Inspection on 02/06/06 for Edwardian Care Home

This inspection was carried out on 2nd June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 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 Mr Pursotamraj Hirekar Unannounced Inspection 02/06/06 10:42 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.V297573.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.V297573.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 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.V297573.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th February 2006 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. At present, the home does not have a registered manager. Edwardian Care Home DS0000037799.V297573.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of the unannounced key inspection carried out on 02/06/06 over 6hours by pursotamraj hirekar. The method of inspection included review of outstanding requirements and recommendations, notified incidents, study of a sample of care plans, risk assessments, discussion with the service users’, staff on duty, deputy manager, co-owner and observations. The deputy manager coordinated the entire inspection. At present, the home does not have a registered manager. What the service does well: What has improved since the last inspection? What they could do better: The home must appoint a registered manager to run the home and meet its stated purpose, aims and objectives. 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 ensure all care plans are generated and drawn up in consultation with the service user or their representatives. Edwardian Care Home DS0000037799.V297573.R01.S.doc Version 5.2 Page 6 The home must complete the analysis of the service users’ survey, publish and make available to the service users’ representatives and relevant stakeholders. 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. The home was registered for older people only. However, the home had service users’ with dementia and needed to apply to the commission for varying the conditions of registration. Clare Hammond, Occupational therapist standard 22 environment assessment report recommended handrails and toilet support rails which needed adjustment. The deputy manager had agreed to do a status report and send across to the commission detailing the recommendations and their implementations. 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.V297573.R01.S.doc Version 5.2 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.V297573.R01.S.doc Version 5.2 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, 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had appropriate arrangements to complete preadmission process that enable the prospective service users’ to make a choice of home which will meet their needs. EVIDENCE: The home had admitted two new service users’ on 31/05/06. Based on the temporary care plan and risk assessment that was prepared by the social services, The home had prepared a temporary care plan, signed by deputy manager and acting manager. Both the service users’ were considered for respite initially for two weeks. Because of their incompatible home situations, the two service users’ may stay longer at the home. Pre-admission assessments and temporary care plans that were prepared and signed by both the manager and deputy manager need to be transferred on to the preadmission format. Staff member on duty had said that a service user has higher needs and require continuous monitoring. Edwardian Care Home DS0000037799.V297573.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All the service users’ have care plans. Evidence of updating information and changing actions do not appear on all care plans. All the completed care plans were comprehensive and have detailed service users’ needs and activities to be actioned. EVIDENCE: 6 service users’ were case tracked during this inspection and their outcomes are as follows; service user – 1 had care plan, assessment of need, monthly reviews carried out by the home, GP & hospital notes written, risk assessments daily record sheet were available. However, there were no reviews carried out by the social services. Service user – 2 had need assessment, care plan, monthly reviews carried out by the home, client’s property not available, risk assessments and daily records were maintained. However, there were no reviews carried out by the social services. Service user – 3 care plan, risk assessment, and need assessment, monthly reviews carried out by the home, client’s property no information. However, there were no reviews carried out by the social services. Service user - 4 care plan, risk assessments, need assessments, monthly reviews carried out by the home, GP visits no information, daily record notes were written. However, there were no reviews Edwardian Care Home DS0000037799.V297573.R01.S.doc Version 5.2 Page 10 carried out by the social services. Service user - 5 care plan, risk assessments, needs assessments – mobility, speech, hearing, sight, communication, washing, bathing, oral health, feeding, dietary preferences, toileting, bowel/bladder, dressing, manual dexterity, feet, personality, mental condition, memory loss, depression and other, monthly reviews carried out by the home, GP visits no information, daily records notes written. However, there were no reviews carried out by the social services. Service user – 6 had care