programme. Evidence of health care professional visits showed an attentive awareness to service user’s needs. It was noted that each day had a different schedule of events encouraging therapeutic and social activities geared to meeting service users sense of belonging. Four residents were case tracked with a full examination of care records, health records including general practitioners and consultant visits, risk assessments, dependency charts, records of reviews and action plans. Records inspected showed that residents freely make decisions about their life in the home. Risk assessments were carried out on an individual basis and reviewed. Included in the care records were applications of established monitoring systems following a process of goals, care and evaluation models. The activity centre provided facilities for independent expression and facilitating life skills for individuality. During the inspection a lively occupational therapy session was in full swing with a team led by the activities co-ordinator. It was clear that much work had gone into promoting personal awareness and a sense of belonging. Edgeview E53-E09 S22324 EDGEVIEW V209013 250505 Stage 4.doc Version 1.30 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,13,14,15,16 and 17 Throughout the inspection residents were seen to be enjoying a high degree of encouragement to express themselves in positive and meaningful ways. Bedrooms were seen to demonstrate that individuality, each different to match personal outcomes. On the day of inspection there were no events involving the local community, but reports from staff and residents indicated sense of belonging within that community. A fully flexible open visiting policy was seen to be in operation with some visitors present throughout the inspection, reflecting the importance placed upon family or friends’ regular contact. The residents and staff were seen to be enjoying a beautifully presented lunch. Edgeview E53-E09 S22324 EDGEVIEW V209013 250505 Stage 4.doc Version 1.30 Page 13 EVIDENCE: It was most encouraging to see the advances made in social and occupational therapy initiatives. The activity centre continues to act as a centre providing a range of life skills training events led by an enthusiastic full time activity coordinator and assistant with an arts therapist. There was a very strong influence of creativity, not only in the centre, but also throughout the Home. Several residents were anxious to show the mounted paintings in corridors and lounges, especially one created in memory of a recent bereavement of a popular resident. The Home is developing a ‘snoezelan’ room, a multi sensory room where individuals can watch light displays, listen to music for therapeutic relaxation sessions. The care manager and activities co-ordinator has initiated training for staff, to present an expanding facility adjacent to the games/leisure room. Discussions with the care manager and residents provided evidence of holidays taken, and planned for, to different parts of the country, funded and planned by the residents themselves. Resident’s life-styles and interests are recorded in their care plans, discussed with their relatives prior to admission, and documented as far as possible to enhance a position of supported independence. Routine is seen as flexible to acknowledge individuality, yet maintain a focal point for service users to latch on to without dictating events. The overall emphasis on the importance of nurturing a solid foundation of trust and respect with the local and wider community is impressive and merits particular recognition. Relations with local police and other public bodies were observed to be excellent. The Home’s policy on sexuality is dealt with in a sensitive and professional manner acknowledging that residents are able to develop and maintain intimate relationships in a discrete and sensitive fashion. Sexuality was seen to be an important element of care planning and assessment. The kitchen continues to be very well organised, clean and well equipped. The catering staff were helpful and efficient, accommodating an inspection at one of the busiest times of the day. Menus were seen to be varied and offered a nutritious and well-balanced diet. Service users living in the independent living bungalow are able to prepare and cook their own meals, in well-equipped kitchenettes, observed by their key worker. Edgeview E53-E09 S22324 EDGEVIEW V209013 250505 Stage 4.doc Version 1.30 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,20,and 21 The Home operates an environment conducive in support of individual physical and emotional needs. The routines involving medication was inclusive whenever possible, yet safe, secure and efficiently administered. Discussion concerning an aging population is commonplace and meaningful in respect of long-term planning. EVIDENCE: Professional and personal support is offered through key workers and named nurses to maximise the service users individuality, privacy and dignity, to lead an independent life style, with as much privacy and dignity as possible. Regular GP visits ensured a continual medical review and assessment presence. A psychiatrist visits weekly, and a sessional psychologist attends the home on a fortnightly agreement. Through case tracking, discussions and inspection of records, it was recognised that should special health care needs be recognised the relevant service was consulted. At the time of inspection there were 24 highly dependent service users. Each had had a full review of risk factors including threats of falls and pressure sores. Edgeview E53-E09 S22324 EDGEVIEW V209013 250505 Stage 4.doc Version 1.30 Page 15 The policies, procedures and practices concerning the administration of medicines were found to be