Inspection on 27/06/08 for Edwardian Care Home

This inspection was carried out on 27th June 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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 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 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Edwardian Care Home 168/170 Biscot Road Luton LU3 1AX Lead Inspector Sally Snelson Unannounced Inspection 27th June 2008 07:30 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.V367362.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.V367362.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Edwardian Care Home Address 168/170 Biscot Road Luton LU3 1AX Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01582 705100 01582 705106 edwardian170@yahoo.co.uk The Edwardian Care Home Ltd Care Home 30 Category(ies) of Dementia - over 65 years of age (12), Old age, registration, with number not falling within any other category (30) of places Edwardian Care Home DS0000037799.V367362.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 named person above the age of 60 years Date of last inspection Brief Description of the Service: The Edwardian is a purpose built care home that provides single room accommodation for 30 people over 65 years of age including those who have dementia and/or physical disabilities. The home is on a busy road, which is a short car or bus ride away from Luton Town Centre. Accommodation for people using the service is on the ground and first floor with a further third floor that accommodates administrative and staffing offices. Access to all floors is via staircases and a shaft lift. The home borders straight onto the pavement area of the street with a small ornamental garden to one side that is not suitable for recreational purposes. A small patio area with summertime pagoda and garden furniture is situated to the rear of the building, as is car parking. The manager told us that fees were under review, as the home was not accepting admissions, but were in the region of £450-£550 depending on the assessed needs and the room occupied. Edwardian Care Home DS0000037799.V367362.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection was carried out in accordance with the Commission for Social Care Inspection’s (CSCI) policy and methodologies, which requires review of the key standards for the provision of a care home for older people that takes account of residents’ views and information received about the service since the last inspection. Evidence used and judgements made within the main body of the report include information from this visit. The inspection of The Edwardian was a key inspection, was unannounced and took place over four hours on the 27th June 2008. Two inspectors Sally Snelson lead inspector, and Louise Trainor undertook the inspection, so in effect it was an eight hour inspection as each inspector looked at various aspects of the home and came together to give the feed-back. The manager Sandra Mahlangu, who had been in post two months was present for the majority of the inspection, and one of the providers, Mr I Hussain, also met with us. During the inspection we case tracked the care of two people who used, or had used the service (residents). 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 judgement about the service. We had not requested an Annual Quality Assessment Audit (AQAA) since the last inspection. Because previous inspections had indicated that there were poor outcomes for people living at the home and there had been a number of safeguarding referrals, the Local Authority had imposed an admission embargo on the home over the last months. At the time of the inspection only 15 of the 30 beds were occupied. At this inspection we found that the new manager had worked hard to make many improvements and was working towards meeting all the requirements. Where requirements were repeated from previous inspection reports the date of the inspection was given as the date for compliance, as a new date cannot Edwardian Care Home DS0000037799.V367362.R01.S.doc Version 5.2 Page 6 be given to an exsisting requirement. When it was not possible to assess a requirement the date of the inspection was also given to this repeated requirement. However, given the improvements so far, and that the new manager has only been in post a few weeks, we are taking a proportionate view and extending the timescale of requirements and not moving to enforcement. However, any further failure to comply will result in enforcement action following the next inspection. The inspector would like to thank all those involved in the inspection for their input and support. What the service does well: What has improved since the last inspection? There had been a number of changes since the last inspection, most significantly a new manager who had a good relationship with the staff team and was committed to making the necessary improvements to the home. All of the people living at the Edwardian had the same type of care plan which detailed the care they needed and if used correctly prompted staff as to the risk they needed to look for. The new care plans included a lot of information about the types of interests the residents had and what they would enjoy doing. Edwardian Care Home DS0000037799.V367362.R01.S.doc Version 5.2 Page 7 Staff were observed to speak to and about residents in a manner that respected their privacy and dignity. New staff were being recruited correctly and all the necessary checks were done before they started work. There was suitable operational laundry equipment in the home and the laundry person had a back-up plan if a machine failed. On the whole we were pleased with the changes we saw at the home and the plans for the future. We were aware that some other professionals still had concerns but we saw enough improvements to make the judgement that the outcomes for the people at the home had improved from poor to