Inspection on 01/02/08 for Edwardian Care Home

This inspection was carried out on 1st February 2008.

CSCI found this care home to be providing an Poor service.

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

Edwardian Care Home 14/10/09

Edwardian Care Home 18/06/09

Edwardian Care Home 07/05/09

Edwardian Care Home 30/03/09

Edwardian Care Home 10/12/08

Edwardian Care Home 27/06/08

Edwardian Care Home 31/10/07

Edwardian Care Home 09/05/07

Edwardian Care Home 02/06/06

Edwardian Care Home 10/02/06

Edwardian Care Home 03/11/05

Edwardian Care Home 23/08/04

Edwardian Care Home 22/06/04

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

CARE HOMES FOR OLDER PEOPLE Edwardian Care Home 168/170 Biscot Road Luton LU3 1AX Lead Inspector Sally Snelson Unannounced Inspection 1st February 2008 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 Edwardian Care Home DS0000037799.V358070.R01.S.doc Version 5.2 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. Edwardian Care Home DS0000037799.V358070.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Edwardian Care Home Address 168/170 Biscot Road Luton LU3 1AX 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) 01582 705100 01582 705106 edwardian170@yahoo.co.uk The Edwardian Care Home Ltd Mrs Alison Margaret Jackson Care Home 30 Category(ies) of Dementia - over 65 years of age (12), Old age, registration, with number not falling within any other category (30) of places Edwardian Care Home DS0000037799.V358070.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 named person above the age of 60 years Date of last inspection 31st October 2007 Brief Description of the Service: The Edwardian is a purpose built care home that provides single room accommodation for 30 people over 65 years of age including those who have dementia and/or physical disabilities. The home is on a busy road, which is a short car or bus ride away from Luton Town Centre. Accommodation for people using the service is on the ground and first floor with a further third floor that accommodates administrative and staffing offices. Access to all floors is via staircases and a shaft lift. The home borders straight onto the pavement area of the street with a small ornamental garden to one side that is not suitable for recreational purposes. A small patio area with summertime pagoda and garden furniture is situated to the rear of the building, as is car parking. A copy of the statement of purpose including a copy of previous inspection reports is available at the home. The manager provided the following information on charges in October 2007. The fees for this home vary from £418.00 to £480.00 per week. Edwardian Care Home DS0000037799.V358070.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of this inspection was to undertake a key inspection. Sally Snelson and Katrina Derbyshire carried out this unannounced visit on 1st February 2008; it was the second key inspection of the year. The registered manager, Alison Jackson, was present during the inspection. We were made aware that one of the owners visited the home, but he did not choose to meet with the inspectors, who were feeding back to the manager in the office at the time. During the visit the communal areas of the home were seen alongside some of the individual accommodation. One inspector spent time with many of the people who lived at the home, and the other concentrated on documentation in the office. The care of three people was examined in detail and other files were sampled. As this inspection was only three months after the last, satisfaction surveys were not sent to people on this occasion. However any comments made before, and during the inspection by those who use, or visit, the service, was taken into account when forming the judgements. Observations of care practice and communication between the people living at the home and staff was also made at the inspection. The focus of this inspection was to look at the key standards and to follow up on previous requirements. The inspectors would like to thank residents and staff for their support with this inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. What the service does well: This home provided a tidy environment for the people who live there, and food that was described as “ almost always very good”. Edwardian Care Home DS0000037799.V358070.R01.S.doc Version 5.2 Page 6 Observations of care throughout the day, and discussions with the people who lived at the Edwardian, indicated that relationships between staff and residents was familiar. What has improved since the last inspection? What they could do better: Staff morale was very low, one member of staff reported, “It is the lowest I have ever known the home”. There were a number of requirements made after this inspection many of which must be acted on urgently or we will have to take legal action to ensure that the requirements are met. For example, staff at the home must have specialist training to meet the specialist needs of the residents to ensure proper care is provided. All new residents must be assessed before they are admitted to the home to ensure that the home can meet their needs and has any necessary equipment in place. Care plans must be in more detail and tell care staff how to provide the care. Where possible the plans should be written in consultation with the resident or their relatives. The plans must also identify any risks and provide instructions for prevention. Staff must give medications according to the medication policy. Staff must speak to and about residents in a manner that respects their privacy and dignity. Any staff must report any suspicions or evidence of abuse or neglect to ensure the safety and protection of the residents. There must be a regular programme for decorating and replacing carpets and furniture so that a homely environment is provided. Edwardian Care Home DS0000037799.V358070.R01.S.doc Version 5.2 Page 7 There must be suitable laundry equipment in the home and a system that ensures if there is a breakdown it is repaired or replaced immediately. 