Inspection on 10/02/06 for Edwardian Care Home

This inspection was carried out on 10th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

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 01/02/08

Edwardian Care Home 31/10/07

Edwardian Care Home 09/05/07

Edwardian Care Home 02/06/06

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 Mr Pursotamraj Hirekar Unannounced Inspection 10th February 2006 11:00 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.V272388.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Edwardian Care Home DS0000037799.V272388.R01.S.doc Version 5.1 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 705100 The Edwardian Care Home Ltd Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Edwardian Care Home DS0000037799.V272388.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd November 2005 Brief Description of the Service: The Edwardian was a purpose built residential home that provided single room accommodation for 30 older people including those who had dementia and/or physical disabilities that would be met within the registration for older persons. The home was located on a busy thoroughfare, which was a short car or bus ride away from Luton Town Centre. The home had been suitably adapted to meet service users’ assessed needs. At this inspection the accommodation for the service users was arranged on the ground and the first floor with a further third floor that accommodated administrative and staffing offices. Access to all floors was via staircases and a shaft lift. The bedrooms were arranged on the ground and first floor of the house. They were pleasantly decorated, each fitted with a hand washbasin, call system and TV point. Communal facilities were a lounge/diner on both floors and sufficient bathing and toilet facilities for convenient access. The home bordered straight onto the pavement area of the street with a small ornamental garden to one side that was not suitable for recreational purposes. A small patio area with summertime pagoda and garden furniture for the use of the service users was situated to the rear of the building, as was car parking for several vehicles. Edwardian Care Home DS0000037799.V272388.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of the unannounced inspection carried out at 11.00am on 10.02.06 by Pursotamraj Hirekar over 4 ½ hours. The method of inspection included a review of outstanding requirements and recommendations, study of personnel files, discussion with the manager, deputy managers and staff on duty, conversations with the service users and their representatives, observations, study of care plans and reviews, partial tour of the home and study of other records relevant to the operation of the home. What the service does well: What has improved since the last inspection? What they could do better: The home must ensure care plans are generated and drawn up in consultation with the service user or their representatives Nutritional screening is undertaken on admission and subsequently on a periodic basis, a record of nutrition, including weight gain or loss, and appropriate action taken. Medicines in the custody of the home are handled according to the requirements of the Medicines Act 1968, guidelines from the Royal Pharmaceutical Society. A record is kept of all complaints made and includes details of investigation and any action taken. All complaints are investigated appropriately to prevent service users being placed at risk of harm. Edwardian Care Home DS0000037799.V272388.R01.S.doc Version 5.1 Page 6 The home must ensure completion of a satisfactory police check for all staff before their employment is confirmed. The home must ensure that the manager has at least 2 years experience in a senior management capacity and has a qualification, at level 4 NVQ, in management and care or equivalent The home must appoint a registered manager to run the home to meet its stated purpose, aims and objectives The home should ensure all personnel records are up to date and accurate. 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. Edwardian Care Home DS0000037799.V272388.R01.S.doc Version 5.1 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 Edwardian Care Home DS0000037799.V272388.R01.S.doc Version 5.1 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 The home had not ensured in all instances that it had the capability to meet the assessed needs of those moving into the home. EVIDENCE: The previous inspection report had made a requirement that the home must ensure there is appropriate consultation regarding the assessment with service users or their representatives. When asked about the status of this requirement, the manager said she was not aware and that she was just two weeks into the post of acting manager. Later the manager had agreed to comply with the same before 30/04/06. The service users’ guide and the notice in the reception continue to carry the name of the manager who left in October 2005. Edwardian Care Home DS0000037799.V272388.R01.S.doc Version 5.1 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): 7,9,10 The home’s medicine policy and practices were not appropriate and expose the service users to risk of harm. EVIDENCE: The home had a medicine policy and procedure dated 2002. However, on the top of the cover page of the policy there were two signatures of the then manager, reviewed 2004 and reviewed 2005. When