strictly enforced, and diligently recorded. There has been a centralisation of medicines control with the Annexes serviced from the main house. Staff spoken to were conversant with their responsibilities in the safe storage, handling and disposal of drugs in accordance with the Medicines Act 1968. The administration of medicines was found to be accurate and up to date. The individualised style of care provided openly addresses the issues of serious illness and death. Care records showed that service users were aware of the concern that care staff hold, to ensure that all appropriate care and attention will be given, and if necessary, that prescribed medication will be arranged. The spiritual affiliation of each service user is determined and recognised with dignity. Edgeview E53-E09 S22324 EDGEVIEW V209013 250505 Stage 4.doc Version 1.30 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 The residents demonstrated a confidence associated to belonging, trust and friendship. Those residents spoken to felt safe and secure within a ‘family’. Staff indicated that residents were encouraged to be open about problems. This point was confirmed by several residents. EVIDENCE: A complaints policy and procedure was seen and found to be comprehensive. The care manager kept a complaints file for minor issues resolved locally. The management showed satisfactory evidence of a protocol and response to anyone reporting any form of abuse, to ensure effective handling of such an incident. This includes the right to ‘whistle blowing’ consistent with the Public Disclosure Act 1998. Staff induction and in-house training programmes clarified the responsibilities of all staff in their daily contact with service users, especially their privileged position in protecting service users from abuse, of all natures. The Operations Manager of the home has a qualification as a Crisis Prevention Institute Instructor for Non-violent Crisis Intervention. Other members of staff are actively pursuing the qualification. Edgeview E53-E09 S22324 EDGEVIEW V209013 250505 Stage 4.doc Version 1.30 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,26,27,28,29 and 30 Edgeview continues to offer a well-maintained and homely environment. Great attention is given to ensure a safe, comfortable and secure residence. Bedrooms were well maintained to meet service user’s personal preferences, expressing a highly personal presentation in décor and furnishings. Facilities for toilet and bathrooms are adequate, with up dating presently taking place. Lounges, activity centres and dining rooms were well-appointed and popular areas for socialisation. All areas throughout the Home were clean and hygienically presented. EVIDENCE: Edgeview is well appointed to meet the needs of service users with learning difficulties, in providing a safe and comfortable environment. External access is satisfactory for service users access and visitors parking, fire escapes were kept free of obstruction and well maintained. Edgeview E53-E09 S22324 EDGEVIEW V209013 250505 Stage 4.doc Version 1.30 Page 18 Service users take advantage of attractive gardens and grounds and it was noted that the activity co-ordinator has introduced a resident’s garden, which he hopes will develop along therapeutic lines. Each room offers single accommodation with adequate and safe radiators, windows, each with smoke alarms and light dimmer switches. Each resident is encouraged to bring their own personal possessions and furniture if they so wish. The intended aim is seen to be successful in achieving a sense of identity, a place of comfort and privacy. The Stables and annex have had some recent remedial repairs made to décor and fabric. The kitchenette areas in the annexes were generally well presented, adequately stocked and equipped with domestic appliances. The home’s policies and procedures complied with the fire service requirements in general, a recent fire officer’s report has been received and is presently being complied with, in every recommendation made. Adequate attention has been given to ensure maximum privacy within riskassessed boundaries. Upgrading of bathrooms was in progress to meet a full upgrade objective by the autumn, including conversion of one to a hydrotherapy facility. It was noted that one bath had been damaged, needing repair. The newly positioned laundry area was clean and very well organised; procedures were in place for coping with soiled/infected linen with the provision of alginate bags to minimise handling and cross-infection. Chemical cleaners were used appropriately throughout the home, were seen to be secure and under COSHH recommended practices. Edgeview E53-E09 S22324 EDGEVIEW V209013 250505 Stage 4.doc Version 1.30 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35 and 36 Edgeview has consistently had a very pro-active attitude to staffing and personnel management. Staffing levels of quantity and skills are commensurate to meet the needs of highly dependency residents. This policy was seen to be meaningful in talking to residents and families. Staff recruitment, appointment and training are of a high quality. EVIDENCE: There is evidence through case tracking of a multi-disciplinary approach to holistic needs, with staff appreciating each other’s contributions and that of relatives, well presented in the Home’s staff induction programme, and reinforced through continued supervised training sessions. On appointment staff are offered a job description, which is complimented with the GSCC code of conduct and staff appraisal. The numbers and skill mix of the staff adhere to, and exceed the Notice of Staffing. Three weeks of off-duty were examined, providing evidence that the home is suitably staffed in numbers, skills and qualifications to ensure the