Inspection on 31/01/06 for Edmore House

This inspection was carried out on 31st 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

Edmore House 19/11/08

Edmore House 11/10/07

Edmore House 12/09/06

Edmore House 06/09/05

Edmore House 01/12/04

Edmore House 11/06/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Edmore House 20 Oakham Road Oakham Dudley West Midlands DY2 2TB Lead Inspector Deborah Sharman Unannounced Inspection 31st January 2006 09:40 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 Edmore House DS0000024953.V281082.R01.S.doc Version 5.1 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. Edmore House DS0000024953.V281082.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Edmore House Address 20 Oakham Road Oakham Dudley West Midlands DY2 2TB 01384 255149 01384 255149 annnewton@aol.com 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) Mr Charanjit Singh Atwal Mrs Ann Newton Care Home 18 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (1), Physical disability over 65 years of places of age (17) Edmore House DS0000024953.V281082.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th September 2005 Brief Description of the Service: Edmore House is a privately owned care home and is registered to provide accommodation for 18 elderly persons. It is a converted property consisting of three floors. The first and lower ground floors can be accessed via the lift or stairs. All bedrooms are tastefully decorated and service users are encouraged to bring small items of furniture with them if they wish. There are three lounges on the ground floor and a dining area. At the rear of the property is a patio with garden furniture, potted plants and a large garden. Car parking is available at the front of the house and visitors may visit at any time. Care staff are available 24 hours a day to meet the needs of the service users and ancillary staff are employed during the day. Edmore House DS0000024953.V281082.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection meaning that prior notification was not given and it was therefore not possible for the home to prepare before hand. The inspection began at 9.40am,finished at 5.00pm and was conducted by one Inspector. On arrival the Inspector found that the Manager had been off sick for 3 weeks but she came in upon learning of the inspection. The proprietor was available throughout the inspection day. The plan for the inspection was to assess those National Minimum Standards not assessed at the previous inspection including progress made towards related previous requirements issued for improvement. The Inspector was able to assess documentation, case track the care of some service users, and interview the Manager and proprietor as well as a senior staff member, the cook, a visiting relative and a service user. The Inspector was also able to observe the main meal of the day and briefly tour the premises. What the service does well: Relatives, residents and staff continue to express high levels of satisfaction with the service provided. A visiting relative whose family visit daily said of the staff – they are ‘very nice, sociable, very pleasant and caring’. She said that visitors are always made very welcome and are offered a drink. She added that ‘the staff attitude is beautiful’. She said that the resident she visits is eating very well in spite of having some quite specific and restrictive likes and dislikes. She felt that service users are safe and there is plenty of activity and that service users are spotlessly clean. A relatively new service user said that Edmore House is a ‘nice home’ and ‘they look after me very well’. She said that she feels safe and that she is offered a choice of what to eat adding that she has enough to eat. She said that ‘staff have been very nice’ and said that activities are available but laughingly added that you ‘don’t feel like dancing around when you are 85’. She said that she was happy. A staff member said she felt that they have a really good staff team and that staff and management work well together. She said that Edmore House is ‘friendly with a nice atmosphere’ and that service users are ‘well looked after Edmore House DS0000024953.V281082.R01.S.doc Version 5.1 Page 6 with any problems being dealt with promptly’. She wasn’t aware of anything that could improve. The Proprietor is proud of the homely environment provided at Edmore House and is quick to respond to the need for improvement. For example following comment at the last inspection, the ground floor bathroom has been refitted and the tiling is almost complete. What has improved since the last inspection? What they could do better: The Inspector was concerned at this inspection about the Manager and Proprietor. The Manager was off sick and the proprietor was very tired. They have realised that they both need support and had identified that they need to restructure the staff team in order to achieve this. They plan to create a Deputy Manager post responsible for care practice and senior staff responsible for shifts on a day-to-day basis. The 3-week absence of the manager through sickness had awoken them to the need for this. The Managers absence was evident in some outcomes found at this inspection. For example, a Doctor had not