adequate overall. What they could do better: There were a number of requirements made as a result of this inspection but we also saw a number of areas of improvement. Some areas that still need to be improved are:A comprehensive assessment must be undertaken prior to the admission of any person to ensure there is sufficient information to ascertain if staff at the home are suitably qualified and competent to meet the needs of the person. A care plan must be in place for each assessed need for every person, which provides sufficient guidance to staff to ensure continuity of care is provided. Medication systems and training must be sufficient to ensure safe recording, handling and administration of medication. This is to ensure effective auditing can take place and people receive their medication when required. There must be activities arranged for the people living at the home who are less able. All incidents of injury that required medical attention must be reported to the commission. The carpeting which is heavily stained must be replaced to provide a suitable environment for people to live in. There must be a training matrix in place that ensures that the staff team have the necessary skills and qualifications to meet the needs of the people living at the home. Edwardian Care Home DS0000037799.V367362.R01.S.doc Version 5.2 Page 8 The home must evidence effective quality assurance and quality monitoring systems and must have an annual development plan for the home, based on a systematic cycle of planning - action - review - reflecting aims and outcomes for service users. All staff working at the home must be supervised at least six times a year. There must be documentation to support what has been done when a health and safety checks indicates a deviation. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Edwardian Care Home DS0000037799.V367362.R01.S.doc Version 5.2 Page 9 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.V367362.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,6. People who use this service experience adequate quality outcomes in this area. The written process for admissions was correct and would offer potential residents the chance to visit the home in advance of an admission in order to allow an informed decision to be made. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The manager had updated the Service Users Guide and was working on the Statement of Purpose. She now needs to check that the documents contained all the information required by standard 4 and 5 and schedule 1 of the National Minimum Standards, and that the information was written in sufficient detail to describe the service and was up-to-date. She was aware that these Edwardian Care Home DS0000037799.V367362.R01.S.doc Version 5.2 Page 11 documents needed to be correct and in place once the embargo was lifted so they could be given to potential residents. Because there had been an embargo on the home taking in new admissions it was not possible to assess the current admission processes. However, the manager was able to talk us through how she would assess and admit a prospective resident. The requirement relating to admission assessments will remain in place until we inspect when the home have had an admission, and we can confirm the pre-admission assessments are correct. The home did not offer intermediate care. Edwardian Care Home DS0000037799.V367362.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 10 People who use this service experience adequate quality outcomes in this area. The system that had been introduced to document the care that was needed and given to people living at the home (care plans) was written in sufficient detail to ensure consistent care was given. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Since the last inspection the home had completely introduced a new care planning system. The system was a booklet that outlined the questions that needed to be answered in order to assess the care that needed to be provided. These systems were in place for all the residents, and by transferring details from one system to another staff had had to rewrite care needs and had used this time to ensure that they had all the documents they should have. Edwardian Care Home DS0000037799.V367362.R01.S.doc Version 5.2 Page 13 During the inspection we tracked the care of two people, one who had recently been discharged to home, and one who had been poorly during the night and taken to hospital. Both plans had been sympathetically written in a person centred style, taking account of information provided by families and friends. For example, comments such as **(residents name) will get up when ready and come into the lounge for breakfast when ready, gave clear instructions to the care staff. In addition to care needs the booklet included the persons essential information, such as contact details of family, and the telephone numbers of the health professional involved in their care. It also asked about previous medical conditions, interests and hobbies. When the care plans had been written they were reviewed monthly and the staff were guided on to identify risks and how these should be addressed. For example the mobility care plan described how the person moved around the home and included links to a moving and handling assessment and an assessment of tissue viability. The manager told us that an occupational therapist had been employed to assess the moving and handling needs of all the residents and that every resident had been issued with their own sling to be used with a specific hoist. Some visiting professionals told us that they had recently identified some areas of care for a person that did not have a care plan. They had discussed this with the manager who agreed that there had been an omission. Families had been involved in writing the risk assessments and helping to make decisions, such as whether a person could have a key to