asked about the relevance of the two signatures, the manager had said, she does not know. There was no record of evidence to show what areas of the policy and procedures have been reviewed and what changes have been proposed and made. There were 3 cardboard boxes and 5 fibre containers/boxes full of medicines in the manager’s room. When asked, the manager said that these medicines have arrived a day before and the staff were in the process of sorting them out. The sorting of medicines would be completed in a day or two. The staff responsible for administration of medication had only received in-house training. It is very important to review the home’s medicines policy and procedures and put in place the current best practices to prevent any risk of harm to the service users. The manager had agreed to review and update the medicine policy and procedure before 31.03.06. Edwardian Care Home DS0000037799.V272388.R01.S.doc Version 5.1 Page 10 The care plans and the needs assessment studied were not comprehensive, covering all aspects of physical, health, nutritional and social care needs. There was no evidence available to show that the needs were assessed and care plans were drawn up in consultations with the service users, their representatives and professionals. The home should revisit the needs assessment and care planning tool and incorporate the current best practices for the care of older people. The service users spoken to in the dinning areas have expressed satisfaction with the care provided by the home. However, service users who were in their bedrooms at the time of this inspection were not spoken to. Two service users relatives also have expressed satisfaction with the care provided by the home and in particular the caring attitude of the staff. Edwardian Care Home DS0000037799.V272388.R01.S.doc Version 5.1 Page 11 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): 14, 15 Service users had the opportunity to express their choices and comforts. Service users were satisfied with the food. However, the home may undertake nutritional assessments of all service users and provide individual specific diets that meet the goals of a balanced diet. EVIDENCE: The service users who were spoken to said they exercised choices to decide where they would like stay, whether in the bedroom or lounge, when they want to have baths and hair dressing. The staff were polite and co-operative and were available for help as and when required by the service users. The home should take assistance from the British Dietetic Association – Nutrition Advisory Group for the Elderly People to conduct nutritional assessments of the service users. Basing on nutrition assessments and needs covering details such as eating time and habits, weight, vitamins C, D, fibre and iron. The home should incorporate the above information into the care plans and need to be actioned. Edwardian Care Home DS0000037799.V272388.R01.S.doc Version 5.1 Page 12 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, 17, 18 The complaints policy and procedures were comprehensive but in practice lack support to protect service users from abuse. EVIDENCE: The commission had received a complaint dated 17.01.06 regarding the appointment of a new manager. The service provider was asked to investigate and report to the commission on the complaint. In his letter of 04.02.06 the service provider confirmed that the new manager was a care assistant, then promoted to senior carer, administrator and then promoted to deputy manager at a sister home. The reference letter dated 12.01.06 given by the service provider to the new manager mentioned that the new manager worked as deputy manager for the past five years. The service provider’s letter dated 28.09.05 to the new manager said that she had been appointed as deputy manager of the sister home from Thursday 29.09.05. The application by the new manager for the post of manager, mentioned in the employment history that she was deputy manager at a sister home since 2001 and signed. The new manager had confirmed that this was a mistake. Service Users Guide and the notice displayed in the reception of the home had the name of the manager of the sister home. Edwardian Care Home DS0000037799.V272388.R01.S.doc Version 5.1 Page 13 During the discussions with the deputy manager and the current manager on the outstanding requirements from the previous inspection report, both said that the manager of the sister home had written to CSCI on the requirements front. Interview letter dated 19.12.05 inviting the then deputy manager of sister home for an interview at 2.00pm on 28.12.05 for the post of manager Edwardian, was signed by the manager of the sister home. The referee and the interview panel member for the recruitment of the manager of the home was the manager of the sister home. Edwardian Care Home DS0000037799.V272388.R01.S.doc Version 5.1 Page 14 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): 26 The home provided clean, safe and well-maintained environment, which met the service users’ needs. EVIDENCE: Satisfactory arrangements have been made to keep the home clean, safe and well maintained. The person responsible for the cleanliness and hygiene was seen during the inspection always on the job attending to some or other work maintaining the premises of the home. Edwardian Care Home DS0000037799.V272388.R01.S.doc Version 5.1 Page 15 