This inspection was carried out on 3rd November 2005.
CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 made no statutory requirements on the home as a result of this inspection
and there were no outstanding actions from the previous inspection report.
CARE HOMES FOR OLDER PEOPLE
Edwardian Care Home 168/170 Biscot Road Luton LU3 1AX Lead Inspector
Mr Pursotamraj Hirekar Unannounced Inspection 3rd November 2005 08:30 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.V276860.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Edwardian Care Home DS0000037799.V276860.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Edwardian Care Home Address 168/170 Biscot Road Luton LU3 1AX Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01582 705100 01582 705100 The Edwardian Care Home Ltd Mrs Mary Ainsbury Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Edwardian Care Home DS0000037799.V276860.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 23rd August 2004 Brief Description of the Service: The Edwardian was a purpose built residential home that provided single room accommodation for 30 older people including those who had dementia and/or physical disabilities that would be met within the registration for older persons. The home was located on a busy thoroughfare, which was a short car or bus ride away from Luton Town Centre. The home had been suitably adapted to meet service users’ assessed needs. At this inspection the accommodation for the service users was arranged on the ground and the first floor with a further third floor that accommodated administrative and staffing offices. Access to all floors was via staircases and a shaft lift. The bedrooms were arranged on the ground and first floor of the house. They were pleasantly decorated, each fitted with a hand washbasin, call system and TV point. Communal facilities were a lounge/diner on both floors and sufficient bathing and toilet facilities for convenient access. The home bordered straight onto the pavement area of the street with a small ornamental garden to one side that was not suitable for recreational purposes. A small patio area with summertime pagoda and garden furniture for the use of the service users was situated to the rear of the building, as was car parking for several vehicles. Edwardian Care Home DS0000037799.V276860.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Mrs. L. Milton and Mr. P. Hirekar carried out this unannounced inspection between 08.30 and 15.40 hours on 3rd November 2005. The acting manager was present throughout. The methods of inspection included a review of the service user’s care plans of the arrangements for their care and their private accommodation, communal lounge, dinning, toilet and bathing facilities. Conversations took place with four service users, a visitor, two members of staff and the acting manager. Records relevant to the operation of the home were also studied. What the service does well: What has improved since the last inspection? What they could do better:
The home must ensure to undertake its own assessment of need to determine that it had the ability to properly care for the service user prior to their admission. They must update all personnel records with accurate information to avoid misleading any stakeholder. The home must have a registered manager to ensure the continuity of good management and adherence to the care standards in the best interest of service users. Edwardian Care Home DS0000037799.V276860.R01.S.doc Version 5.1 Page 6 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.V276860.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Edwardian Care Home DS0000037799.V276860.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Service users and, where appropriate, their representatives had been provided with sufficient information to enable them to make an informed decision about moving into the home, with one exception. The home had not ensured in all instances that it had the capability to meet the assessed needs of those moving into the home EVIDENCE: The statement of purpose had been reviewed in July 2005 and a guide that covered most of the elements required by the legislation. The service users’ guide had been reviewed annually. It was noted that the details of the acting manager were inaccurate in the statement of purpose in that she had already achieved an NVQ in care at level three. Such inaccurate information might mislead those seeking to choose this home. The care plans for two service users were assessed. One showed that an assessment of need had been obtained under the care management procedures of the placing authority. There are no records to identify that the
Edwardian Care Home DS0000037799.V276860.R01.S.doc Version 5.1 Page 9 home had carried out its own assessment of need to determine that it had the ability to care properly for the service user. Edwardian Care Home DS0000037799.V276860.R01.S.doc Version 5.1 Page 10 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): Service users, health care needs were fully met. There were insufficient written records about each service user’s needs and therefore a risk that some might be overlooked and remain unmet. EVIDENCE: The home does not have appropriate arrangements that new service users’ health care, physical and social care needs are set out in care plan. These shortfalls have the potential to place new service users at risk. The service user case-tracked had a care plan prepared by social services with details of their history, physical health, mental health, dementia, poor-short memory loss. This was dated 25th October 2005 and had been not signed by the service user or manager of home. The service user has expressed satisfaction with the care provided by the home. Whilst medication procedures were not assessed at this inspection it was noted that some personnel with the responsibility for administering medications had only received in-house training. Edwardian Care Home DS0000037799.V276860.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home had appropriate activities that meet the choice and needs of the service users. EVIDENCE: Service users were enjoying watching TV and chatting with other service users in the ground floor communal lounge. On the first floor communal lounge some service users were happily listening to music. A few slept in their armchairs. The home had displayed a weekly social activities programme, summer holidays, and annual fireworks. Service users spoken to confirmed that they had been able to maintain regular good relations with their relatives and children. Service users commented on the food and said how well it was and that they welcomed the daily choices offered. Dietary needs of service users were well catered for with a balanced and varied selection of food available that met their tastes and choices. Menus inspected were found to be balanced and varied and include special dietary needs. Members of the staff were seen to provide service users with appropriate support to take their meals. Service users responded well to the support they were given. Social activities were well managed, creative and provide a variety and interest.
