Inspection on 17/11/05 for Edward House

This inspection was carried out on 17th November 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 no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Edward House 11/07/07

Edward House 27/06/06

Edward House 14/07/05

Edward House 24/03/05

Edward House 18/01/05

Edward House 18/02/04

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

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

CARE HOME ADULTS 18-65 Edward House Matson Lane Matson Gloucester Glos GL4 6ED Lead Inspector Ms Tanya Harding Unannounced Inspection 17th November 2005 08:20 Edward House DS0000030393.V267347.R01.S.doc Version 5.1 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 Edward House DS0000030393.V267347.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 Adults 18-65. 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. Edward House DS0000030393.V267347.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Edward House Address Matson Lane Matson Gloucester Glos GL4 6ED 01452 307069 01452 311742 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) Selwyn Care Limited To be appointed Care Home 9 Category(ies) of Learning disability (9), Physical disability (9) registration, with number of places Edward House DS0000030393.V267347.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Suitable dining arrangements must be put in place as agreed with the Responsible Individual and the Registered Manager. Condition to be reviewed by 31 March 2005. Two additional staff must be employed to cover daytime shifts to accommodate the increase in numbers (once the ninth person has been accommodated). Condition to be reviewed by 31 March 2005. The Registered Manager must access additional training & development opportunities & receive regular formal support from the Group Care Manager in order to further develop the skills in managing the care home. Details of the necessary training & timescales for completion have been agreed with the Registered Provider. 14th July 2005 3. Date of last inspection Brief Description of the Service: Edward House is part of the care provision offered by Selwyn Care Limited. The home is situated on the outskirts of Gloucester in the Matson area. The organisation provides residential and day care services to adults with Autistic Spectrum disorders and associated behaviours. The home shares the site with the organisational office, another home and the day care facility. There are spacious grounds around the home, with a lake, garden, fields and a large car park. All communal and individual accommodation is on ground floor level. There are nine single bedrooms all with full en-suite facilities. There are two spacious communal lounges, one incorporating a dining / activities area, as well as an additional dining room accessed via the kitchen. Just outside the main building there is a laundry area and an additional room, which is used for art and craft activities by the residents. The laundry and the art room have stepped access. Edward House DS0000030393.V267347.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over five hours on a day in November 2005. The registered manager was not present at the inspection and has since moved on from the home. The acting management role has been given to the deputy manager on temporary basis. The deputy manager supported this inspection. Some service users at Edward House have difficulties in expressing their views about the care they receive and some people have limited verbal expression. All of the residents were greeted and three were spoken with. Interactions between staff and service users were observed. Three members of staff were spoken with and a number of records were examined. These included service users’ files, daily diaries and staff files. The relatives returned five comment cards with their views about the service and support provided. The tour of premises was not carried out on this occasion. The Care Director has been in contact with the Commission to discuss the plans for recruiting a new manager for the home. Since the last inspection a meeting has taken place with the registered providers to discuss the improvement strategy for the home. Two conditions remain relevant to the registration of the home. Condition one has not been satisfied at the time of the inspection and this has been brought to the attention of the Care Director. Condition two will become applicable when all the vacancies are filled. What the service does well: The home provides spacious communal and private accommodation for the residents. People who live at Edward House have access to structured activities and are supported in accordance with individual routines led by people’s needs. Comment cards received from relatives provided evidence that visitors are welcome in the home and are kept informed about any important matters affecting their relative. The relatives also felt there were adequate staff on duty and showed an overall satisfaction with the care provided. Service users spoken with said that staff in the home were nice. Edward House DS0000030393.V267347.R01.S.doc Version 5.1 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. Edward House DS0000030393.V267347.