been called to a resident whose care notes showed no health improvement and staffing ratios had not been maintained leading to the need to issue an immediate requirement notice. The rota too had not been kept up to date. The home does not have an adequate contingency in the event of staff sickness and is not addressing long-term staff sickness. Staff training is on a rolling programme and there are good records to inform the training programme. However as with staff sickness, steps are not being taken to address a small minority of staff who refuse to undertake mandatory training courses. The training programme must now begin to include training that will Edmore House DS0000024953.V281082.R01.S.doc Version 5.1 Page 7 provide staff with specific knowledge and skills to support service users needs e.g. nutrition, mental health awareness and causes of behaviour including appropriate behaviour management training. There continues to be shortfalls in the care planning system used which have been recognised by the manager who said the plan is to purchase a care planning system imminently. Nutrition management has not improved in spite of ongoing previous requirement. Service users case tracked were found to have lost weight without action having been taken. Staff spoken to were not aware that service users meals could be fortified to prevent weight loss highlighting the need for training and care plans that provide sufficient guidance. 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. Edmore House DS0000024953.V281082.R01.S.doc Version 5.1 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 Edmore House DS0000024953.V281082.R01.S.doc Version 5.1 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): EVIDENCE: These standards were not assessed at this inspection. Edmore House does not provide intermediate care and therefore Standard 6 was not assessed. Edmore House DS0000024953.V281082.R01.S.doc Version 5.1 Page 10 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): 8, 10 Service users health care needs are generally but not fully met. Service users feel they are treated with respect and that their right to privacy is upheld. EVIDENCE: It has been an ongoing prior requirement since September 2003 to improve nutritional management. This inspection shows that this has not been met. Nutritional risk assessments are still not being carried out to identify nutritional risk and action not taken although the pro formas have been obtained for the dietician service. Nutritional care plans are not in place. Discussion with the cook and a senior staff member showed no knowledge of nutritional fortification. There is evidence of service users case tracked losing weight. M.G lost ten pound in weight between September and November 2005. Similarly between September and October 2005 M.D. lost 6 pound in weight. Her records show that between April 2005 and December 2005 she has lost 7 pound. Care plans do not indicate safe weight ranges for service users to help staff to know when service users weight loss is of concern. Edmore House DS0000024953.V281082.R01.S.doc Version 5.1 Page 11 L.W’s records illustrate daily concern about her refusal of meals since 12 January 2006. There is no nutritional risk assessment or plan of care to address this. The Doctor visited on 23 January 2006 and suspected a small stroke. There is a record of a blood test but no results by the day of inspection. There are daily references in records to this service user continuing to be unwell with no improvement since the Doctors visit but no record that the Doctor has been recontacted. Staff were observed to interact with service users with kindness and respect. Staff also knock on doors before entering rooms. Service users preferred terms of address are recorded and are used by staff and a pay phone is available for use in private by service users. Two service users use one bedroom as a shared bedroom. The room is fresh, furnished with twin basins and has a dividing curtain for added privacy. Edmore House DS0000024953.V281082.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Generally service users are satisfied by the lifestyle provided by the home. Service users maintain contact with family and friends as they wish. Service users are helped to exercise choice and control over their lives. Service users receive an appealing varied diet in pleasing surroundings. Knowledge and systems to identify and meet all nutritional need are not satisfactory. EVIDENCE: Activity provision has increased. Since Christmas an exercise lady has been booked to provide group activity every other week and 4 singers provided entertainment in 2005. The Salvation Army visited at Christmas and a family party was held too. Service users were supported to shop at Merry Hill prior to Christmas in groups of two and five service users were taken to Stourbridge to see the Christmas lights. Food choices have improved but an alternative is not provided when a roast dinner is cooked which does not offer choice to the service user assessed as not liking meat. A relative confirmed that religious observance was not adhered to in the home but this did not concern her. Edmore House DS0000024953.V281082.R01.S.doc Version 5.1 Page 13 Relatives can visit at any reasonable time