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. The summary of this inspection report can be made available in other formats on request. Edwardian Care Home DS0000037799.V358070.R01.S.doc Version 5.2 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 Edwardian Care Home DS0000037799.V358070.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4,6 Quality in this outcome area is poor. There was limited documentary evidence to indicate that assessments were carried out on people prior to their admission, therefore their needs may not be clearly identified and fully met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Following the last inspection a requirement was made that ‘A comprehensive assessment must be undertaken prior to the admission of any person to ensure there is sufficient information to ascertain if staff at the home are suitably qualified and competent to meet the needs of the person.’ Edwardian Care Home DS0000037799.V358070.R01.S.doc Version 5.2 Page 10 The manager informed us that there had been no new admission to the home since the last inspection. However, we became aware of two residents who had recently been admitted. Both had received respite in the home in the past. However one had had only a short period of respite in July 2007 and his care file indicated that his initial assessment had not been very comprehensive. The manager explained that while she was on holiday this resident was ‘sent in’ by the social worker. There was no recent documentation from the social worker to support this admission, and the manager had not asked for any. The second resident had been at the home prior to going into hospital, but when leaving the hospital he had been discharged back home. He had presented himself at the home and the manager had agreed his stay. At the time of the inspection the manager did not know how his stay was to be financed and was waiting for a social worker to make an assessment. Again there was no pre-admission assessment to suggest how his needs may, or may not, have changed during the time he was in hospital. As original preadmission assessment for these people had not been comprehensive, and because of the requirement made following the last inspection it would be expected that comprehensive pre-admission assessments would have taken place. Staff were attending a variety of mandatory trainings, as detailed in the staffing section of this report, but it was apparent that staff did not have the specialist training to meet the needs of some of the residents. For example at least one resident had a mental health diagnosis and another had a PEG tube and a laryngectomy which staff had not been trained to care for. Staff reported that the resident with the laryngectomy was self-caring, but then spoke of emergency aid they had had to give when needed. There was nothing to suggest what the resident was expected to do. We were particularly concerned about infection control as his room was not clean and we did not know who was responsible for cleaning his suction equipment. The Edwardian did not offer intermediate care. Edwardian Care Home DS0000037799.V358070.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is poor. The quality of the care plans was not good enough to ensure that consistent care would be provided. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection the manager had introduced new care planning documentation. The new documentation was a book that included all care information and risk assessments, and talked the user through the assessment, reviewing and evaluation processes. The change over from one set of documentation to another had not been coordinated and as a result few of the residents had care plans for all their needs. At the start of the inspection the manager explained the new system to us and told us that all but two residents had the new system in place. However during case tracking it became apparent that the new books may have been labelled, and in some Edwardian Care Home DS0000037799.V358070.R01.S.doc Version 5.2 Page 12 cases assessments made, but of the three files sampled detailed plans had not been written. Other plans were randomly sampled to check this judgement. Where assessments had been undertaken they had not been signed and dated by the person making the assessment and were therefore meaningless. When discussing this during feed-back, the manager told us that she had planned to work on the plans with one of the deputies, but because of pressure of work and staff sickness was unable to find the time. Staff told us that they were confused and were unsure what was expected of them, as sometimes the manager asked them to complete one type of plan and sometimes another. During a strategy meeting soon after the inspection a social worker made the same comment. The care plan of a resident who had died recently was also looked at. In this file it was not clear from the daily notes how the decision to move the resident to the local hospital had been taken and what was done to address his/her condition prior to the move. It was also noted that this person had lost 6kg in three months, but in that time the nutritional assessment had not been reviewed. We also noted that fluid balance charts were being completed, but we were uncertain if the amount recorded as being taken was accurate as most older people would find it difficult to take the amount of fluid suggested on the record, although the manager believed it to be normal intake. When discussed in detail the manager did agree that the records appeared to be incorrect. The processes for receiving into the home, administering and recording medication were checked on both floors. They were found to be satisfactory with the exception of medication that had been bought into the home by a new resident and had not been signed in at the time. It was therefore not possible to reconcile these tablets and audit correctly. It was also apparent, and staff agreed, that when administering ‘as required medication’ such as paracetamol, the same medication, labelled for one person would be used for someone else who also needed it. Consequently these medications did not reconcile. Throughout the inspection we noticed that all staff, including the ancillary staff, included residents in conversations. We were however disappointed to hear a member of staff, who had been detailed to watch over a resident who was inclined to wander and fall, explain to visitors that she was on ‘guard duty’, and could not leave this particular resident. This comment was later repeated to more visitors to the home. A social worker reported that when resident was being pushed into the lounge to speak to her the member of staff asked, “where do you want me to dump him”. Edwardian Care Home DS0000037799.V358070.