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Edward House DS0000030393.V267347.R01.S.doc Version 5.1 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 the following standard(s): 2 The revised admissions process should mean that people who are admitted to the home can be sure their needs and aspirations will be identified and met. EVIDENCE: The Organisation has an admission process which has been reviewed and updated following an inappropriate admission in December 2004. The Organisation felt that the process is now more robust and would ensure that only people whose needs can be met by the home are accepted. One person has moved into the home since the last inspection. The person came from the sister home through an informal admission route. This is because the person themselves chose to move. The Group Care Director advised that the move should benefit the person long term. The acting manager has been asked to clarify whether the placing authority and the relatives have been informed of the move. There are plans for one person to move out to a self-contained unit on site. This is in recognition that the person’s needs may be better met when they do not have to share accommodation with other service users. At the time of the inspection the home had not received confirmation of funding and approval about the move from the placing authority. Edward House DS0000030393.V267347.R01.S.doc Version 5.1 Page 9 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 the following standard(s): 6, 7 and 9 Increased detail in care plans should ensure that people are supported appropriately and consistently. Raising awareness about person centred approaches is likely to promote people’s involvement in their care and enable service users to have more input into the decision making process. People’s independence and rights may be compromised because of restrictive approaches. EVIDENCE: Notable improvements have been introduced to the care planning systems in the home. Initially this has been to the way the care plans and guidance about support needs are presented. New files are being compiled for each service user which contain essential information and where an assessed need is evident, staff are given concise but relevant information about how this should be responded to. Review of care plans is a positive step and demonstrates the renewed commitment from Selwyn Care Limited to improve the quality of the service provided. At the time of this visit six files were completed in the new format. Changing needs will be monitored through monthly key-worker reviews. Edward House DS0000030393.V267347.R01.S.doc Version 5.1 Page 10 The acting manager explained how people’s personal finances are managed. All service users receive their personal allowances, which are paid into an instant access savings account which requires two signatories. Two service users are also in receipt of mobility allowance. Access to personal money is managed by senior staff and records of expenditure are kept. Risk issues were discussed with care staff and the acting manager. From this it was evident that many of the risks which service users are being protected from are perceived and may not be actual and real risks. For example, when discussing restricted access to the kitchen, it became clear that only two of the eight residents may actually be at a greater than average risk from items such as kettles and sharp knives. It seemed as if the kitchen was locked to remove all associated risks, regardless of how it impacted on the individual service users. The acting manager has started to challenge the reasons for restrictive practices in the home with the staff team. These practices consist mainly of locking certain areas of the home and prevent the service users from going to some rooms freely. The National Minimum Standards talk about service users having free access to all areas of the home, unless there is an agree restriction in place. The expectation is that where a restriction has been imposed, there must be clear documented evidence of who has made this decision, what information this is based on and why it is seen to be in the best interest of the individual. Until these issues have been carefully considered and the necessary information is available it is possible that people’s freedom is being restricted unnecessarily and this is a breach of their human rights. The inspector accepts that the home has a duty of care to protect the service users and that there needs to be a balance of this and preserving people’s liberty. The responsibility for both issues remains with the registered provider. Steps must be taken to ensure that the relevant risk assessments are empowering not restrictive. Further training in this area should be offered to all staff. This should include principles of service user empowerment and independence. Records for one person showed that placement reviews have taken place following the person’s admission in January 2005. There has been input from the local Community Learning Disabilities Team, who have made some written recommendations about engaging with the person. The acting manager was aware of these recommendations although none had been incorporated into a working care plan. She advised that some equipment has been purchased, but its use has not been formally included into the persons programme. It is important that this is done, to ensure that the CLDT professionals receive feedback about whether the proposed recommendations are effective or not. Edward House DS0000030393.V267347.R01.S.doc Version 5.1 Page 11 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 the following standard(s): 12, 13, 15, 16 and 17 Service users are supported to engage in activities and maintain links with their families. Restrictions in the home environment compromise people’s independence. EVIDENCE: At the start of the visit some service users were having breakfast in the main dining room. To get to this room, people have to walk through the kitchen which is kept locked. It was observed that services