without restrictions and visitors are always seen to be present during inspections. A visiting relative confirmed that service users are able to receive visitors in private and that her family visits daily. The Inspector was able to talk to a service user in private without interruption. One service user without a family has an advocate who visits regularly to promote her interests. Families manage service users finances with the home holding small amounts of cash for some service users to pay for hair appointments etc. Service users are able to choose when the get up and go to bed and now have a greater choice at meal times. The variety of deserts available has also increased. Whilst the visiting exercise lady was entertaining a group of service users the Inspector observed a service user enter the room supported by a staff member. She was encouraged to join in but her ultimate decision not to was respected by the staff member and she was supported to leave the room. A relative spoken to explained that her relative living at Edmore House had always had a wide variety of food dislikes and enjoyed only a very limited range of food. The relative said that in spite of this ‘they are coping very well here. They ask her what she wants and she is eating ok’. She said that in accordance with the service users expressed wish she is provided with sandwiches for breakfast. A staff member confirmed this and was aware of this service users individual wider preference. The cook works to a rolling menu with alternatives listed including diabetic meals and deserts. The menu was not adhered to on the day of inspection as stocks had ‘run short’ but food being served was written on the notice board in the dining room. Systems are not sufficiently in place to identify and respond to service users who may be losing weight or underweight. Systems including staff knowledge and awareness must improve to better protect service users health. Mealtime was calm and pleasant with service users eating together in the dining room. Portions were seen to be appetising as well as small and large based upon individual preference. A service user told the Inspector that the dinners are ‘alright so far’. She confirmed that she can choose what she eats adding that ‘staff ask’ and she said that she has enough to eat. Edmore House DS0000024953.V281082.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Service users are protected from abuse. Systems must however be better developed to assure that physical and or verbal aggression is understood and dealt with appropriately. EVIDENCE: Discussion with staff and assessment of care records show that service user ‘T’ is displaying agitated behaviour with significant trigger points resulting in the service user grabbing staff wrists and appearing to want to leave the premises. Staff have not received training in behaviour management and behaviour management care plans are not in place to guide their understanding and approach. Discussion with an experienced staff member however showed that she had an awareness of this service users needs. The Manager could verbally describe what triggers his anxiety but written guidance will better assure a consistent and appropriate response by all staff. There has been no disciplinary action taken against staff, no allegations, no physical restraint of service users and there few behaviours defined as challenging. Most staff with the exception of three have done Adult Protection training. Discussion with an experienced staff member evidenced a good understanding of what abuse is and what her role would be in the event of concern about a vulnerable adult. A care staff member, an ancillary staff member, a service user and a relative all confirmed to the Inspector that they believed Edmore Edmore House DS0000024953.V281082.R01.S.doc Version 5.1 Page 15 House is a safe place for service users to be. A staff member said that service users are ‘really looked after’ and that she had ‘no concerns’ about the home, adding ‘none at all’. Edmore House DS0000024953.V281082.R01.S.doc Version 5.1 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): EVIDENCE: These Standards were not assessed at this inspection. Edmore House DS0000024953.V281082.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 30 Ratios of care staff required are not kept under review and service users needs are not always met by appropriate numbers of staff. Service users are in safe hands. All staff have not undertaken all mandatory training with some staff having done significantly less training than others. Little training has been done to prepare staff with specific knowledge and skills to ensure they are prepared to meet the needs of some service users admitted to the home e.g. mental health and disability awareness. EVIDENCE: The rota has not been kept up to date and does not accurately reflect hours worked by staff. For example the Manager and a staff member were not marked as sick for week beginning 23 January. The rota had not been altered to evidence staff appointed to cover staff absence on 27 and 28 January 2006 and therefore there is no evidence that cover was provided and that staffing levels were appropriately maintained on these dates. Assessment of the rota and discussion with the