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. Some activities were provided but there was nothing to suggest that they were what residents wanted to do, or how the activities benefited them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home was divided into the ground floor and first floor for operational purposes and many of the activities were arranged by the staff on a particular floor and were specific to the residents on the particular floor. On the ground floor three residents had visitors, while on the first floor residents were doing gentle exercises to a music DVD. Unfortunately, because only two staff were allocated to each floor and a number of the resident required the support of two members of staff for their care needs, activities had to stop whenever a resident had care needs. During the year the staff team had organised a number of events, such as parties, to which the residents could invite their families and friends. Edwardian Care Home DS0000037799.V358070.R01.S.doc Version 5.2 Page 14 People were able to maintain independence and we spoke to one resident who was going from the home to his flat to pick up more equipment. It was noted that staff encouraged those residents who could, to get up and mobilise where possible. Residents confirmed that they were able to choose when they had their breakfast and what they had. The cook worked to a four-week menu plan and would ask residents after breakfast for their lunch choices. During the inspection residents were asked to choose from baked fish in breadcrumbs or vegetable nuggets with chips. Staff provided help and support to those that needed it. Staff that were working a twelve hour shift also had their meal with the residents. However care must be taken that they only eat with the residents when they have finished providing support and not while they are supporting residents. Staff offered residents frequent drinks, but it was disappointing to see biscuits being offered straight from the packet. Edwardian Care Home DS0000037799.V358070.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is poor. The manager’s poor response to unwitnessed injuries and potential safeguarding issues puts residents at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: According to the complaint log there had been one complaint made to the home since the last inspection, which according to available documentation, had been dealt with appropriately. The complaints policy had been altered as required following the last inspection. At the last inspection the manager had stated that she had not been made aware of any complaints, however a member of staff reported that a complaint had been received the week before and an internal complaints form completed. A requirement was made for the owners to look into this and provide us with information. The information that the Commission for Social Care Inspection received did not sufficiently detail how the complaint had been investigated and the outcome of the investigation. The manager again at this inspection stated that she had not been aware of the complaint recorded on the form: therefore this matter remains unresolved. Edwardian Care Home DS0000037799.V358070.R01.S.doc Version 5.2 Page 16 The staff have attended training on the safeguarding of vulnerable adults which included information about their responsibility to identify and report any cases of possible abuse. As a result staff reported to us that they have identified a number of incidents that they believed should have been reported, but the manager has disagreed with them. One incident involved a resident bullying another. When asked the manager stated “ I have had her down here, but I don’t know it is bullying”, meaning that the alleged perpetrator has been receiving the majority of her care away from the alleged victim. However the safeguarding board had not considered this case, as it had not been reported. Following the inspection we made a referral. We also had to refer an incident that was reported to us about a resident who was alleged to be had found covered in blood, but an accident had not been witnessed. Staff were aware of the need to report these incidents but stated that the manager made the decision not to. Some staff reported to being very worried about this. Edwardian Care Home DS0000037799.V358070.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,24,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The varying quality of the environment does not provide people with a comfortable and homely place in which to live. EVIDENCE: At the last inspection we had commented about the front door being kept locked from the inside and how this infringed on peoples rights to leave the building if they were able and wished to do so. We suggested the possibility of fitting a keypad so that those who were able could have the number. The manager reported that the fire service had not agreed to this so a bolt had Edwardian Care Home DS0000037799.V358070.R01.S.doc Version 5.2 Page 18 been fitted. We believed a bolt would also restrict residents who might want to leave the building from doing so. Since the last inspection some carpets had been replaced in communal and private areas, but there were still some heavily stained carpets in