Inspection on 06/09/05 for Edmore House

This inspection was carried out on 6th September 2005.

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

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

Other inspections for this house

Edmore House 19/11/08

Edmore House 11/10/07

Edmore House 12/09/06

Edmore House 31/01/06

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 Announced Inspection 6th September 2005 10:00 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.V250498.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. Edmore House DS0000024953.V250498.R01.S.doc Version 5.0 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.V250498.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1.12.04 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.V250498.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out by one Inspector and started at 10.00a.m and finished at 5pm. The inspection was unannounced meaning that the proprietor, manager and staff had no prior notification. The Inspector assessed progress towards many previous requirements issued to ensure improvement. The inspector also assessed a selection of key Standards. To do this a range of documentation was assessed, the premises were inspected and the Inspector had the opportunity to interview in detail the proprietor, the manager, a staff member and visiting relatives. The home is making good progress meeting 28 previous requirements at this inspection. Nine previous requirements were not assessed. Four new requirements have been issued as a result of this inspection but none have been immediately required. The home had 2 service user vacancies at the time of inspection. What the service does well: Edmore House continues to improve. Twenty-eight previous requirements were assessed at this inspection as fully met and have therefore been deleted from this report. Progress has been made in part towards some others. The garden and summer bedding plants and in particular the lawn are maintained to a high standard providing a pleasant outlook from some bedrooms. Maintenance records are all available, up to date and well-ordered assuring residents of safety within the premises and its equipment. Staff are to be commended as the home has exceeded the target for obtaining 50 of staff qualified to level NVQ 2 or equivalent by 2005. The home is also regularly consulting with its staff about their satisfaction levels with positive results. There is a homely and happy atmosphere within Edmore House. A relative spoken to said ‘this home is friendly with a nice atmosphere. The carers seem pretty good. It’s quite a good home. They will work with you if they think you are not happy about something – they don’t brush you off. She’s (the resident) kept clean. I feel she’s safe here. I would recommend it’. A staff member said that staff have enough time to sit and chat with residents. Edmore House DS0000024953.V250498.R01.S.doc Version 5.0 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. Edmore House DS0000024953.V250498.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Edmore House DS0000024953.V250498.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Service users are admitted to the home on the basis of an assessment to assure that the home can meet the service users needs prior to the decision to move in. EVIDENCE: The Inspector case tracked the admission of a service user admitted to the home 2 weeks prior to this inspection. Appropriate assessments had been undertaken but nutritional assessments are not carried out. The home had a copy of the assessment undertaken by the placing social worker and the manager had visited the service user and carried out an assessment prior to admission. The service user had signed to indicate agreement to the outcome of assessments of need. There was a care plan in place that was based on the outcomes of these assessments. The service user has an independent advocate who has supported the transition to Edmore House. Edmore House DS0000024953.V250498.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9. Care plans are in general addressing the needs of service users with action in respect of nutrition being insufficient. Service users health needs are in general promoted with some omissions identified for some service users. Service users health care needs are therefore not fully met. Medication practice with policies and procedures have improved providing service users with greater protection but further development is required to provide maximum protection. Edmore House DS0000024953.V250498.R01.S.doc Version 5.0 Page 10 EVIDENCE: Care plans are being drawn up based upon assessment of need although some omission in nutritional assessment has lead to these needs not being included in the plan of care. Oral care has been included as required previously but not in sufficient detail. ‘Dentures’ for example does not sufficiently guide staff as to the care required. There is evidence within the home that service users are involved in reviewing their care plans and have signed to indicate this. The home now needs to involve service users in drawing up the original plan of care. Risk assessments were in place for the newly admitted service user including pressure sore and moving and handling risk assessments. The service users falls history had been considered. Nutritional risk assessments are however not being carried out by the home. Care plans are being reviewed monthly. A second service user was