Proprietor showed that staffing levels had not been maintained on Tuesday 24 January and Thursday 26th January when only two staff instead of three had been on duty in the afternoon from 2pm – 8pm. Edmore House DS0000024953.V281082.R01.S.doc Version 5.1 Page 18 The home does not have a bank of staff to call on and does not use agency staff. The home therefore does not have an effective contingency plan for unexpected staff absence. A recognised tool has not been obtained by the home to calculate staffing hours required. During this period the Registered Manager had been absent for 3 weeks sick and was not due to return to work for a further week. There are no senior staffs with defined roles. The proprietor / Deputy Manager has been covering care shifts with there being no effective management time available and no one clearly responsible for arranging staff cover or updating the rota. It is a previous requirement to notify the Commission for Social care Inspection on each occasion that staffing levels are not met as a result of previous similar concerns. Notification to the Commission was not made. The Inspector was told that the consequences of these omissions had become apparent to both the Manager and Proprietor shortly before this inspection and that there are firm plans in place to review and change the staffing structure with a view to creating accountability through a hierarchy by March 2006 which will be confirmed in writing to the Commission for Social care Inspection. Long-term staff absence due to sickness is being carried by the home. There are no policies, procedures or systems in place to manage this. Over 50 of care staff have the required NVQ qualification exceeding the national target and those staff are to be congratulated for their commitment and hard work. There is however a small core of staff who the Manager and Proprietor said are refusing to attend training courses which will affect the overall performance of the home and compromise the knowledge required to meet the needs of service users effectively. There are no staff currently employed by the home who are under 18 or 21 years old. A training programme is in place and the manager has records that inform this process. Training is provided on a rolling programme basis but planned training consists of mandatory training only. Training to enhance the specific knowledge and skills of staff in conditions, which may be associated with service users admitted to the home, is not available and this must be developed. A group training matrix and individual training profiles would better support the coordination of training and the Manager said she is aware of the need for this. Systems are in place for new staff to receive appropriate induction training and although staff sampled hadn’t finished within the required 6 weeks, night staff had successfully completed the programme within 8 weeks of employment. As referred to above not all staff are taking advantage of courses on offer and not all staff have undertaken the minimum 3 days paid training in 12 months. Training provided to two staff members in the previous 12 months was sampled. One staff member had done 4 training Edmore House DS0000024953.V281082.R01.S.doc Version 5.1 Page 19 courses, the other had only benefited from half day training in the 12-month period prior to inspection. Edmore House DS0000024953.V281082.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 Service Users live in a home, which is run and managed by a person who is fit to be in charge. Staff and a relative spoke highly of the Manager. Staffing structures however require revision to ensure that the Manager is able to discharge her responsibilities fully. Currently Edmore House is not monitoring its own service quality to assess whether the home is meeting its objectives or whether it is run in the best interests of service users. Service Users financial interests are safeguarded. EVIDENCE: The Manager who is registered with the Commission for Social care Inspection as Manager of Edmore House informed the Inspector that she has completed all the required course work to obtain the qualification needed to be a Care Edmore House DS0000024953.V281082.R01.S.doc Version 5.1 Page 21 Home Manager and is currently awaiting its verification. The Proprietor who works at the home too has also obtained these qualifications. Whilst the Manager has been working towards this national qualification she has not undertaken any other periodic training but intends to now with a course on Dementia booked for March 2006. The Manager does not have a Job description and in addition has not had a staffing structure in place where she has been able to share the workload or delegate care practice tasks. This has meant that there is no clarity of role and she is not fully able to monitor, oversee and develop the home as would be expected. The proprietor works as a carer and provides management support with the building and its maintenance. The Manager and Proprietor have discussed the need for support and clear lines of accountability shortly before this inspection and there are firm plans to make the necessary improvements. Since the last inspection the provider has purchased a quality assurancemonitoring package, which the Inspector