This inspection was carried out on 30th March 2009.
CSCI found this care home to be providing an Adequate service.
The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.
Inspecting for better lives Random inspection report
Care homes for older people
Name: Address: Edwardian Care Home 168/170 Biscot Road Luton LU3 1AX one star adequate service The quality rating for this care home is: The rating was made on: 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. This is a report of a random inspection of this care home. A random inspection is a short, focussed inspection. Details of how to get other inspection reports for this care home, including the last key inspection report, can be found on the last page of this report. Lead inspector: Sally Snelson Date: 3 0 0 3 2 0 0 9 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 Conditions of registration: 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 Care Homes for Older People Page 2 of 10 Brief description of the care home 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. Care Homes for Older People Page 3 of 10 What we found:
On the morning of 30/03/2009 we received a phone message from immigration, advising us that they had met with the manager of the Edwardian, Sandra Mahlangu, on 12.03.09 and told her that she did not have the relevant papers to be living and working in the UK and was therefore considered an illegal immigrant. She was asked to send in her paperwork and advise the owner of the situation. Immigration advised us that they had not heard from her since and did not know if she remained employed. At 15.40 hours Sally Snelson and Louise Trainor (regulation inspectors) arrived at the Edwardian. We spoke to the manager about the situation and she told us that she believed that she had been given until April to contact immigration. She said she had written to immigration and explained that her circumstances had changed. She said she had made a new application for a work permit. We asked her what she had done when her last permit had expired. 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. She was, and had been, employed to work full-time for a number of years. The Responsible individual (RI) for the home, Mr S Hussain, was on the last day of annual leave. The manager contacted Mr I Hussain who is part owner of the home, but not the RI. He said the manager had mentioned something about a visit from immigration to him, but he believed she was sorting it out. When advised of the current situation Mr I Hussain asked the manager to leave the premises. He showed an understanding of employment law and worked with us to look at the staff files of those staff on duty at the time, and those who would be on duty overnight. 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 one week who had a work permit that ran out at the end of her probationary period. Some staff were 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. The home would be asked to submit a new duty rota when all the files had been reviewed. What the care home does well: What they could do better:
As already detailed the service must ensure that they follow robust recruitment procedures. Care Homes for Older People
Page 4 of 10 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 2. Care Homes for Older People Page 5 of 10 Are there any outstanding requirements from the last inspection? Yes R No £ 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, Regulations 2001 and the National Minimum Standards.
No. Standard Regulation Requirement Timescale for action 1 3 14 A comprehensive assessment 27/06/2008 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 7 15 A care plan must be in place 27/06/2008 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 3 9 13(2), 17(1) Medication systems and 27/06/2008 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.
Page 6 of 10 Care Homes for Older People 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, Regulations 2001 and the National Minimum Standards.
No. Standard Regulation Requirement Timescale for action This requirement is almost met but is re-stated. Previous time-scale 01/04/08. 4 12 16(2) There must be activities 15/08/2008 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. 18/07/2008 5 18 37 6 19 16(1) The carpeting which is 15/08/2008 heavily stained must be replaced to provide a suitable environment for people to live in. This requirement is restated. Previous time-scale 01/04/08. 7 27 18(1) 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. 01/09/2008 8 33 24 (1) (2) (3) The home must evidence 01/09/2008 effective quality assurance and quality monitoring systems and must have an annual development plan for
Page 7 of 10 Care Homes for Older People 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, Regulations 2001 and the National Minimum Standards.
No. Standard Regulation Requirement Timescale for action the home, based on a systematic cycle of planning - action - review - reflecting aims and outcomes for service users. 9 36 18(2) All staff working at the home 27/06/2008 must be supervised at least six times a year. This requirement is restated. Previous time-scale 01/04/08. 10 38 12(1) There must be documentation to support what has been done when health and safety checks indicates a deviation. 18/07/2008 Care Homes for Older People Page 8 of 10 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 1 29 19 That all staff on duty and 04/04/2009 employed by the home must have documentation that validates their permission to work. they must also have the correct pre-employment screens. This ensures that residents are kept safe. Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, 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 Recommendations 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 Care Homes for Older People Page 9 of 10 Reader Information
Document Purpose: Author: Audience: Further copies from: Inspection Report CSCI General Public 0870 240 7535 (telephone order line) Our duty to regulate social care services is set out in the Care Standards Act 2000. Copies of the National Minimum Standards –Care Homes for Older People can be found at www.dh.gov.uk or got 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 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 10 of 10 - 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!