plans, assessment of need, monthly reviews carried out by the home, GP & hospital notes written, risk assessments daily record sheet were available. However, there were no reviews carried out by the social services. Medication policy had been reviewed in March 2006 and updated based on the requirements of National care standards and Royal Pharmaceutical Guidelines. The medication policy and procedures were comprehensive. Service users’ spoken to have expressed their satisfaction and have said that the staffs were cooperative and attend to them when required. The home had organised a visit of nutrition specialist in the month of May 2006 who provided literature with regard to nutritional assessment tool and explained how to use the same. 10 staffs members have had the opportunity to attend the same. The home now had prepared plans to use the nutritional risk assessment tool as part of their risk assessment and care planning process. Edwardian Care Home DS0000037799.V297573.R01.S.doc Version 5.2 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): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had made appropriate arrangements to engage the service users’ in a variety of socioculturally relevant activities that match with the choice and needs of the service users’. EVIDENCE: The home had wide range of activities for the service users’. Such as visit to the garden centre, theatre, zoo, shopping centre, coffee shop, walk to the museum. The home also had craft based activities paper mashes, card, video afternoons and monthly communion. The home had organised Chiropodist visit every 6 to 8 weeks or as and when called, hairdresser once a fortnight. The theatre group visited twice after Christmas and performed sing song, Easter parade and entertainment for birthdays. The home had planned to take 4 service users’ for a weeklong holiday in coordination with sister home, and fashion show was due end of this month. 2 service users’ said they take active participation in the home’s garden work and enjoy doing the same. Edwardian Care Home DS0000037799.V297573.R01.S.doc Version 5.2 Page 12 Edwardian Care Home DS0000037799.V297573.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had a robust complaints policy and procedure. The home’s complaint’s procedures were appropriately applied when service users’ make complaints. EVIDENCE: The home had a robust complaint policy and procedures. The home’s complaints policy and procedures was available for residents, their representatives. The manager had taken appropriate measure in line with the home’s complaints policy and procedure, on a complaint that was made by a service user about a staff member regarding the treatment she was meted. The staff member was no longer working at the home and the home had no contact from her since February 2006. The complaints made by the service users’ were actioned by the management of the home. Edwardian Care Home DS0000037799.V297573.R01.S.doc Version 5.2 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): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable environment. It had rolling programmes to improve the decoration, fixtures and fittings. EVIDENCE: The home was clean, tidy and there were no offensive odours. However, the carpets needed shampooing /cleaning and some place replacement. The home had the services of a maintenance person who works three days a week and was available whenever there was a need at the home. A record of things to do was maintained for the maintenance person to attend. New gates have been ordered for the car park. Hot water temperatures checks were conducted once a week and the records were maintained. The home had a contract with the pest prevention services, which visit twice a year to check and fix any problems and also visit when required by the home. Edwardian Care Home DS0000037799.V297573.R01.S.doc Version 5.2 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): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had a good mix of staffs with relevant skills. The staffs were provided with appropriate training to meet the assessed needs of the service users’. The staff records were updated and systematically organised. EVIDENCE: The home had carried out staffs training needs assessment and had prepared a training calendar to implement the same. The trainings scheduled for the months of June and July 2006 include Dementia awareness, first aid, POVA, manual handling, medicines in the care home, bereavement awareness and food hygiene. The home currently had 26 employees on the rolls and as per the staff checklist provided on this inspection 1 staff member’s CRB was awaiting, 4 staff members had 1 reference and all the staff had contracts. On a random sample 6 staffs document were reviewed and the outcomes are as follows: staff member – 1 CRB report awaited, staff supervision needed signature of employee, staff member – 2 had her CRB on 13/3/06, had contract, staff supervision held on 12/04/06 both signed. Staff member – 3 had CRB, contract, and staff supervision both signed, staff appraisal carried out. Staff member – 4 had CRB, contract, staff supervision, staff appraisals carried out. Staff member – 5 had CRB and contract. Two new staff members have been appointed recently and have got CRB, references and qualifications. Staff Edwardian Care Home DS0000037799.V297573.R01.S.doc Version 5.2 Page 16 deployment records