users had to knock on the kitchen door for staff to let them in. Once in the kitchen, some service users are able to make own breakfast and drinks and some may require staff support. Most service users were up by about 9am and majority were seen at that time sitting in one of the lounges with the radio on. Service users have access to a number of activities outside of the home. Some people attend the day centre which is on the same site as the home. Other activities include sessions with art and music therapists, aromatherapy, skiing, walking, swimming, and trips out for meals, to the pub, shopping and to the cinema. Edward House DS0000030393.V267347.R01.S.doc Version 5.1 Page 12 Some service users have dedicated one to one staff support throughout the day because of assessed needs. One service user confirmed that a restrictive practice which used to be implemented when they got angry is no longer used. There are a number of restrictions in the home, as described under Standard 24. Some people have a key to their bedrooms; however, they do not have a key to the kitchen or to the front and back doors. Restrictions which are in place must be reviewed as discussed under Standards 7 and 9. Comments received from a parent suggested that there have been no visits from their relative for some time. The manager advised that plans are in place for the person to visit their parents this month. For other service users records provided evidence of regular visits to relatives and people were planning home stays for Christmas. Edward House DS0000030393.V267347.R01.S.doc Version 5.1 Page 13 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 the following standard(s): 19 and 20 Shortfalls in medication administration procedures could compromise the welfare of the service users. EVIDENCE: Records of health appointments and health monitoring are kept for service users. This includes records of incidents, accidents and bruise charts. At the start of the inspection none of the staff on duty were able to administer medication. Staff advised that this happens on occasion. Two of the staff had also worked the night shift. This means that if there was a need to give out ‘as required’ medication in the middle of the night, someone else would have to be called in. Staff advised that it is also practice to call someone from the sister home to give medication out. This could present its own problems, if for example the staff member is required to give medication out in two homes at the same time and this may delay the time of administration for some people, possibly having an impact on their activities and even their health. It could also lead to mistakes being made. The acting manager was aware of the problem and felt this was not satisfactory. She was putting plans in place for increasing the numbers of staff who could administer medication and made enquiries about suitable training. This needs to be done as a matter of urgency. Edward House DS0000030393.V267347.R01.S.doc Version 5.1 Page 14 Medication administration records were examined and some shortfalls were noted as follows: 1. Some medication on MAR sheets is no longer in use, but is still being added to the printed documents by the pharmacy. This could lead to potential confusion. 2. There was no information on the medication file about how people want to be supported to take their medication and the about the route of administration. 3. The current list of medication taken by each person should be present on medication file. 4. Hand written additions to the MAR sheets must be signed by two staff and dated. 5. There were numerous gaps in signatures on MAR sheets without any explanation for this. It was not possible to determine whether staff had administered the medication and forgot to sign or whether the medication has not been given. This must be closely monitored and any gaps must be explored. There must be evidence that all necessary medication has been given. Action must be taken in response to any errors. 6. Information must be present about how the person will be given their medication when they are on ‘social leave’ (away from home). 7. Guidance for administering medication for one service user has not been updated since 25/02/04 and must be reviewed. One person looks after their own medication and this was observed during the visit. The person has been provided with secure storage and records when they have taken their tablets. There are protocols for ‘as required’ medication. For one person this is supported by a traffic light behaviour guidance chart, which indicates at what point the person should be offered this additional medication. According to the chart, this medication needs to be given when the person is in the ‘RED’ zone. However, it was noted that when the person reaches this level of agitation, they are likely to refuse their medication. The acting manager advised that she has already picked up on this conflicting guidance and has contacted the psychiatric community nurse to review the guidance. A meeting has been scheduled for early December 05 to discuss whether a better approach can be found. This is an example of proactive action by the home. Edward House DS0000030393.V267347.R01.S.doc Version 5.1 Page 15 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 the following standard(s): 22 and 23 Better awareness of the complaints process would offer increased protection for service users. EVIDENCE: The home has a formal complaints process. Comments received from relatives showed that some people are not aware of what this process is. The home should look at ways of providing this information to the