was told, includes tools for gaining feedback about the homes performance from service users and third parties. This has not yet been implemented and so currently there is not any continuous self-monitoring. The development of a management team as planned will better support the Manager to ensure that quality systems are undertaken and the results responded to. The home holds some money on behalf of some service users to pay for incidentals and hair appointments. Systems are in place to protect service users financial interests with staff signatures accounting for financial activity, balances recorded and checked correct by the Inspector. Crime prevention has provided advice about the storage of service users monies and minimal changes have been made as a result of that advice. The provider has not sought the advice of his insurers as required. This is a long outstanding requirement that has not been met but has been deleted from this report on the understanding that it is at the proprietors risk. Service users monies are not pooled but are stored in named separate compartments of the locked cabinet. The use of named moneybags would better serve financial accounting. Staff confirmed that the number of people who have access to service users money is restricted. Where families have not provided sufficient funds it appears from records that the provider has contrary to the terms and conditions of residency funded service users hair appointments etc to protect the service users free will and dignity. Edmore House DS0000024953.V281082.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 2 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 X X X X X X X X STAFFING Standard No Score 27 1 28 3 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 X X X Edmore House DS0000024953.V281082.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4,5 Requirement The Statement of Purpose must state the range of needs the home is intended to meet. Requirement first made and not met since September 2003. Not assessed at January 2006. 2. OP4 4,16 The home is to make arrangements for residents to worship in accordance with their preference and as recorded in their assessment and care plan. Requirement first made September 2003. Not Assessed September 2005 Not Assessed January 2006. 31/03/06 Timescale for action 31/03/06 Edmore House DS0000024953.V281082.R01.S.doc Version 5.1 Page 24 3. OP7 5 Evidence to be provided of Service Users’ involvement of drawing up care plans. Requirement first made and not met since May 2002. Not Assessed January 2006. 31/03/06 4. OP7 1513(3) The management of a urine bottle must be included in the service users plan of care. Not assessed Sept 05. Not assessed January 2006. All manual handling care plans must include more detail e.g. how residents must be transferred / equipment to be used / techniques / specific requirements etc. determined by risk assessment. Not assessed Sept 05. Not Assessed January 2006. Care plans must include foot care, oral care and nutrition. Requirements first made June 2004. Not assessed January 2006 – nutrition not met at Jan 06 31/03/06 5. OP7 13(2), 15 Care plans must include all service users medication details and must be updated regularly to reflect any changes. Care plans must include specific details of all medication prescribed as ‘as required’ including the name of the drug, the dosage, frequency of administration, maximum dose, the criteria for administration. New Requirement September 2005. Not Assessed at January 2006. 31/03/06 Edmore House DS0000024953.V281082.R01.S.doc Version 5.1 Page 25 6. OP8 13 The manager is required to seek the advice of an occupational therapist for individual residents, as their physical needs change in order to secure appropriate disability equipment. Requirement first made and not met since September 2003. Not Assessed at January 2006. 31/03/06 7 OP8 13(4) 13 The manager must seek and follow the advice of the diabetic nurse with respect to untrained staff monitoring the blood sugars of diabetic service users. Advice given must be communicated in writing to the Commission for Social Care Inspection. New Requirement September 2005. Not Assessed at January 2006. 31/03/06 8 OP8 12, 13 To re refer service user LW for medical advice and confirm outcome in writing to CSCI by date given. New Requirement at January 2006. The home must provide a medication policy to cover, medication prescribed as required and covert medication, Requirement first made and not met since September 2003 The medication policy must include guidance on double dispensing in accordance from 10/02/06 9 OP9 13 31/03/06 Edmore House DS0000024953.V281082.R01.S.doc Version 5.1 Page 26 advice, which must be sought from the contracted pharmacist. New Requirement September 2005. Not Assessed at January 2006. 10. OP9 13(2) Procedures are required to guide staff in the event of medication errors. Requirement first made and not fully met since September 2003 Not Assessed at January 2006. An alternative to the main meal of the day is to be offered on the menu and residents choices recorded. Requirement first made September 2003 Not Assessed at September 2005 Part Met at January 2006 – no alternative when roast dinner on menu. One resident does not like meat. 12. OP15 14, 15, 16 The home is required to provide food that meets the assessed dietary requirements of individual residents. This should be included in the individuals care plan, its intake recorded and monitored. At Sept 05 judged as not met as Nutritional assessments not carried out and nutrition /diet care plans not sufficiently in place – at January 2006 no change. 