Inspection on 18/06/09 for Edwardian Care Home

This inspection was carried out on 18th June 2009.

CQC found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Edwardian Care Home 14/10/09

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 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 25/11/2009.

Inspecting for better lives Key inspection report Care homes for older people Name: Address: Edwardian Care Home 168/170 Biscot Road Luton LU3 1AX     The quality rating for this care home is:   one star adequate service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Sally Snelson     Date: 1 8 0 6 2 0 0 9 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Older People Page 2 of 29 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 29 Information about the care home Name of care home: Address: Edwardian Care Home 168/170 Biscot Road Luton LU3 1AX 01582705100 01582705106 edwardian170@yahoo.co.uk Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: Conditions of registration: Category(ies) : The Edwardian Care Home Ltd care home 30 Number of places (if applicable): Under 65 Over 65 12 30 dementia old age, not falling within any other category Additional conditions: 1 named person above the age of 60 years Date of last inspection Brief description of the care home 0 0 1 0 1 2 2 0 0 8 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. Care Homes for Older People Page 4 of 29 Brief description of the care home The manager told us that fees were under review, as the home was not accepting admissions, but were in the region of £446-£460 depending on the assessed needs and the room occupied. Care Homes for Older People Page 5 of 29 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: one star adequate service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This inspection was carried out in accordance with the Care Quality Commissions (CQC) policy and methodologies, which requires review of the key standards for the provision of a care home for older people. The methodology takes account of residents views and information received about the service since the last inspection. Information from the home, through written evidence in the form of an Annual Quality Assurance Assessment (AQAA) has also been used to assess the outcomes within each standard. Evidence used and judgments made within the main body of the report include information from this visit. Sally Snelson and Louise Trainor undertook this inspection of the Edwardian. It was a key inspection, was unannounced, and took place from 07.45hrs on the 18th June Care Homes for Older People Page 6 of 29 2009. This report also includes information from random inspections carried out on 10th December 2008, the 30th March 2009 and 7th May 2009. Mary Ainsbury the interim manager was present for the majority of the inspection. Feedback was given throughout the inspection, and at the end. During the inspection the care of four people who use the service (residents) was case tracked in detail. This involved reading their records and comparing what was documented to what was provided. In addition to sampling files, people who lived at the home, visitors, and staff were spoken to, and their opinions sought. Any comments received from staff or residents about their views of the home, plus all the information gathered on the day was used to form a judgment about the service. We would like to thank all those involved for there assistance with the inspection. What the care home does well: What has improved since the last inspection? What they could do better: The service continues to have a number of areas that need to be improved including:_ The need to ensure that all documentation provided for users of the service and their representatives is accurate and kept up-to-date. The need for care plans to be simply laid out and provide the reader with the information they need where they expect to find it. Care plans must always reviewed as needs change and at least every month. Risk assessment must be used to determine risk and how the risk can be managed and not to write all aspects of how care should be delivered. There should be a record to confirm that the activities provided for the people using the service are acceptable to them. There should also be a record of how residents reacted to the activity provided. Care Homes for Older People Page 8 of 29 Staff must ensure that they follow SOVA policies and practices at all times. Windows opening on the ground floor should not be opened wide enough to allow entry or exit via them. The service must ensure that staff are deployed throughout the home at all times. The service must have a system in place to ensure that staff have understood any training offered and will follow the processes and procedures they have learnt correctly. Staff must have at least six supervision sessions a year. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line –0870 240 7535. Care Homes for Older People Page 9 of 29 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 29 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There was a need to ensure that the documentation available to prospective residents and their families was complete and in date. This ensured that people using the service had a clear understanding of what the home provided. Evidence: The home had a statement of purpose and a service users guide that needed to be updated to reflect the management changes, our change of name, and all the information required by standard 4 and 5 and schedule 1 of the National Minimum Standards . At the time of the last inspection the previous manager had started to update these documents but further progress had not been made on them since she left in March. It was now considered a task that the newly appointed manager would wish to complete when she came into post on the 29th June. Although the Service Users Guide needed to be reviewed it remained available to new residents and gave them basic information but still did not included information about the fees. Ideally Care Homes for Older People Page 11 of 29 Evidence: these documents should also be available in other formats. For example, suitable for those people with visual impairment or English as a second language. We looked at the contracts for two people using the service who had been admitted since the last inspection. Both contracts were completed and signed and these documents included information about the fees. We looked at the pre-admission assessment for one of the residents who had been admitted since the last inspection. The assessment was completed in sufficient detail to show the residents needs and how these needs should be met. The