case tracked to form a judgement about health provision. The service user chosen was diabetic and poorly in bed at the time of the inspection. Access to health provision was evidenced through appropriate optical and chiropody services and by 13 recorded visits from the GP in 6 months. GP instructions to change medication were well evidenced as acted upon by the home. Records indicate that on 1.4.05 the GP had requested a urine sample for this service user. There is no evidence that this was provided. None of the service users at Edmore House currently have pressure sores. Nutritional screening is not undertaken, leaving residents needs unknown and potentially not met. Staff have historically always monitored diabetic service users blood sugars. This is an invasive procedure and formal training has not been provided to staff to insure sufficient knowledge and practical skill to assure the safety of the service users. The Inspector observed medication being administered and practice on the whole was good. Upon conclusion of the observation the staff member acknowledged that she had become aware that she had not locked the door of the medication cabinet prior to leaving the room to administer the medication. Medication training has been provided but the manager has booked more detailed training for 12 staff for September 2005. The home does not have any controlled drugs. The manager continues to audit the medication records and is now identifying fewer incidents as a result. Assessment of the medication administration records showed there to be no gaps in recording, which is progress. New staffs do not administer medication and a staff member verbally confirmed this to the Inspector. The home is supported by regular pharmacy visits. These measures serve to protect service users. Edmore House DS0000024953.V250498.R01.S.doc Version 5.0 Page 11 Care plans do not include medication details. Written guidance is required in respect of medication prescribed as ‘as required’. The medication policy now includes many aspects of practice previously identified as missing with ‘as required’ medication guidance remaining excluded. The policy also advocates double dispensing which is not good medication practice and the manager must seek further advice about this. Further written advice in respect of medication errors is also required. The policy now states that there is a no blame policy and all errors must be reported but staff are not guided as to what immediate action they must take in the event of an error. Discussion however with a staff member who does not administer medication demonstrated that this staff member had a good understanding of required action in the event of an error. Edmore House DS0000024953.V250498.R01.S.doc Version 5.0 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): These Standards were not assessed at this inspection. EVIDENCE: Edmore House DS0000024953.V250498.R01.S.doc Version 5.0 Page 13 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 Service users and their relatives are confident that their complaints will be listened to, taken seriously and acted upon. EVIDENCE: The complaints procedure is appropriate and is clearly displayed in an accessible format in the entrance to the home. This includes the contact details of the National Care Standards Commission but must be updated to reflect the organisation’s name change to the Commission for Social care Inspection. A previous requirement to improve the recording of complaints has been fully met and complaints are now recorded well with details of action taken evidencing timely and appropriate responses to complaints made. The nature of complaints has been connected with laundry and tough meat but appropriate action has been taken. The service user guide informs service users how to make complaints and this has been issued via the advocate to the most recently admitted service user to the home. Since the last inspection in December 2004 there have been 3 complaints, a compliment whereby a visiting professional is said to have said ‘this is the nicest home in the area and s/he would like to come here if s/he ever needs a home’. The home has also received 4 thank you cards that the Inspector was able to see. Edmore House DS0000024953.V250498.R01.S.doc Version 5.0 Page 14 The Inspector spoke to a visiting relative who said: ‘They will work with you if they think you are not happy about something – they don’t brush you off.’ Staff are also provided with evaluation forms each month with their wages to seek their feedback so that any problems or unease can be quickly identified and acted upon. The Inspector had sight of these and there was evidence of its positive effect. Edmore House DS0000024953.V250498.R01.S.doc Version 5.0 Page 15 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, 26 Service users live in a safe, largely well-maintained environment where systems are in place to minimise the risk of infection. EVIDENCE: Edmore House is homely and domestic in style Service user bedrooms are well maintained and individually decorated providing service users with pleasant communal and personal living space. All maintenance records for the fabric of the building and equipment were available, ordered and up to date. Bacteriological tests in the water supply have been undertaken but the system has not been chlorinated but the proprietor said that he would seek advice about this. All in house fire system checks are regularly undertaken and the most