families. One complaint has been received about the home within the last 12 months and has been investigated by the Commission. The findings of this can be found in the last inspection report. This report provides evidence that a number of changes have been implemented by the Registered Providers to raise the quality of the care provided. Future inspections will monitor whether the quality of the service shows a sustained improvement. A complaint received earlier in June 2005 highlighted concerns about how service users in the home were being protected from violent behaviours by other residents. Since then there has been a marked reduction in reported incidents which affect service users. In the main this can be attributed to better staffing levels and more structured one to one support. The acting manager has followed up some incidents with staff involved to establish the cause. This is a good way of monitoring whether staff practice or lack of vigilance may be at fault or whether there are other contributing factors. This must continue in view of recent Regulation 37 notifications. The Organisation has investigated concerns about practice of some staff in the home and during this time staff were suspended. One person has been dismissed and two staff were reinstated. However, no record of this or the Edward House DS0000030393.V267347.R01.S.doc Version 5.1 Page 16 outcome of the suspension was found on file for the two staff who returned to work. All information relevant to the employment and conduct of the staff must be kept and available for inspection. The Organisation has been asked to provide a copy of their policy about employing members of the same family and further discussion on this matter is likely at future inspections. Edward House DS0000030393.V267347.R01.S.doc Version 5.1 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 the following standard(s): 24 Freedom of access to some areas is restricted and this makes the environment feel less homely. EVIDENCE: Since its opening three years ago a number of restrictions have been imposed in the environment which remain in place today. The front door of the home is locked at all times and the kitchen is also locked and is only accessible to the residents with staff support. At the time of the visit none of the residents had a key to the front door or to the kitchen. There is an enclosed courtyard next to the manager’s office and laundry, and this is accessed through the double doors in the corridor which are also locked. It was observed that service users needed to knock on the kitchen door and be let in by staff if they wanted to come in and make a drink or to access the dining room. Free access to the communal dining room was subject of a condition by which registered numbers were increased to nine in early part of 2005. At the time the Organisation agreed to ensure that access to the dining room will not be restricted. Provisions were made to enable people to eat in a different area of the home where there were no locked doors. However, at this visit it was observed that the majority of the service users continue to eat in the main dining room which can only be accessed through the kitchen. One Edward House DS0000030393.V267347.R01.S.doc Version 5.1 Page 18 person is supported on occasion to eat in a different area of the home with a one to one support. This breach of the agreed condition has been brought to the attention of the Care Director and further action by the Commission is likely. The magnetic closure on the door to the lounge was broken at the time of the visit. Staff had placed a chair against the door to keep this open. The inspector was advised that this is being addressed. Edward House DS0000030393.V267347.R01.S.doc Version 5.1 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Effectiveness of the staff team could be further improved through targeted training, regular supervision and by challenging existing attitudes to ensure service user’s rights are promoted at all times. EVIDENCE: Staff should be reminded that using terms of endearment, such as ‘love’ and ‘sweetheart’ could be seen as unprofessional and disrespectful towards the service users. Staff should be aware that use of such terms could increase the vulnerability of the service users as well as compromise their emotional expectations. People’s names and preferred terms of address (if different) should be used. Preferred terms of address should be recorded on individual files. A new member of staff was observed to have developed a good understanding of the specialist communication needs of one of the service users. Staff spoken with advised that they have the opportunity to read care plans and other guidance. Since the last inspection the staffing situation in the home has improved and there is now an increased clarity of steps to take in cases of unexpected staff shortages. Links with local care agencies have been established in the recent months and this is a useful resource to cover for absences. Edward House DS0000030393.V267347.R01.S.doc Version 5.1 Page 20 Staff spoken with said that some nights continue to be covered by two sleeping in staff rather than one waking and one sleeping in staff. This arrangement was found to be unsatisfactory following the last inspection. The home must provide a written confirmation of what the staffing requirements are with assurances that this reflects the needs of the service users and is appropriate to the funding arrangements agreed with the placing authorities. At the time of the visit there were seven staff on duty. Two of those staff have also worked the night shift and four of these staff