pre-admission assessment therefore provided the evidence that the person doing the assessment had made an informed decision that the prospective residents needs could be met by the service. The staffs ability to meet the assessed needs of the residents will be discussed in the staffing section of the report. The Edwardian did not provide intermediate care. Care Homes for Older People Page 12 of 29 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans needed to be more orgainised to ensure that information was recorded where the reader would expect to find it. Medication systems were in place to ensure that people using the service received the correct medication at the correct time. Evidence: At a random inspection of the home in December we were pleased with the progress made towards meeting the requirement about care plans and expected that when we returned for the next key inspection this requirement would be fully met. Unfortunately, for reasons detailed in the staffing and management section of this report, the manager had to leave at the end of March and it became apparent that shortly after that Random inspection in December she had not been so vigilant and some areas had slipped. Therefore at a visit in May 2009, when there was no manager in post, we discovered that care plans were again not being regularly reviewed and updated. At this inspection, under the leadership of an interim manager regular reviews of care plans were again being undertaken. However the care plans were muddled and some did not clearly identify the focus of the plan. For example Care Homes for Older People Page 13 of 29 Evidence: information about weight loss was written with comments about mobility and the evaluation was non-specific stating for example continue to gain weight Actions = 1.Continue to meet her needs, 2. Continue to give choices, 3.Continue to monitor weight. These were non-descriptive and did not promote continuity of care. The outcome for the person using the service was judged to be adequate as the information about providing care was available, but often as part of the risk assessment and therefore documentation was not consistent. The care plan used (a book which takes the carer though each area of care) advised the writer to use SMART objectives to write the plans. This would mean that the following areas should be considered for each plan: Are they Specific, Measurable, Achievable, Realistic and Timely. We saw little evidence of goals and concluded that staff were completing paperwork and making assessments but were not sure about what they were recording. The interim manager had made the same conclusion and had started to address this with staff and provide additional inhouse training. During the inspection we observed moving and handling equipment being used correctly, although we were disappointed to read in the diary that a hoist could no be serviced because a charger could not be found, other equipment was correctly maintained. Community nurses were regular visitors to the home and it was clear that staff asked their advice and referred concerns to them. We looked at one daily log that provided a clear audit trial as to how staff had managed a resident who had a blocked catheter. They had taken the correct action in a timely fashion and had carried out the instructions given to them by the health professional. We were therefore disappointed to read that staff had identified another medical cause for concern and although they had recorded the effect to the resident had not immediately passed it to the health professionals. The interim manager had referred these slow actions to the safeguarding team and dealt with the staff involved. Intake and fluid charts were being completed as necessary but would benefit from being totaled up at least daily, and output recorded more accurately where possible. For example the exact amount of urine could be recorded if someone had a catheter not simple a tick. We looked in detail at the medication processes and procedures on each floor of the Care Homes for Older People Page 14 of 29 Evidence: home. Medication Administration records (MAR) charts had been correctly completed including using omission codes and completing the reverse of the MAR charts. The interim manager had requested the GPs to undertake a medication review for each residents but at the time of the inspection this request had not been responded to. We witnessed a homely atmosphere in the home with the majority of the staff conversing well with the residents and the residents appearing to have a good relationship with the staff. As with all families some of the residents spoke more fondly of some of the staff and vice versa. Where any problems had been identified staff allocation was adjusted. Each file included the paperwork that needed to be completed to support the staff in ensuring the wishes of the person using the service were carried out in the event of sudden illness and death. These were not routinely being filled in. Care Homes for Older People Page 15 of 29 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Activities had been planned for the residents, but how these benefited people needed to be more clearly recorded. The home provided people with a wholesome varied diet. Evidence: A new activity co-ordinator had been appointed in the last few months and there was evidence that he had spoken with the residents and ascertained their ideas for an activity plan. Initially it had been thought that he may work on activities full-time, but this had been altered and he now provided activities for two hours daily. He had a varied programme and an effort was being made to secure outside groups and volunteers to provide additional activities, for example a church group to provide a regular service within the home. People using the service told us of day centres and lunch clubs that they attended and there was a plan for a seaside visit. The activity coordinator felt that he needed a budget to buy some additional equipment, but was managing to provide something with the equipment he had. Residents told us that they had some strong friendships within the home and enjoyed spending time chatting. At the time of the inspection there was little documentation to support how activities were planned and the benefit or enjoyment they held for the individual. Care Homes for Older People Page 16 of 29 Evidence: It was apparent that visitors were welcomed into the home and that residents could make some choices about how they spent their day. We were conscious that at breakfast time the cook was aware of the needs of the residents on the ground floor and was able to provide their breakfast as