recent fire drill was held in July 2005. Fire training was held in March and the next is booked for 8.11.05. Two staff missed the training in March. Edmore House DS0000024953.V250498.R01.S.doc Version 5.0 Page 16 The manager must aim to organise training more than twice per year to ensure that all staff attend at least twice in a 12-month period. The Environmental Health Department visited two months prior to this inspection with minor suggestions for improvement. The Fire Officer visited in April 2005 and suggested that the external bin and airing cupboard be locked. The Inspector was told that these had been actionned. A maintenance programme is newly in place which provides assurance that there are plans to ensure the ongoing up keep of the environment. The bathroom requires refurbishment but is not included in the maintenance and renewal programme. A staff member spoken to demonstrated a good knowledge of infection control techniques to protect service users and themselves from the risk of cross contamination. The Inspector assessed the laundry and laundry procedures and systems and equipment support good practice. The laundry is small but is well organised and it is not sited near to food serving or preparation areas. It is furnished with hand washing facilities and sluicing functions within industrial washing machines. The home has a clinical waste removal contract. A urine bottle was stored in the ground floor bathroom, which however contradicts good infection control practice. A previous requirement to implement a detailed cleaning schedule remains required. These were the only omissions identified in respect of infection control. Bathrooms require refurbishment to provide both a more pleasant and welcoming atmosphere but to also positively promote infection management. Edmore House DS0000024953.V250498.R01.S.doc Version 5.0 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): 29 Service users are supported and protected by the home’s recruitment policy and practices. EVIDENCE: The personnel files of two newly recruited staff members were assessed. All previous outstanding requirements for improvement have been deleted as fully met. All documentation to assure that the appropriate checks have been carried out to safeguard service users was available and appropriate demonstrating good practice marking a significant improvement. New staff are undertaking induction training to the required standard. The home does not have any volunteers and it is their policy not to do so. This is not stated in the home’s volunteer or recruitment policy. Criminal Record Bureau checks have now been obtained in respect of the visiting hairdresser which meets a longstanding previous requirement. Nine out of thirteen staff now hold NVQ level 2 exceeding the National minimum target of 50 by 2005. Edmore House DS0000024953.V250498.R01.S.doc Version 5.0 Page 18 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): 38 The safety and welfare of service users and staff are promoted and protected. EVIDENCE: The manager and proprietor have both achieved the required NVQ 4 in Care and the Registered Manager’s Award since the last inspection. Five staff remains in need of Food Hygiene and First Aid training but the training plan indicates this and the manager in bringing it to the attention of the Inspector is aware of it and waiting to book the courses. Two staff are first aid appointed persons qualified and eight staff have first aid awareness training. The first aid box is well stocked. Kitchen staff are reluctant to undertake the immediate food hygiene training and the manager stated there remains ongoing debate about whether this is essential. Following discussion the manager and proprietor agreed upon its importance and undertook to do this training themselves. Edmore House DS0000024953.V250498.R01.S.doc Version 5.0 Page 19 Hot food temperatures were recorded appropriately and cold storage appropriately recorded on the whole but with some confusion, which was not resolved during inspection about the records for the freezer temperatures for the fridge freezer in the kitchen (appeared to be recorded as fridge temperatures). All windows identified as a risk have been restricted. COSHH assessments are in place. There is a risk assessment albeit brief in place to address the security of the building. A risk assessment had been undertaken to minimise risk to and protect the best interests of a staff member who is expecting a baby. A previous requirement to obtain safety documentation in respect of the equipment used by the visiting hairdresser has now been met. See additional comments with respect to the safety of the premises detailed under Standard 19 and 26. Edmore House DS0000024953.V250498.R01.S.doc Version 5.0 Page 20 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 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 x 2 x x x x x x 3 STAFFING Standard No Score 27 x 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x x x x x x 3 Edmore House DS0000024953.V250498.R01.S.doc Version 5.0 Page 21 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. Standard Regulation Requirement Timescale for action 1 OP1 4,5 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. 