Inspection on 31/10/07 for Edwardian Care Home

This inspection was carried out on 31st October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Edwardian Care Home 168/170 Biscot Road Luton LU3 1AX Lead Inspector Katrina Derbyshire Unannounced Inspection 31st October 2007 11:15 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.V350288.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.V350288.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.V350288.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 9th May 2007 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. A copy of the statement of purpose including a copy of previous inspection reports is available at the home. The manager provided the following information on charges in October 2007. The fees for this home vary from £418.00 to £480.00 per week. Edwardian Care Home DS0000037799.V350288.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of this visit was to undertake a key inspection. This unannounced visit was carried out on 31st October 2007. The manager was present during the inspection. During the visit the communal areas of the home were seen alongside some of the individual accommodation. The inspector spent time with many of the people who live at the home in the first floor sitting area. The care of three people was examined. Information from the home had been provided and included documents relating to meals, staff training and activities to assist in assessing the outcomes within each standard. Evidence used and judgements made within the main body of the report include information from this visit, feedback from people who live at the home and the management’s submission of documentation. In addition staff views through returned surveys were also received. Observations of care practice and communication between the people living at the home and staff was also made at the inspection. The focus of this inspection was to look at the key standards and to follow up on previous requirements. What the service does well: What has improved since the last inspection? The manager had tried to analyse information from questionnaires that had been received from people living at the home and their relatives. Although this had not been done fully, she had tried to look at the information. It is important to do this because management need to know where they need to improve by listening to the views of the people living there. The manager has now introduced monitoring tools relating to the nutritional needs of the people living at the home, and if they are at risk of developing Edwardian Care Home DS0000037799.V350288.R01.S.doc Version 5.2 Page 6 pressure ulcers. This gives a score that alerts staff if someone needs additional support in these areas, for example if they would be at risk of losing weight. Staff should then know that a dietician would need to be called upon for help and guidance. What they could do better: 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.V350288.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.V350288.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The standard of pre admission information continues to be sufficient to provide people with information about services, however pre admission assessment remains inadequate to ensure staff have sufficient information to know if they will be able to meet the individual needs of the person. EVIDENCE: A copy of the statement of purpose and service user guide was examined. Information on staff, the environment and services available had been included in the document. During staff interviews it was confirmed that they were aware of the purpose of the document. Pre admission assessments of those people selected for case tracking were also examined. Information from the funding authority was also kept within the individual care folders of each person. The assessment undertaken by Edwardian Care Home DS0000037799.V350288.R01.S.doc Version 5.2 Page 9 personnel in the home was of a mixed standard. The assessment document for a person who had recently moved into the home was incomplete. The document had not been signed or dated, in addition sections had not been filled in and it did not make clear the individual needs of the person or was it directly linked to the care plans for that person. Intermediate care is not provided at the home. Edwardian Care Home DS0000037799.V350288.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Medication systems are not fully effective to ensure safe practice at all times. Care planning is not sufficient to ensure continuity of care for all those living at the home. EVIDENCE: Changes had been made since the previous inspection on how care documents were being stored and the format being used. All documents were now kept in individual folders. One document provided the template for assessment relating to the nutritional needs, risk of falls and tissue viability for the people living at the home. A score had been given that indicated the level of risk. It was noted however during the examination of staff files that many had undertaken training in the use of the MUST tool; yet this was not being used. The manager stated that she wasn’t sure why she had not implemented this. There was also Edwardian Care Home DS0000037799.V350288.R01.S.doc Version 5.2 Page 11 documentary evidence to show that people had been weighed on a monthly basis. At the front of the 3 folders examined there was a selection of sheets that were named summary care plans. All plans contained limited information and direction to staff to ensure continuity of care. In addition one person who had been identified as being at risk of falls had no plan in place for this. Several other assessed needs also had no plan for the remaining 2 people whose care was tracked. A discussion was held with the manager who felt the risk assessments were mainly the plan of care with the summary providing an overview the previous requirement remains. In addition the person whose care was being written about and planned had not signed the documents that were seen. Medication storage and stocks were examined. 