they wanted it whereas a trolley had to be taken to the first floor. On the day of the inspection it was 9.20am before people on the first floor had their breakfast even though some were sitting at the breakfast table from 8am. They also had their medication before breakfast , so for many tablets were given on an empty stomach. The cook had been working at the home since July 08 and she had a good relationship with all the residents and the residents spoke highly of the meals provided. One resident said of the cook, shes brilliant, Ive never had to ask for anything else, I have always liked something on the menu. The cook told us she put the four-week rolling menu plan together and ensured that the choices at each meal included a vegetarian option. For example on the day of the inspection the choice was liver or vegetable burgers. Two mornings a week the cook offered a cooked breakfast and also made home-made cakes and biscuits as time allowed. The Kitchen was very clean and tidy . All fridge, food and delivery temperatures were recorded at least daily. At the time of the inspection,in addition to providing soft, and diabetic diets the cook had also learnt how to prepare some halal dishes and and other foods to suit the Asian palette. Care Homes for Older People Page 17 of 29 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The policies and procedures relating to the handling of complaints were very clear to people at the home and their visitor, however there was still a high number of safeguarding referrals made. Evidence: The home had policies relating to the handling of complaints which were available to those using the service and their visitors. The interim manager told us that there had not been any complaints made to the home since the last inspection. We had received one complaint which had escalated to a safeguarding referral. Whilst investigating this complaint it became apparent that staff were not protected by some of the policies and confused messages had been given. We were aware that at the end of the investigation the complainant was satisfied with the response from all concerned. Over the 11 months since the last key inspection there had been a number of incidents that had been referred as a safeguarding issues, including medication errors, unexplained bruising and skin tears and poor practices. As a result the service were reporting all incidents for consideration of safeguarding and not following the local policy on reporting specific incidents. The safeguarding team were happy for this while the service moved into a period of stability. All staff had received an update in the Safeguarding of Vulnerable Adults (SOVA) reporting and recognition and were now more confident to make referrals and not leave them to a senior member of staff, Care Homes for Older People Page 18 of 29 Evidence: which had often resulted in a delay. At the time of the inspection there were open SOVA issues for money that had gone missing and had been reported to the police, an unexplained incident of bruising for which the police had interviewed the victim and an incident, referred to in this report, where a member of staff had been slow to instigate medical intervention. In March 2009 we had reason to believe that a number of staff, including the manager were working at the home without the correct documentation from the home office to allow them to do do. This was addressed and a number of staff left the home. Over the past year the home had been the subject of serious concern meetings and we had met with the Responsible Individual to ensure he was aware of our enforcement process. More recently the local Authority has held standard of care meetings and made a commitment to the service to work with them to ensure improvements. Care Homes for Older People Page 19 of 29 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home was clean and tidy and provided people with a homely place in which to live. Evidence: At the time of this inspection there were 21 residents accommodated over the two floors of the home. The home was clean tidy and free of any odours. Stained carpets had been replaced and bedrooms had been refurbished. With the exception of the a toilet on the ground floor that had been out of action for sometime (because of the distribution of other toilet facilities this did not appear to impact on the residents) the home was well maintained. The interim manager told us that a skip had been booked to get rid of some unwanted items that were cluttering the inside and outside of the home. Despite this these items were being stored appropriately. We noted that a faulty washing machine had been repaired in a timely fashion and our only concern was that at 07.40hrs, when we arrived to start the inspection a ground floor bedroom window, that opened onto the pavement was wide open. The opening was enough to allow a person access. We spoke to the resident in this room who said staff had opened the window as her room was warm. We were concerned that this opening could allow unnoticed access into and out of the building. Care Homes for Older People Page 20 of 29 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service was committed to providing the staff team with training, but the team did not always appear able to put this training into practice consistently. Evidence: During the random inspection in December 2008 we focused on outcomes for the people using the service and did not look at staff files. The second random inspection in March 2009 was as a result of being informed by immigration that the then manager did not have the relevant papers to be working in the UK and was therefore considered an illegal immigrant. She had been asked by immigrations to send in her paperwork and advise the owner of the situation, some 10 days previously; they had heard nothing from her since. She told us that in 2002 she had been granted a student visa and her documents had been with the home office since that visa expired later that year. She had nothing on file to support this. We asked her if she knew she was working illegally, and she said she knew she could not work more that 20 hours a week on a student visa, even though she had been working full-time for a number of years. At that inspection we looked at a number of staff files and found other discrepancies. For example a member of staff who had been employed in 2009 with two references that had been written in 2007, a member of staff without any references, and another member of staff who had been employed for Care Homes for Older People Page 21 of 29 Evidence: one week who had a work permit that ran out at the end of her probationary period. Some