were very new (starting in August and September 2005). None of the staff present were trained in administering medication. This task was to be undertaken by the acting manager when she arrived at 9am. Later on two more staff arrived to take two of the service users Christmas shopping. Staff recruitment procedures were assessed following this visit. The necessary checks are being carried out and details are kept on files. There are still shortfalls in the information held about staff in the home and this must be addressed. This includes obtaining full employment history for people and ID documents. Evidence of staff receiving formal supervision was seen. Those carried out by the acting manager are comprehensive and detailed. However, some staff have not had a formal supervision for a long time and although this is now being addressed, shows a worrying gap in compliance with Regulation 18. Edward House DS0000030393.V267347.R01.S.doc Version 5.1 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 and 39 The home would benefit from employing a competent and experienced manager who will safeguard service user’s interests and promote good practice. Implementation of the new quality assurance systems should benefit the service users through an ongoing monitoring and improvement of the home. EVIDENCE: The registered manager has left the home and at the time of the visit the deputy manager was acting up. She showed a good understanding of the staff management issues as well as commitment to observing good care practices. The Care Director and an allocated personnel officer are supporting her in the acting manager’s role. There are plans to recruit a new manager and this should give the home and the staff team increased stability and consistency. The Organisation has implemented new quality assurance processes which include improving channels of communication between the staff and the management team. There is also a greater focus on building a more effective Edward House DS0000030393.V267347.R01.S.doc Version 5.1 Page 22 management team and on increasing awareness of the requirements under the Care Standards Act 2000. The full benefits of these changes will be assessed at future visits. Comments received from the relatives were overall positive. One comment card stated that the relatives were ‘very happy’ with the care, and felt their relative was contented and well occupied. Comment cads also provided evidence that the relatives may not be aware of how to access inspection reports in the home. The home should look at ways at making inspection reports more accessible to the relatives as this will increase transparency of the service. Edward House DS0000030393.V267347.R01.S.doc Version 5.1 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 Standard No Score 1 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 2 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 2 X 2 X 2 X X X X Edward House DS0000030393.V267347.R01.S.doc Version 5.1 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. 2. Standard YA6 YA9 Regulation 15 (2) 13 (4) Timescale for action Complete revision of all care 31/03/06 plans and other guidance in line with the new format. 31/03/06 Review the risk assessments which dictate the need for restrictive practices in the home to ensure these are empowering not restrictive. Information must be provided on individual files about the real risks to each person and how the current restrictions are impacting on service users’ right to free access in their home. Ensure there are sufficient staff on duty who are suitably qualified to administer medication to service users. The home must ensure that the staff cover at night is appropriate to the needs of the service users and in line with contractual agreements. Written confirmation of Edward House DS0000030393.V267347.R01.S.doc Version 5.1 Page 25 Requirement 3. YA20 18 and 13(2) 28/02/06 4. YA33 18(1) 15/02/06 5. YA34 18 and 19 what the agreed arrangements are for night cover and for staffing levels during the day must be provided to the Commission. Information about all staff working in the home must be obtained in line with the Regulation and the relevant schedules. This must include a full employment history and ID documents. (Some progress made). Records about all aspects of employment and conduct of staff must be kept and available for inspection (to include details of any disciplinary action and outcomes). Provide a copy of the policy on employing members of the same family to the Commission. Staff must be appropriately supervised. A competent person must be appointed to manage the home and apply for registration with the Commission. 28/02/06 6. YA34 13 (6) 28/02/06 7. 8. YA36 YA37 18 (2) 8 28/02/06 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA33 YA33 Good Practice Recommendations Staff should be provided training about service user empowerment and on how to promote independence. Terms of endearment when addressing service users DS0000030393.V267347.R01.S.doc Version 5.1 Page 26 Edward House should not be used for reasons described in the text. People’s names and preferred terms of address (if different) should be used at all times. Preferred terms of address should be recorded on individual files. The home should look at ways at making inspection reports more accessible to the relatives. Copies of the home’s complaints procedure should be provided to relatives where appropriate. 3. 4. YA39 YA39 Edward House DS0000030393.V267347.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Edward House DS0000030393.V267347.R01.S.doc Version 5.1 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!