10/02/06 31/03/06 11. OP12 16 31/03/06 Edmore House DS0000024953.V281082.R01.S.doc Version 5.1 Page 27 Requirement first made and not met since September 2003. 13 OP18 15 13(6) Behaviour care plans must be put in place to guide staff to understand behaviour triggers for individual service users and how to manage behaviour that challenges. New Requirement at January 2006. Detailed cleaning schedules for all areas of the home are to be written and implemented. Requirement first made and not met since September 2003. Not Assessed at January 2006. 15. OP27 37, 18 The manager is also required to inform the National Care Standards Commission on occasions when it does not meet its staffing quota. Requirement first made June 2004. (Ongoing) Not Met at January 2006 – See new Immediate Requirement. 16 OP27 37, 18 10/02/06 To maintain the rota accurately at all times as a written record of who has worked. To maintain minimum staffing levels (3:3:2) at all times with immediate effect To provide an adequate staffing contingency plan to effectively provide for staff cover in the Edmore House DS0000024953.V281082.R01.S.doc Version 5.1 Page 28 10/02/06 14 OP26 13 31/03/06 31/01/06 event of unexpected staff absence to maintain minimum staffing levels. To calculate staffing hour requirements using a recognised tool and act upon its outcome. To inform the Commission for Social Care Inspection on each occasion that minimum staffing levels are not met. To communicate in writing to the Commission for Social care Inspection action taken and outcomes in respect of each requirement above by Friday 10th February 2006. Immediate Requirement at January 2006. 17 OP30 18 Staff must be provided with training in: • • • Nutrition Mental Health Awareness Behaviour that challenges – causes have and responses to. 31/03/06 Training must be booked by the date given. New Requirement at January 2006. All staff must receive a minimum of three paid days training per year. New Requirement at January 2006. 18 OP30 18 31/12/06 Edmore House DS0000024953.V281082.R01.S.doc Version 5.1 Page 29 19 OP31 18 There must be clear lines of 31/03/06 accountability within the home to support its effective management New Requirement at January 2006. The Manager must be provided with a job description that fully outlines her responsibility and duties. New Requirement at January 2006. The option of residents meetings must be kept under review and alternative ways of seeking resident views about the management of the home must be implemented, with records kept. Requirement first made and not met since June 2004. 20 OP31 9 31/03/06 21. OP32 24(3) 31/03/06 22. OP33 12 Not Met at January 2006. All relevant policies & procedures must be available within the home and reviewed on a regular basis. (Ongoing) Service Users money must be held in individually labelled moneybags. New Requirement at January 2006. All service user records are to be updated in accordance with Schedule 3 (Regulation 17(1)(a). Requirement first made and not met since September 2003. Staff must sign to acknowledge understanding of all risk assessments undertaken. DS0000024953.V281082.R01.S.doc 31/03/06 23 OP35 13(6) 31/03/06 24. OP37 17 31/03/06 25. OP38 13(4) 31/03/06 Edmore House Version 5.1 Page 30 All signatures must be obtained for all risk assessments by date set. Requirement first made January 2004. Not Assessed at September 2005 or January 2006. 26. OP38 13,16,12 All staff are to undertake: Infection Control training, moving and handling refresher training, The manager is required to identify appropriate personnel to undertake Person Centred Planning training and to provide this training. Requirement first made and not met since September 2003. Not Assessed at September 2005 Not Met at January 2006 – 6 staff not done infection control training and 3 staff not done moving and handling training. 27. OP38 16 The two cooks must undertake food hygiene training to Intermediate level. At September 05 inspection agreed manager and proprietor would undertake this training. To be booked by date given. Requirement first made and not met since September 2003. Not Met at January 2006. 30/04/06 30/04/06 Edmore House DS0000024953.V281082.R01.S.doc Version 5.1 Page 31 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 OP22 Good Practice Recommendations The home should consider commissioning a private occupational therapist to assess the suitability of the premises and facilities. The home should state in it volunteer and recruitment policy that it does not use volunteers. Residents should be informed of their right to access their records 2. 3. OP29 OP37 Edmore House DS0000024953.V281082.R01.S.doc Version 5.1 Page 32 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 Edmore House DS0000024953.V281082.R01.S.doc Version 5.1 Page 33 - 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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