staff had been able to produce current documentation that was not held on file. This suggested that the manager was not regularly auditing the status of the people working at the home with permits. We left an immediate requirement that only staff with the correct documentation could work at the home. One of the owners and the interim manager carried out an extensive audit of the staff files Following the audit further discrepancies were found and more staff had to be asked to leave We were confident that all the remaining staff had been correctly checked as being suitable to work in the role. As a result of the input from the Local Authority the home had been supported with places on a variety of training courses and the records held demonstrated that the staff team had the necessary skills and qualifications to provide the care required by the residents living at the Edwardian. Staff told us that they had a number of opportunities to attend a variety of training and staff files identified this. However there was evidence that staff were not always able to transfer what they were taught into practice. During the inspection on the 7th May we reported, there were four staff on duty for 19 residents. Residents were in the lounge or their bedrooms on the ground and first floor. On the whole staff ensured that their was at least one member of staff on each floor, but at one point in the day all four staff were on the first floor. This was quickly rectified. At this inspection there were five staff for 21 residents in addition to a cook and cleaner and the interim manager, it was more usual for there to be four staff on duty. This meant that when two staff were providing personal care residents in the communal areas could be unattended for periods. We were advised that more staff would be employed as more admissions were made into the home. Care Homes for Older People Page 22 of 29 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There was a need for the service to be managed in a consistent way to ensure that areas of care currently considered adequate can be improved. Evidence: As explained in this report the last manager had left before becoming the registered manager for the service. As a result the home had appointed a new manager who was currently working a three month period of notice and was due to start work 29th June 2009. In the meantime a manager from another home that was owned by one of the joint owners of the Edwardian was supporting the staff with management duties. This had been difficult for her as she continued to manage her own home. The interim manager had sent out questionnaires to stakeholders and had produced an action plan from the results. The questionnaire was basic and needed to be expanded as did the evaluation of the results but it showed a commitment to listening to want people said about the service. Care Homes for Older People Page 23 of 29 Evidence: As already reported money that was held on behalf of residents was only audited when the manager took money out. Two days before the inspection the manager had audited the wallets and found money missing from two. The police had been called and the money returned by the company while an external investigation takes place. The interim manager had made the decision to leave the safe key locked in the controlled drug cupboard so that residents had access to their money if she was unavailable. This had proved to be a wrong decision. The interim manager had appraised all the staff and some staff had received supervision but the records did not confirm that all staff had received six supervisions in the year. Although this requirement had been made in the past we felt it was appropriate to re-state it as under the circumstances staff supervision was one of the areas not fully addressed. There was evidence to indicate that fire call points and the emergency lighting were being tested on a regular basis, and that fire drills were carried out periodically. Maintenance issues and redecorations were being addressed in a timely fashion. Care Homes for Older People Page 24 of 29 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 25 of 29 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 1 5 The service must ensure that all documentation provided for users of the service and their representatives is accurate and kept up-to-date. This ensures that people are aware of what the service provides. 31/07/2009 2 7 15 Care plans must be simply laid out and provide the reader with the information they need where they expect to find it. This ensures that a there is a consistent approach to providing care. 01/08/2009 3 8 13 Risk assessment must be 01/08/2009 used to determine risk and how the risk can be managed and not to write all aspects of how care should be delivered. This ensures that when staff look at care plans the Care Homes for Older People Page 26 of 29 information about providing care is not muddled with that about risk. 4 12 12 There should be a record to 01/08/2009 confirm that the activities provided for the people using the service are acceptable to them. There should also be a record of how residents reacted to the activity provided. This ensures that people are offered stimulation that suits and benefits them and not simply passes time. 5 18 12 Staff must ensure that they follow SOVA policies and practices at all times. This will ensure that all those living at the Edwardian are protected from harm or abuse of any type. 6 19 25 Windows opening on the ground floor should not be opened wide. This is to prevent people entering or leaving the building unnoticed 7 36 18 Staff must have at least six supervision sessions a year. This allows staff the opportunity to discuss in a safe environment there training needs and any aspects of their role. 01/01/2010 10/07/2009 01/07/2009 Recommendations Care Homes for Older People Page 27 of 29 These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 2 7 15 The service should ensure that care plans are always reviewed as needs change and at least every month. Consideration should be given to enabling all people using the service to have their breakfast as they become ready for it. The toilet on the ground floor should be made serviceable as soon as possible. The new manager should be supported to become the registered manager as soon as possible to show a commitment to the role. The quality assurance system in place should be built upon. 3 4 19 31 5 33 Care Homes for Older People Page 28 of 29 Helpline: Telephone: 03000 616161 or Textphone: or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Older People Page 29 of 29 - 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!