31/10/05 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 30/11/05 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. The management of a urine bottle must be included in the service users plan of care. Not assessed Sept 05 All manual handling care plans must include more detail e.g. how residents must be transferred / equipment to be DS0000024953.V250498.R01.S.doc 31/03/06 31/10/05 4 OP7 15 13(3) Edmore House Version 5.0 Page 22 used / techniques / specific requirements etc. determined by risk assessment. Not assessed Sept 05 Care plans must include foot care, oral care and nutrition. Requirements first made June 2004. Care plans must include all service users medication details and must be updated regularly to reflect any changes. 5 OP7 13(2),15 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 arising from this inspection, September 2005 The manager is required to seek the advice of an occupational therapist for individual residents, as their physical needs change in order to secure 31/10/05 appropriate disability equipment. Requirement first made and not met since September 2003. The manager must extend the variety of desserts available to residents in accordance with their recorded wishes. Requirement first made January 2004. Not Assessed September 2005 Opportunities for physical exercise and self-care must be planned for in residents care plans where appropriate and in line with residents’ wishes and abilities. Requirement first made and not met since January 2004. 9 OP8 13(4) The manager must seek and follow the advice of the diabetic nurse with DS0000024953.V250498.R01.S.doc 31/10/05 6 OP8 13 7 OP15 16,2,i 17,1,a S3,3,m 31/10/05 8 OP8 15,13(4) 12(3) 30/11/05 31/10/05 Edmore House Version 5.0 Page 23 13 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 arising from this inspection, September 2005. 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 31/10/05 10 OP9 13 The medication policy must include guidance on double dispensing in accordance from advice, which must be sought from the contracted pharmacist. New Requirement made at this inspection, September 2005. Procedures are required to guide staff in the event of medication errors. 31/10/05 Requirement first made and not fully met since September 2003 An alternative to the main meal of the day is to be offered on the menu and residents choices recorded. 11 OP9 13(2) 12 OP12 16 (Alternative is now on menu – but not being offered to residents) Requirement first made September 2003 Not Assessed at September 2005 Activities outside the home must be facilitated and opportunities circulated to residents in an appropriate format. Requirement first made January 2004. Not Assessed at September 2005 31/10/05 13 OP12 16(2) 30/11/05 14 OP15 14, 15, 16 The home is required to provide food that meets the assessed dietary requirements of individual residents. DS0000024953.V250498.R01.S.doc 31/10/05 Edmore House Version 5.0 Page 24 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. Requirement first made and not met since September 2003. The proprietor is required to submit in writing to the Commission for Social Care Inspection a detailed plan for the refurbishment of the bathroom with timescales for completion stipulated. New Requirement at September 2005 Detailed cleaning schedules for all areas of the home are to be written and implemented. Requirement first made and not met since September 2003. 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) 15 OP19 23 31/10/05 16 OP26 13 31/12/05 17 OP27 37, 18 06/09/05 18 OP32 24(3) 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. 31/10/05 19 OP33 12 All relevant policies & procedures must be available within the home and reviewed on a regular basis. (Ongoing) 31/12/05 Edmore House DS0000024953.V250498.R01.S.doc Version 5.0 Page 25 The manager must implement a system to ensure greater accountability when residents’ money is handed to senior staff. The manager must ensure that inventories of all existing residents’ possessions and valuables are recorded and regularly updated. Inventories must in future be completed upon admission of a new resident. Requirement first made June 2004. Not Assessed at September 2005 The home is required to seek advise from the Police Crime Prevention unit and their insurers and undertake a written risk assessment of their current method of safekeeping residents’ monies and valuables and action appropriately. Requirement first made and not met since September 2003. Not Assessed at September 2005 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. 23 OP38 13(4) All signatures must be obtained for all risk assessments by date set. Requirement first made January 2004. Not Assessed at September 2005 All staff are to undertake: 24 OP38 13,16,12 Infection Control training, moving and handling refresher training, The manager is required to identify appropriate personnel to undertake Edmore House DS0000024953.V250498.R01.S.doc Version 5.0 Page 26 20 OP35 17(2)S4(9) 31/10/05 21 OP35 23 31/10/05 22 OP37 17 31/10/05 31/10/05 30/11/05 Person Centred Planning training and to provide this training. Requirement first made and not met since September 2003. Not Assessed at September 2005 The two cooks must undertake food hygiene training to Intermediate level. 25 OP38 16 At September 05 inspection agreed manager and proprietor will undertake 31/10/05 this training. To be booked by date given. Requirement first made and not met since September 2003. 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.V250498.R01.S.doc Version 5.0 Page 27 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.V250498.R01.S.doc Version 5.0 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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