Edwardian Care Home DS0000037799.V276860.R01.S.doc Version 5.1 Page 12 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home had a robust complaints system and procedure the service users felt confident that their views will be listened to and acted upon. Recruitment procedures were not sufficiently robust to ensure service users were protected from abuse. EVIDENCE: The home had a robust complaints system and procedure written in plain English, easy to read and understand. There were no records of complaints since the previous inspection. A service user and his son spoken to expressed their satisfaction with the home’s complaints system and procedure and have said they have no complaints to make. The acting manager was not sufficiently aware of the sequence for reporting allegations to other statutory authorities under the Adult Protection Procedures. Edwardian Care Home DS0000037799.V276860.R01.S.doc Version 5.1 Page 13 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): The home provided a clean, safe and well-maintained environment, which met service users needs, with the exception of privacy arrangements, where there were some shortfalls. EVIDENCE: The home provided a clean, safe and well-maintained environment, which met service users needs, with the exception of privacy arrangements, where there were some shortfalls. Edwardian Care Home DS0000037799.V276860.R01.S.doc Version 5.1 Page 14 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): The staff recruitment procedures do not provide enough safeguards to offer protection to service users living in the home. The members of staff on duty presented as skilled and committed to service users’ well being. EVIDENCE: The staff members on duty expressed satisfaction with their jobs. Service users spoken to said that they are happy with the conduct of staff and services they provide. Records also indicated that supervision and training for staff assessed were up to date and consistent with standard. Edwardian Care Home DS0000037799.V276860.R01.S.doc Version 5.1 Page 15 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): Recent management arrangements appeared not to have benefited the home. EVIDENCE: The registered manager had been transferred on a temporary basis to another home ten days prior to this inspection. The deputy had been appointed to the acting manager post. The acting manager has been in the current post for ten days. The personnel record of the acting manager did not provide evidence of her employment history and experience prior to joining the Edwardian. The acting manager is currently pursuing NVQ3 level training in care, early years care and education, play work and community work between from 11-08-05 to 14-04-06. The acting manager was not able to demonstrate her capacity in respect of reporting issues concerning protection of vulnerable adults services under the local authority procedures. Edwardian Care Home DS0000037799.V276860.R01.S.doc Version 5.1 Page 16 The manual of policies and procedures was comprehensive and had been reviewed on a regular basis. Appropriate measures were in place to monitor the quality of the service through informal consultation with service users and formally through the use of a questionnaire. Edwardian Care Home DS0000037799.V276860.R01.S.doc Version 5.1 Page 17 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 1 x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 1 3 3 2 x 3 x x x STAFFING Standard No Score 27 3 28 x 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 x 3 x x x 2 x Edwardian Care Home DS0000037799.V276860.R01.S.doc Version 5.1 Page 18 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 OP1 Regulation 14(1)(a) (b)(c) Requirement Timescale for action 10/12/05 2 OP7 15(1)(2) Sch3 (1)(b) 13 (6) 18(1)(a) (c)(i) 19(4)(c) sch 2 (7)(8) 9 3 OP18 The home must ensure there is appropriate consultation regarding the assessment with service users or their representatives The home must ensure care 31/01/06 plans are generated and drawn up in consultation with the service user or their representatives The home must ensure staff are 15/12/06 appropriately trained to prevent service users being placed at risk of harm or abuse The home should ensure any gaps in employment records are explored and that staff are satisfactorily checked on the POVA register The home must appoint a registered manager to run the home and meet its stated purpose, aims and objectives 31/01/06 4 OP29 5 OP31 15/12/05 Edwardian Care Home DS0000037799.V276860.R01.S.doc Version 5.1 Page 19 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 Refer to Standard OP21 OP37 Good Practice Recommendations The home should ensure the repair of the ground floor lavatory door lock The home should ensure all personnel records are up to date and are accurate Edwardian Care Home DS0000037799.V276860.R01.S.doc Version 5.1 Page 20 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
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