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): 28, 29, 30 The staff recruitment procedures do not provide enough safeguards to offer protection to service users living in the home. EVIDENCE: The home does not have a clear recruitment policy and procedures. The home manager’s recruitment had discrepancies in the appointment. Please refer to the complaints section of this report for additional information on this. The owner of the home, the interview panel member, as well as the referee, were the same person. The second referee and interview panel member, as well as the line manager, were the same person. There was no clarity on the role the manager of the sister home had in the management affairs of this home. On a random check, two staff personnel records indicated that one deputy manager’s CRB was dated 2003 as a care assistant with BUPA, and there was no evidence of a CRB with this home as an employer. Also, the deputy manager said she was working at this home for the last six years. The home must have clear policy and procedures for staff recruitment and preemployment checks and comply with the care standards act. Three staff members have received POVA training and POVA training was planned for 7 more staff members. Edwardian Care Home DS0000037799.V272388.R01.S.doc Version 5.1 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 38 Recent management changes appeared not to have benefited the home. EVIDENCE: The current management ethos and leadership were not in favour of promoting the welfare and interests of the service users. There were concerns expressed regarding the previous acting manager in the unannounced inspection report dated 03.11.05, and later she was returned to deputy manager’s position of the home. The management had appointed a new manager from 30.01.06 and there were concerns around her appointment, which have been detailed under complaints and protection and staffing sections of this report. One person from outside the home rang the bell; the deputy manager opened the door and asked him to sign the visitor’s book. The gentleman signed in the same row of the visitors’ book, which was already entered by another visitor. This gentleman had not written his name, time of visit or the purpose of his visit. Edwardian Care Home DS0000037799.V272388.R01.S.doc Version 5.1 Page 17 He went inside and had chat with the deputy manager for 7 minutes and went out without entering the time of leaving in the visitors’ book. There was no staff member to monitor the main door at the reception to check who was going out. Two visitors just picked up the key from the top of the switch box in reception, opened the door and went off. After some time another couple of visitors opened the main door of the reception room and went out. In the feedback meeting to the current manager the above incidences were shared and the visitor’s book was also shown as part of the evidence. The manager had assured to take action as soon as possible. Edwardian Care Home DS0000037799.V272388.R01.S.doc Version 5.1 Page 18 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 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 1 17 1 18 1 X X X X X X X 3 STAFFING Standard No Score 27 X 28 2 29 1 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 1 X X X X X 2 Edwardian Care Home DS0000037799.V272388.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? Yes Edwardian Care Home DS0000037799.V272388.R01.S.doc Version 5.1 Page 20 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 OP7 Regulation 15(1)(2) sch3(1)(b ) Requirement The home must ensure care plans are generated and drawn up in consultation with the service user or their representatives (previous requirement not met 31/01/06) Nutritional screening is undertaken on admission and subsequently on a periodic basis, a record of nutrition, including weight gain or loss, and appropriate action taken. Medicines in the custody of the home are handled according to the requirements of the Medicines Act 1968, guidelines from the Royal Pharmaceutical Society. A record is kept of all complaints made and includes details of investigation and any action taken. All complaints are investigated appropriately to prevent service users being placed at risk of harm. Timescale for action 30/04/06 2. OP8 14(1)(a) (2) 31/03/06 3. OP9 13 (2) 31/03/06 4. OP16 17 (2) 15/03/06 5. OP18 13 (6) 31/03/06 6. OP29 7. OP31 The home must ensure completion of satisfactory police check for all staff before their employment is confirmed. 9(1)(2)(b) The home must ensure that the manager has at least 2 years experience in a senior DS0000037799.V272388.R01.S.doc Sch 2 (7) 31/03/06 30/04/06 Edwardian Care Home Version 5.1 Page 21 8. 9. OP31 OP31 19(5)(d) 9 management capacity and has a qualification, at level 4 NVQ, in management and care or equivalent The home must ensure full and satisfactory information is available before employing staff. The home must appoint a registered manager to run the home and meet its stated purpose, aims and objectives 31/03/06 30/04/06 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. Refer to Standard OP37 Good Practice Recommendations The home should ensure all personnel records are up to date and are accurate Edwardian Care Home DS0000037799.V272388.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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. 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