their bedroom door. Community nurses including specialist nurses such as diabetic nurses are frequent visitors to the home and available, if requested, to offer advice and support. We witnesses a medication round and then reconciled the medications held in the home. This meant that we counted how many tablets were recorded as being given, how many had arrived at the home and checked that the amount left in blisters, boxes and bottles were correct. All we sampled were correct, except where the prescription stated that one or two tablets could be given, as the staff did not detail how many they had been given, making reconciliation impossible. The manager must ensure that all staff write on the back of the Medication Administration Record (MAR) sheet when medicines are refused, given as required (one-off doses) or discarded for some reason. One person who attends a day centre takes her medication with her this should be recorded on the sheet, as staff have not witnessed her taking it, but it is no longer in the home. Edwardian Care Home DS0000037799.V367362.R01.S.doc Version 5.2 Page 14 Staff were observed to be relaxed and attentive with the people they were caring for. We did not observe personal care being provided without consideration being given to the person’s privacy and dignity. Residents were wearing their own clothes and appeared well presented. Most resident spoke positively about the staff and the care provided, one said, “Its brilliant here, everything’s provided I have not looked back”. Edwardian Care Home DS0000037799.V367362.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 People who use this service experience adequate quality outcomes in this area. Those people living at the home that were able to move around, make decisions, and speak, would be able to join in the activities provided, but for those that were less able there was little stimulation. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Staff reported that as there were a reduced number of people in the home they were able to arrange more trips out and visits for those that wanted it. At least one of the people living at the Edwardian attended a day centre regularly. There was an activity programme displayed which included a variety of different activities including jigsaws, dominoes, arts and crafts, DVD, music, knitting, manicures, reading and newspapers, yoga, an outing at least monthly and a residents meeting. Edwardian Care Home DS0000037799.V367362.R01.S.doc Version 5.2 Page 16 One carer told us that she had taken two people out for lunch the day before, she said, ‘when you take them out they come to life, I love to see the residents happy’, indicating that she could see the importance of taking some people out of the home occasionally. The design of the home was such that people could meet with relatives or friends in their bedroom, or in one of the communal areas. The new care plans included a lot of detail on peoples past hobbies and interests. This needed to be built upon to show what staff were doing to keep these interests going and how activities were impacting on a persons life in the home. We had received one ‘Have your say about …..questionnaire from a relative who reported always being welcomed into the home, but did criticize the amount of activities provided. The manager was keeping a separate activity log, in which staff recorded exactly what each resident did every day. This needed to be expanded to indicate how people had reacted to a specific activity and show that the relevant activities were provided for those people with a diagnosis of dementia. Every person living in the Edwardian told us that they enjoyed the food. The cook had recently left but a new one had been appointed and was due to start the Monday following the inspection. We witnessed seven people having breakfast either at tables in the lounge/diner, or in their comfortable chairs in that room. Other people were having their breakfast in their bedrooms. Breakfast was cereal, porridge or toast and people were offered a choice of hot or cold milk to put on their cereal, and what they wanted to drink. However everyone was given their toast buttered and we did see some residents who would be quite capable of doing this for themselves and maintain as much independence as possible. There were no condiments on the table. The home had a four-week menu that included a good choice at each mealtime, such as on one day the opportunity to choose from lamb chops, sausages or cheese and onion pasties. The carer that had temporarily taken over the position of cook told us that she made a soup every day, which was very popular at teatime. Another favourite amongst the residents was a pudding such as steamed roly-poly and custard. However a survey suggested that the food could get monotonous with yoghurt appearing regularly. People were officered frequent drinks and cold drinks were available in the lounge areas. Edwardian Care Home DS0000037799.V367362.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 People who use this service experience adequate quality outcomes in this area. The policies and procedures relating to the handling of complaints were very clear and easy to understand and people at the home and visitors confirmed that they knew how to make a complaint. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: There was a complaints procedure for the home and the manager informed us that there had not been any complaints made to or about the home since the last inspection (4 months ago). A relative who completed a survey indicated that they were aware of whom to complain to. A member of staff told us that the new manager ‘listens to us and changes things that are not right’. This was particularly important to many of the staff who had reported incidents to the previous manager and not seen anything done about them and could have stopped reporting. Since the last inspection there had been three referrals to the safeguarding team (SOVA) about bruises or cuts that had been seen on people and the exact cause was unknown. Two of the reports had been made by visiting Edwardian Care Home DS0000037799.V367362.R01.S.doc Version 5.2 Page 18 district nurses, but in one case the bruising had been noted by the home prior to the referral. However we were aware of an incident that had not been referred to us. One of the directors while auditing the service felt that it was acceptable because of the nature and circumstances of the incident. This is not so as the guidance on our professional website states, Any serious injury to a person who uses the service such as:•The development of a pressure sore of grade 2 or above. •A serious injury that results in a consultation with a medical practitioner. •Self-harm not already anticipated in the person’s care plan must be reported. This incident fitted into one of the above categories. The accident book was used appropriately and the manager was regularly auditing it to identify any obvious trends or patterns in the accidents and incidents in the home. Edwardian Care Home DS0000037799.V367362.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 People who use this service experience adequate quality outcomes in this area. The home was clean and tidy, but people living at the home could feel cramped and confused as they were all living on one floor after being used to more space. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Since the last inspection the ground floor of the home had been closed and all the service users had bedrooms, and used the communal rooms, on the first floor. This had been agreed in advance with the people living at the home and/or their families. This was a temporary measure while the home was Edwardian Care Home DS0000037799.V367362.R01.S.doc Version 5.2 Page 20 functioning with only half the usual amount of service users. The reason behind the decision to care for everyone on one floor could be understood however, it was not risk assessed in enough detail to show that it was in the best interest of the people living at the home, particularly those with dementia. One accident may have been as a result of a person becoming disorientated in their new bedroom that was laid out differently from their original one. The owners had taken the opportunity to make some environmental changes. A bathroom that could not be used by many of the people living at the Edwardian had been taken out and replaced with a walk-in shower. We noted that the carpet in upstairs lounge was stained but did not have any odour. The manager told us that it had been cleaned twice recently but the stain would not come out. A tour of the building indicated the people living at the home had the opportunity to personalise their bedrooms. There were also picture notices on doors to indicate what the room was used for such as a bath on the bathroom door. However it could be confusing for those people with dementia to see Laundry baskets stored in bath. Since the last inspection the home had new laundry equipment and also had a back-up washing machine to use if the original went wrong. Edwardian Care Home DS0000037799.V367362.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 People who use this service experience adequate quality outcomes in this area. If the manager continues to show a commitment to staff training, there will be evidence that the staff team have the skills, training and experience to care for the people living at The Edwardian. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The manager reported that some staff had resigned when she had first started at the home but because of the low number of people living at the home she had sufficient staff to cover the care needs. There were three care staff, plus the manager a cook and a cleaner on duty during the inspection. We were reassured that the manager had ensured that at least one member of staff on duty over-night had an NVQ and had completed medication training. In the past an on-call member of staff had had to be called if a person needed medication. Edwardian Care Home DS0000037799.V367362.R01.S.doc Version 5.2 Page 22 The manager had also begun to look at what training staff had done, who needed additional training, and what training needed to be revisited. We discussed with the manager the need to have a system that easily identified staff training needs. Since taking up the post the manager had organised training in report writing, medication, dementia, mental health, fire awareness and the Protection Of Vulnerable Adults (POVA) awareness for staff to participate in during June and July. She had linked the training plan to the needs of the people living at the Edwardian. We also noted that an NVQ assessor was due to visit staff. A member of staff who found studying and learning difficult told us that with support she had had a lot of training and was currently doing an NVQ level 3. Duty rotas were in place and been completed well in advance but they did not indicate who was the shift leader in the absence of the manager. The manager also kept an allocation book that documented who was detailed to work with what resident and in what capacity each day. The manager had audited the staff files and was able to show us the file she had prepared for the new cook who was due to start. It had all the necessary documentation and clearance checks to ensure that the person was suitable to work with vulnerable people. A contract of terms and conditions and a job description was in place to be completed on the first day. Edwardian Care Home DS0000037799.V367362.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38 People who use this service experience adequate quality outcomes in this area. The manager demonstrated a commitment to leading the team forward and staff, service users, and visitors were aware of the improvements she has made in the short time she has been managing the home. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Recent review notes included a comment from a relative, ‘the new manager is great, we feel we can go to her with any problems’, and from a professional, Edwardian Care Home DS0000037799.V367362.R01.S.doc Version 5.2 Page 24 ‘she is doing a good job’, a member of staff told us ‘she will come down heavy on us, but in a nice way, we love it’. The manager had been a deputy and had been in post for two months at the time of the inspection. She told us that that she was enjoying the challenge but at times had thought of giving up as there was so much to do. She had registered to do the Registered Managers Award (RMA) and must now make a registration with us to become the registered manager. The manager was aware of the need to quality assure the service by sending out questionnaires to stakeholders and using these to plan and change things in the home. She also needed to write a report following this process. Following the last inspection we had required the proprietor to complete a monthly report, (known as a Regulation 26 report) which would also assist the manager in planning services. The proprietor had given this responsibility to another of the directors who had produced a written report in a timely fashion. We must now see this continue and see the information in it shared with the manager, so that improvements can be made. The manager was grateful for the support she received from meeting with other managers in the company. The home only held monies on behalf of a few service users. We looked to check that there was a true record and receipts held for the person who went out to lunch the day before. These were all in place. Staff supervision over the past two years had been extremely ad-hoc. The manager had made a plan, that if kept to, would ensure that staff were supervised the required six times a year. Since the manager had been in post there was evidence that health and safety checks were being carried out. However we were unsure what was being done to minimise the risk where water temperatures were recorded as being over 43 degrees at source. The manager seemed to have confused the need to store water in excess of 60 degrees to prevent Legionella and the temperature that would ensure people were not scaled. Edwardian Care Home DS0000037799.V367362.R01.S.doc Version 5.2 Page 25 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 2 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 2 X 2 Edwardian Care Home DS0000037799.V367362.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14 Requirement A comprehensive assessment must be undertaken prior to the admission of any person to ensure there is sufficient information to ascertain if staff at the home are suitably qualified and competent to meet the needs of the person. This requirement could not be assessed. Previous timescale 01/04/08 2 OP7 15 A care plan must be in place for each assessed need for every person, which provides sufficient guidance to staff to ensure continuity of care is provided. This requirement is almost met but is re-stated. Previous time-scale 01/04/08 Medication systems and training must be sufficient to ensure safe recording, handling and administration of medication. This is to ensure effective auditing can take place and people receive their medication DS0000037799.V367362.R01.S.doc Timescale for action 27/06/08 27/06/08 3 OP9 13(2), 17(1) 27/06/08 Edwardian Care Home Version 5.2 Page 27 when required. This requirement is almost met but is re-stated. Previous time-scale 01/04/08. There must be activities arranged for the people living at the home who are less able. All incidents of injury that requires medical attention must be reported to the commission. The carpeting which is heavily stained must be replaced to provide a suitable environment for people to live in. 4 5 OP12 OP18 16(2) 37 15/08/08 18/07/08 6 OP19 16(1) 15/08/08 7 OP27 18(1) 8 OP33 24 (1) (2) (3) 9. OP36 18(2) This requirement is re-stated. Previous time-scale 01/04/08. There must be a training matrix 01/09/08 in place that ensures that the staff team have the necessary skills and qualifications to meet the needs of the people living at the home. The home must evidence 01/09/08 effective quality assurance and quality monitoring systems and must have an annual development plan for the home, based on a systematic cycle of planning - action - review reflecting aims and outcomes for service users. All staff working at the home 27/06/08 must be supervised at least six times a year. This requirement is re-stated. Previous time-scale 01/04/08. 10 OP38 12(1) There must be documentation to support what has been done when health and safety checks indicates a deviation. DS0000037799.V367362.R01.S.doc 18/07/08 Edwardian Care Home Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP1 OP14 OP19 Good Practice Recommendations The Statement of Purpose should be updated to reflect the recent changes. Service users must be given the opportunities to live as independently as possible. Care should be taken when making environmental changes that all those living at the home can cope and will be safe in a new environment. The need for any additional support to manage change should be clearly documented. The manager should ensure that all original files indicate that staff have been correctly checked to work with vulnerable people. The manager should look to becoming the registered manager as soon as possible. The regulation 26 visits should be more detailed and provide the manager with a report and useful information about the owners views on how the home is conducted. 4 5 OP29 OP31 3. OP33 Edwardian Care Home DS0000037799.V367362.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Edwardian Care Home DS0000037799.V367362.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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