5 medications were selected at random, 3 balances were noted to be correct as were the medication administration records relating to them. However the remaining 2 were incorrect. The stock balance of medication for one person was 10 tablets incorrect, within the current 28-day cycle. Although the cause of this figure had been based on labelling through a pharmacy error, staff had failed to identify this within their own medication procedures. In addition one person had been prescribed antibiotics the day prior to this visit, staff stated that the reason none had been given was as the medication had not been received until late. The medication record had been signed for the day of inspection, although the packet remained unopened. Through discussion with people living at the home, it was evidenced that in the main they felt staff treated them in a dignified way. One person said, “The staff on days are really good, helpful and kind”. However their views of the support that they received late evening were different one person said, “ l wait so long, l know they hear me but l just get left”. Edwardian Care Home DS0000037799.V350288.R01.S.doc Version 5.2 Page 12 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 good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. People living at this home feel that the choice of meals provided are sufficient to meet their tastes and preferences. EVIDENCE: People through discussion at this visit spoke of the activities available to them in the home one person commented “ We have a party on this Saturday, one of the girls is arranging it”. Staff were also interviewed and they confirmed that activities were available most days. Information supplied by the home to the Commission for Social Care Inspection showed that activities arranged in the home-included manicures, board games and quizzes. The Bedfordshire library service also visits the home. Several people during this inspection were seen to receive visitors; this was mainly those accommodated on the ground floor. Everyone spoken to confirmed they were able to receive visitors when they wished and many would chose to see them in the privacy of their own rooms. Entries were also seen within care records that demonstrated that the staff at the home would contact the nominated next of kin if there had been a change in their well being. Edwardian Care Home DS0000037799.V350288.R01.S.doc Version 5.2 Page 13 Options available to people in maintaining control, independence and choices in their lives included, choice of meals, voting, choice of clothing, access to a complaints procedure and access to community healthcare support. People living at the home and records confirmed that the choices associated with people’s daily lives were available to them whilst living there. At this visit a choice was available for the lunch and teatime meal, the options reflected the information detailed on the menu board. Several people confirmed that they found the meals to be sufficient in quantity and flavoursome. Time was spent sitting with people at lunchtime and 3 choices were offered at this meal. Protein, carbohydrates and vegetables were noted to be offered daily providing a balanced diet. Nutritional risk assessments had also been completed and were kept within the care records for each person. Edwardian Care Home DS0000037799.V350288.R01.S.doc Version 5.2 Page 14 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 poor quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Systems in place at this home for receiving and investigating complaints is poor so people are not assured that their concerns will be acted upon. EVIDENCE: As reported at the previous inspection in May 2007, there had been safeguarding adult investigations concerning the service in March 2007 and a subsequent visit to the home by the team. A further referral had been made in October 2007, following information from a visiting medical professional. Recommendations from the safeguarding team had been followed in the first instance, however a staff member had returned to working their previous shift pattern. Following this visit it was established this had not been the agreement from the safeguarding team. The home had a copy of the local protocols and reporting procedure. Staff when interviewed demonstrated that they were aware of what they should do in the event of an alleged/suspicion of abuse. The homes complaints procedure was examined. It advised the reader on how they could complain and information on how to complain was also detailed within the homes service user guide. However reference to the Commission for Social Care Inspection was not clear, although it should show that we could be Edwardian Care Home DS0000037799.V350288.R01.S.doc Version 5.2 Page 15 contacted at anytime by anyone with information it intimated that we formed part of their own complaints procedure and would