were maintained and the home had good mix of staff on duty. Two staff members were seen assisting a service user in getting her on a wheel chair and the staffs were advised by the deputy manager on duty the appropriate usage of footrest of the wheel chair. Discussions were held with 3 staffs on duty and the outcome is as follows: staff member – 1 working as a senior carer since one year and enjoys working. The challenges are just to carryon especially, when some body is ill get an ambulance. Whilst the day-to-day responsibilities include washing service users’, shaving, clean glasses, medication, take service users’ to toilet, change their pads, and give fluid, assist in bathing. The training received are moving and handling, dementia, had NVQ2, going to start NVQ3. Had supervision with the deputy manager 3 weeks ago. Said that, the new manager had brought some positive changes in the home and they are working. Staff member – 2 working as care assistant since just short of an year, doing nvq2 at the moment, training received first aid, moving and handling, medication, pova. Staff member said, we all work as team and service users’ get what they need. There is nothing that the staff member can suggest to improve the service delivery. Staff member – 3 working at the home since 9 months as care worker. The responsibilities include serving tea, dressing the bed, toiletry, bathing, take service users’ for walks, training received in manual handling and moving, pova, doing NVQ1. Need more training in especially a good induction about how to work with older people with dementia. Had supervision meeting every 4 weeks with senior staff and manager. Edwardian Care Home DS0000037799.V297573.R01.S.doc Version 5.2 Page 17 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, 35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The current manager had initiated various measures to meet the needs of the service users’ and help train the staffs to update their skills to meet the growing needs of the service users’. The manager and the staffs work as a team. EVIDENCE: The current manager had taken appropriate measures to meet some of the outstanding requirements and recommendations, please refer for details under various outcome groups. The home had introduced a new service users’ financial management recording system, which had provision for service users’ or their representatives’ signature. However, all service users or their representatives need to counter sign the withdrawals. Two staff members also sign the receipts and withdrawals and the receipts were obtained from hairdressers and chiropody treatment personnel. The deputy manager had Edwardian Care Home DS0000037799.V297573.R01.S.doc Version 5.2 Page 18 agreed to get the signature of all transactions by the concerned service users, or their representatives. The care documents filing system reviewed and very systematically organised with colour folders, content page and dividers. At present, the home do not have a registered manager, the provider had short-listed a candidate and are awaiting 2nd reference for the appointment of the manager. The current manager had tendered her resignation. The home had carried out service users survey and had received good response. However, the home need to do the analysis of the survey and action the recommendations made. The home was registered for older people only. However, the home had service users’ with dementia and the conditions of registration need to be changed. Clare Hammond, Occupational therapist standard 22 environment assessment report recommended handrails and toilet support rails which needed adjustment. The deputy manager had agreed to do a status report and send across to the commission detailing the recommendations and their implementations. Edwardian Care Home DS0000037799.V297573.R01.S.doc Version 5.2 Page 19 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 2 X X 2 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Edwardian Care Home DS0000037799.V297573.R01.S.doc Version 5.2 Page 20 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 OP7 Regulation 15(1)(2) schedule 3(1)(b) Requirement The home must ensure all care plans are generated and drawn up in consultation with the service user or their representatives (previous time scales 31/01/06 and 30/04/06 not met time scales extended). 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 (Previous time scale 31/03/06 not met time scale extended). Timescale for action 15/07/06 2. OP8 14(1)(a) (2) 15/07/06 3. OP31 9(1)(2)(b) 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 (Previous timescales 30/04/06 not met time scale extended). 9 The home must appoint a registered manager to run the DS0000037799.V297573.R01.S.doc 01/07/06 4. OP31 30/07/06 Edwardian Care Home Version 5.2 Page 21 home and meet its stated purpose, aims and objectives (Previous time scale 30/04/06 not met timescale extended) 5. 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. 30/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Edwardian Care Home DS0000037799.V297573.R01.S.doc Version 5.2 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. Extracts may not be used or reproduced without the express permission of CSCI Edwardian Care Home DS0000037799.V297573.R01.S.doc Version 5.2 Page 23 - 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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