corridors. Residents spoken to were happy with their accommodation. One resident took us to see her bedroom, which had been personalised to her own taste with a number of family photographs. We also visited the bathroom and toilet she would use. Both were clean. We were aware that vacant bedrooms were being used to dry laundry. The manager reported that the washing machines and driers had not been working effectively since Christmas. Staff reported that they had to wash items, including towels, by hand. The manager denied that this had been the case. We saw three call-out sheets for the appliance engineers since the New Year. The manager reported that a carer had been dealing with it almost daily. If there were a manager on duty, we would expect him/her, or the owners, to be addressing a problem like this, not a member of the care staff who was needed to provide care duties. We were told that when one of the owners visited the home on the day of the inspection and questioned the laundry drying in vacant rooms, he reported being unaware of an on-going problem with the laundry equipment. Edwardian Care Home DS0000037799.V358070.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staff had not received the specialist training and advice they need to care for some of the needs of the people living at the Edwardian, which could put them at risk. EVIDENCE: As reported in the first section of this report staff did not have the necessary training and skills to deal with some of the potential problems a resident could have. Staff spoke positively about the amount of training they were offered. One carer stated that she had completed risk assessment and fire safety training in the last few months and another reported dementia awareness training. However none of this was specialist training. It was also apparent that some staff did not choose to attend training readily. The manager reported that there had been no new staff recruited to the home since the last inspection, so it was not possible to assess recruitment practices. Edwardian Care Home DS0000037799.V358070.R01.S.doc Version 5.2 Page 20 Therefore the requirement about recruitment will remain with an extended timescale. However while looking at personal files it was apparent that yet another member of staff had historically been working at the home for five and a half months before a Criminal Record Bureau check was obtained. The POVA first check missing at the last inspection, that the manager reported was kept at another office, had not been located. As at the last inspection, Staff felt that there were not enough staff to care for the people living at the home when only 2 staff were allocated to work on a floor, it was reported that at times someone would need to wait for assistance if help was being offered to another person or if the senior was giving out medication that many people required assistance from 2 people at a time and they would have to wait. This had not altered and we were not aware it had been assessed. We were also concerned that having only two staff working a night shift, when the care was over two floors meant that when a carer was on a break only one carer was covering two floors. Edwardian Care Home DS0000037799.V358070.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,38 Quality in this outcome area is poor. Repeated non-compliance in some areas indicates that the manager lacks control of some of the main components involved in the running of the home and the protection of the people who live there. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager appeared to be struggling, and was making some judgements that did not reflect policies or best practice. Edwardian Care Home DS0000037799.V358070.R01.S.doc Version 5.2 Page 22 Following the last inspection, when the conduct of the manager in relation to staff management and a telephone system was highlighted, it was necessary to meet with the provider to share our concerns and remind him of his duty to employ a fit person to run the home. The manager stated that the provider had met with her following this meeting and suggested that she should take time out if she felt stressed. She felt supported by this. We however, were concerned that the provider was not doing anything to monitor the situation and that the requirement for him to visit the home at least monthly and carry out an assessment was not being complied with. The manager confirmed that the provider had visited as required, but had not reported back to her following his visits. We had met with the provider and explained the importance of these visits in supporting the manager, assessing the progress and activity in the home and identifying any issues between inspections. CSCI had been receiving the required notifications relating to the death of residents, but not as many as expected relating to an injury or fall to a resident. We were made aware that the safeguarding team had been informed by community nurses of injuries of an unknown origin to at least two residents, and a social worker had had to report the possible neglected state of a resident. The manager had not attended the last two strategy meetings held on residents living at the home because she said she had not received the invite. All other parties involved would have been invited at the same time and all other invites were received. Therefore, the communication systems in the home may be faulty. A third strategy meeting held after the inspection was also not attended by the manager who was off sick. The reason for her non attendance was not known until then home was contacted and the staff were not aware of this appointment, so no representative from the home was present again. At the last inspection the manager was reminded of the need to not only send out satisfaction questionnaires to a variety of stakeholders but also to audit the responses and act on them. Since the last inspection the manager had sent out more questionnaires, but admitted to being unsure how to audit them. She said that she would be asking