be notified within 24 hours of each complaint. The manager advised that no complaints had been received since the last inspection; examination of the file supported this. However following staff interviews it was confirmed that a complaint had been received the week prior to this visit and a complaints form had been completed. This was not shown to the inspector. Investigation of this matter and the missing information of this complaint is being looked into by the owners of the service, following this inspection and further information relating to this is detailed within the management and administration section. Edwardian Care Home DS0000037799.V350288.R01.S.doc Version 5.2 Page 16 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. We have made this judgement using a range of evidence including a visit to this service. The general maintenance of the environment in some areas of the home is not of a sufficient standard, although this does not place people at risk it does not create a pleasing and pleasant environment to live in. EVIDENCE: Accommodation was seen to be provided in single bedrooms on the ground and first floor. There was a lift and staircases connecting the two levels. The furnishings, fittings and décor in these areas were of a mixed standard, some requiring painting due to scuffing for example. Carpeting in some of the communal areas of the home were very stained. Individual rooms contained personal items of the person to assist in creating a homely atmosphere. Edwardian Care Home DS0000037799.V350288.R01.S.doc Version 5.2 Page 17 All areas visited on this day were tidy and free of odours. Staff were observed to wear suitable protective clothing when carrying out certain activities. Cleaning schedules were in place and clinical waste was disposed of in an appropriate manner and clinical waste contracts are in place. Edwardian Care Home DS0000037799.V350288.R01.S.doc Version 5.2 Page 18 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 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Systems in place for the recruitment of staff remain insufficient to protect people living at the home and places them at risk. EVIDENCE: 3 staff files were examined at this visit all contained application forms, evidence of identification and Criminal Records Bureau checks. However one of the most recently employed staff members had actually commenced their employment prior to the home receiving their criminal Records Bureau disclosure results. The manager stated that a POVA first check had been secured and was kept at another office. Agreement was given for the manager to submit evidence of this to the Commission for Social Care Inspection the following day. Telephone calls were necessary to prompt the manager to submit documentary evidence of this as agreed. Eventually written notification was received that explained that this could not be found. Staff training information submitted by the home to the Commission for Social Care Inspection was also examined and showed that staff had attended a variety of courses and workshops including health and safety, food hygiene and safeguarding adults. Edwardian Care Home DS0000037799.V350288.R01.S.doc Version 5.2 Page 19 Staffing rotas submitted by the home showed that the number and skill mix of staff had recently changed. Staff felt that there were not enough staff to care for the people living at the home when only 2 staff were allocated to work on a floor, it was reported that at times someone would need to wait for assistance if help was being offered to another person or if the senior was giving out medication that many people required assistance from 2 people at a time and they would have to wait. Staff through discussion demonstrated that they were aware of the needs of the people as recorded within their care records and were able to describe the individual. It was observed at this visit that the interaction between the staff and people on the first floor was positive and showed that supportive relationships between them had been established. People living at the home felt that some staff met their needs, whilst others did not as they felt they were not confident when providing care. The safeguarding adults referral in October 2007 described in the complaints and protection section related to inappropriate support being offered to one person and this was discussed with the manager at the time of this inspection. Edwardian Care Home DS0000037799.V350288.R01.S.doc Version 5.2 Page 20 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 & 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Management at the home remains poor placing people at risk of not receiving the care and support that they require. EVIDENCE: As reported following the previous inspection in May 2007, concerns on the management of the service remain. Areas already detailed within this report include management of complaints; care documentation and recruitment of staff. Requirements made at previous inspections remained unmet, again this was reported in May 2007. In addition the owners of the home are now looking into information received during this inspection relating to the conduct of the manager relating to staff management and the telephone system. The owners Edwardian Care Home DS0000037799.V350288.R01.S.doc Version 5.2 Page 21 will submit a copy of their findings to the Commission for Social Care Inspection detailing any recommendations and actions taken if necessary. The views of people living at the home