needs of the service users are met Edgeview E53-E09 S22324 EDGEVIEW V209013 250505 Stage 4.doc Version 1.30 Page 20 On the day of inspection the staffing levels were: 0745 – 1415 1415 – 2045 2045 – 0745 – 2 trained 9 carers - 1 trained 9 carers - 1 trained 3 carers The provider and operations manager continue to present a high profile in the management and organisational process, working closely with a highly committed care manager. This team offers a consistent, detailed, knowledgeable presence, essential to the efficient running of a demanding service need. Four staff files were examined and found to protect equal opportunities, and provide satisfactory evidence that promoted protection of vulnerable service users. Each would benefit from a file photograph of the member of staff. The process of appointing new staff were well organised, consistent and safeguarded the interests of residents. A satisfactory staff induction programme initiates a formal in-house training schedule. There were however gaps in the fire training regime, a matter for immediate attention. NVQ programmes continue with a commitment of internal assessors and the contribution of Dudley and Kidderminster colleges. It is pleasing to see the commitment to care education sustained and enhanced. The supervision programme is firmly established, which involved establishing a shared aspect of responsibility between staff and trainer, with the involvement of cascaded mentor trained staff. Edgeview E53-E09 S22324 EDGEVIEW V209013 250505 Stage 4.doc Version 1.30 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,39, 40,41, 42 and 43 Edgeview has in place a highly effective and motivated management team, sensitive to the needs of each resident, organisational demands and the professional standing of services to people with learning disabilities. Personnel are well trained and appreciated for their professionalism. Policies are meaningful, supported with up to date procedures and skilled application of good practice. Each presents a safe and secure environment in protection of rights, interests, health and safety of the residents. EVIDENCE: The care manager, Julia Jasper has demonstrated her wide experience and is well qualified in meeting the aims and objectives of the home. As previously stated she is a member of a potent and effective management team. Edgeview E53-E09 S22324 EDGEVIEW V209013 250505 Stage 4.doc Version 1.30 Page 22 There is a confidence apparent in the interaction of staff and the Home’s management, that demonstrated a positive relationship that pervades throughout the Home. This open style of management was mentioned by several service users, which provided a source of trust and mutual respect. Quality assurance complements this arrangement with extensive monitoring in areas as care planning, staff meetings, staff training and resident’s suggestions. The case tracking undertaken reinforced the effectiveness of resident’s involvement in their care and environment. The service users were aware of the CSCI inspection and asked to speak with the inspector, showing off their rooms and their accomplishments. Twelve comments sheets and one letter were presented to the Inspector. Each service users has a personal file containing contractual, financial and personal information. Several files inspected evidenced a satisfactory standard of maintenance and security of these files. A sample of administrative, maintenance and care records were examined and found to offer an accurate reflection of a service committed to providing a safe and comfortable environment. Staff training programmes included relevant aspects of Health and Safety, first aid, moving and handling and fire training were recorded, although there were gaps in the fire training records. Servicing records of essential equipment were examined including hoists, and electrical maintenance, including personal electrical PAT testing. All accidents and incidents were recorded for staff and service users, including provisions for Riddor should the need arise. The administration and management of the home is efficient, uncomplicated and sensitive to the needs of service users. All relevant legislation was discussed and is fully understood by the management. Suitable accounting and financial procedures were found to be in place. Service users benefitted from competent and accountable management of Edgeview Homes Ltd. Edgeview E53-E09 S22324 EDGEVIEW V209013 250505 Stage 4.doc Version 1.30 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 4 4 4 4 4 Standard No 22 23 ENVIRONMENT Score 4 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 4 4 4 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 2 3 3 4 Standard No 11 12 13 14 15 16 17 3 4 4 3 4 4 4 Standard No 31 32 33 34 35 36 Score 3 4 4 4 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Edgeview Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 4 4 3 4 4 3 4 E53-E09 S22324 EDGEVIEW V209013 250505 Stage 4.doc Version 1.30 Page 24 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. Standard 23 Regulation 23(4d&e) Requirement Maintenance of twice yearly fire lectures for all staff Timescale for action 25/05/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 23 41 42 Good Practice Recommendations Repair to damaged bath Photograph of each resident in care files (Schedule 3.2) Photogragh of each member of staff in staff files (Schedule 4 (6)). Edgeview E53-E09 S22324 EDGEVIEW V209013 250505 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Stafford - Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Edgeview E53-E09 S22324 EDGEVIEW V209013 250505 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. 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. 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