the owners to help her with this. This was a requirement from the last inspection and sending out more questionnaires has further compounded the manager’s lack of understanding of regulations The home managed ‘spending money’ for some of the people who lived there. The records for three individual’s accounts were inspected. All records balanced correctly with funds, and receipts were present for all expenditures, which were mainly to the visiting chiropodist or hairdresser. The manager had a supervision matrix on the wall, but despite this the three staff files looked at showed that the staff members had not been supervised Edwardian Care Home DS0000037799.V358070.R01.S.doc Version 5.2 Page 23 for the last six months. No staff spoken to had been supervised since the last inspection. The manager reported that she had not been supervised for at least a year. Health and safety records maintained by the home indicated that safety checks were carried out routinely. The manager was in receipt of a report from the fire service listing four deficiencies within the home. The manager reported that she was actively addressing these areas. Catering staff were now wearing protective clothing when cooking. Edwardian Care Home DS0000037799.V358070.R01.S.doc Version 5.2 Page 24 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 1 1 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 2 X X X X 3 X 2 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 1 1 1 X 3 1 1 2 Edwardian Care Home DS0000037799.V358070.R01.S.doc Version 5.2 Page 25 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 OP3 Regulation 14 Requirement A comprehensive assessment must be undertaken prior to the admission of any person to ensure there is sufficient information to ascertain if staff at the home are suitably qualified and competent to meet the needs of the person. This requirement has not been met. Previous timescale 31/12/07 Staff at the home must have the training and experience to meet the specialist needs of the residents to ensure proper care is provided. A care plan must be in place for each assessed need for every person, which provides sufficient guidance to staff to ensure continuity of care is provided. This requirement has not been met. Previous timescale 31/12/07 The home must ensure all care plans are generated and drawn up in consultation with the DS0000037799.V358070.R01.S.doc Timescale for action 01/04/08 2 OP4 12(1) 01/04/08 3 OP7 15 01/04/08 4. OP7 15(1)(2) schedule 3(1)(b) 01/04/08 Edwardian Care Home Version 5.2 Page 26 service user or their representatives (previous time scales have not been fully met) 5. OP8 14(1)(a) (2) People assessed at risk of falling must be referred and receive appropriate support and advise from specialists in this area to minimise the risk of injury to them. A plan must then be written to make clear to staff the interventions that must be carried out. This requirement has not been met. Previous timescale 31/12/07 6 OP9 13(2) Medication systems and training must be sufficient to ensure safe recording, handling and administration of medication. This is to ensure effective auditing can take place and people receive their medication when required. This requirement was almost met. Staff must speak to and about residents in a manner that respects their privacy and dignity. This requirement has not been met. Previous timescale 15/12/07 Staff must report any suspicions or evidence of abuse or neglect to ensure the safety and protection of the residents. The carpeting which is heavily stained must be replaced to provide a suitable environment for people to live in. This requirement has not DS0000037799.V358070.R01.S.doc 01/04/08 01/04/08 7 OP10 12(4)(a) 01/04/08 8 OP18 12(1) 01/04/08 9 OP19 16(1) 01/04/08 Edwardian Care Home Version 5.2 Page 27 10 11 OP26 OP27 13(3), 16 (2)(j) 18(1)(a) been met. Previous timescale 31/01/08 There must be suitable 01/03/08 operational laundry equipment in the home. The home must ensure that at all 01/04/08 times competent staff are working at the home. This requirement has not been met. Previous timescale 30/06/07 12 OP29 19(4) The home must ensure that staff do not work at the home without CRB clearances. (Previous time scale not met, the Commission will now undertake a review to consider how to proceed in this matter). This requirement could not be assessed, as there had been no new staff recruited to the home. Previous timescale 09/05/07 The home must ensure that having regard to the statement of purpose and the needs of the service users, the manager has qualifications, skills and experience necessary for managing the care home This requirement has not been met. Previous timescale 15/12/07 01/04/08 13 OP31 9(2) (b) 01/04/08 14. OP33 24 (1) (a) The home must complete the (b) (2) (3) analysis of the service users’ survey, publish, and make available to the service users’ representatives and relevant stakeholders. This requirement has not been met. Previous timescale 30/06/07 01/04/08 Edwardian Care Home DS0000037799.V358070.R01.S.doc Version 5.2 Page 28 15 OP36 18(2) All staff working at the home must be supervised at least six times a year. 01/04/08 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 4 Refer to Standard OP12 OP15 OP33 Good Practice Recommendations There should be documentation about the type of interests the residents have and what they would enjoy doing. Staff should only eat with residents if they are not supporting them in any way and the occasion can be considered social. The regulation 26 visits should be more detailed and provide the manager with a report and useful information about the owners views on how the home is conducted. Edwardian Care Home DS0000037799.V358070.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Inspection Team CPC1 Capital Park Fulbourn Cambridge CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Edwardian Care Home DS0000037799.V358070.R01.S.doc Version 5.2 Page 30 - 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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