and relatives had been sought. A requirement for the results to be analysed and a report of their findings published had not been met. The manager had attempted to analysis the results but had only made a list of comments; this does not meet the standard. The last monthly monitoring report seen from the Regulation 26 visits was dated April 2007. Several messages had been left for the owners of the home to contact the Commission for Social Care Inspection, at the time of writing, apart from the initial contact no further contact had been made. Health and safety records maintained by the home show that safety checks are carried out to ensure equipment in the home is kept in good working order. Copies of the most recent inspections undertaken by the fire service and environmental health were available for inspection. Staff and training records confirmed that they had undertaken training in this area including, moving and handling, fire safety and food hygiene. However it was observed that catering staff were not wearing any protective clothing during the cooking of the main meal, and had open toe footwear. Edwardian Care Home DS0000037799.V350288.R01.S.doc Version 5.2 Page 22 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 3 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X X X X 2 Edwardian Care Home DS0000037799.V350288.R01.S.doc Version 5.2 Page 23 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 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. The home must ensure all care plans are generated and drawn up in consultation with the service user or their representatives (previous time scales have not been fully met, the Commission will now undertake a review to consider how to proceed in this matter). 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. People assessed at risk of falling must be referred and receive appropriate support and advise from specialists in this area to minimise the risk of injury to them. A plan must then be written to make clear to staff the DS0000037799.V350288.R01.S.doc Timescale for action 31/12/07 2. OP7 15(1)(2) schedule 3(1)(b) 31/12/07 3. OP7 15 31/12/07 4. OP8 14(1)(a) (2) 31/12/07 Edwardian Care Home Version 5.2 Page 24 interventions that must be carried out. 5. OP9 13(2) 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. Staff must respond to people when they have asked for assistance in a manner that respects their rights. People must not be ignored. The complaints procedure must be changed to reflect the regulations and standards. The complaint received on 26/10/07 must be located and responded to and action taken as to why this was not made available for inspection. Recommendations following the strategy meeting in October 2007 must be carried out, to safeguard the people living at the home. The carpeting which is heavily stained must be replaced to provide a suitable environment for people to live in. The home must ensure that at all times competent staff are working at the home. (Previous time scale not met, the Commission will now undertake a review to consider how to proceed in this matter). The home must ensure that staff do not work at the home without CRB clearances. (Previous time scale not met, the Commission will now undertake a review to consider how to proceed in this matter). The home must ensure that DS0000037799.V350288.R01.S.doc 15/12/07 6. OP10 12(4)(a) 15/12/07 7. OP16 22(1),(2), (3) &(4) 15/12/07 8. OP18 13(6) 15/12/07 9. OP19 16(1) 31/01/08 10. OP27 18(1)(a) 01/11/07 11. OP29 19(4) 01/11/07 12. OP31 9 (2) (b) 01/11/07 Page 25 Edwardian Care Home Version 5.2 13. OP31 14. OP33 having regard to the statement of purpose and the needs of the service users, the manager has qualifications, skills and experience necessary for managing the care home (Previous time scale not met, the Commission will now undertake a review to consider how to proceed in this matter). 7(3),9(1)( The owners must undertake an 15/12/07 ii), 10 & investigation into the matters 12(1)(a) raised during this inspection and submit a report of their findings and action taken concerning the management in the home. This is to ensure people living at the home are kept safe through appropriate and effective management of the service. 01/11/07 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. (Previous time scale not fully met, the Commission will now undertake a review to consider how to proceed in this matter). 26 A monthly visit of the home 15/12/07 must be undertaken and a report written of the findings and submitted to the Commission for Social Care Inspection. This is to ensure that quality monitoring of the services are undertaken, to improve standards of care for the people living at the home. Appropriate clothing must be 01/11/07 provided in accordance with food hygiene regulations to staff when preparing food. 15. OP33 16. OP38 16(2)(j) Edwardian Care Home DS0000037799.V350288.R01.S.doc Version 5.2 Page 26 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. Refer to Standard OP15 Good Practice Recommendations The manager should consider the use of the ‘MUST’ tool to assess the nutritional needs of the people living at the home. As she and staff have undertaken training relating to this. Edwardian Care Home DS0000037799.V350288.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF 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.V350288.R01.S.doc Version 5.2 Page 28 - 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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