CARE HOMES FOR OLDER PEOPLE
Edwin Lodge, 6 Victoria Court 6 Victoria Court Wembley Middlesex HA9 6QJ Lead Inspector
Mr Ram Sooriah Unannounced Inspection 30th April 2007 10:00 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 Edwin Lodge, 6 Victoria Court DS0000017496.V338301.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. Edwin Lodge, 6 Victoria Court DS0000017496.V338301.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Edwin Lodge, 6 Victoria Court Address 6 Victoria Court Wembley Middlesex HA9 6QJ 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) 020 8795 2007 020 8902 0303 Kristiina_37@msn.com Mrs Tiina Yasaratna Mr Sabaragamu Yasaratna Mr Sabaragamu Yasaratna Care Home 4 Category(ies) of Old age, not falling within any other category registration, with number (4) of places Edwin Lodge, 6 Victoria Court DS0000017496.V338301.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 3rd August 2006 Brief Description of the Service: The home is an extended semi-detached house, which is registered for four elderly residents of mixed gender requiring personal care. It is found in a residential road off the main Harrow Road in Wembley. As such it is close to local shops and amenities and is also easily accessible by public transport and by car. Parking is available on Victoria Court. The home has been opened for about seven years and belongs to Mr and Mrs Yasaratna. They have both worked for a number of years in the area of health and personal care. They live on the premises and have a separate living area for themselves, which consists of the second floor (the loft conversion). The providers offer the bulk of the care, and are assisted by three carers and a domestic assistant. The main aim of the home is to provide personal care in a homely and family setting. The home is indeed homely and pleasant. Accommodation for residents is provided in single rooms on the ground and first floors. There is a bedroom on the ground floor and three on the first floor. The home, including the internal and the external areas, is pleasantly decorated and looked pleasing and inviting. There were four residents in the home at the time of the inspection. All the residents are publicly funded according to the rates of the local authority. Edwin Lodge, 6 Victoria Court DS0000017496.V338301.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This report contains the findings of a key unannounced inspection which took place on Monday 30th April 2007 from 10:00 to 13:30. The last inspection was on the 3rd August 2006. The inspector looked at a sample of care, personnel and training and health and safety records. He also toured some of the premises, spoke to residents, observe care practices and looked at medicines management in the home. He would like to thank the residents for their kind welcome to the home and the manager and his wife for the support and assistance during the course of the inspection. What the service does well:
The home continues to be well maintained. It provides a homely, clean and welcoming environment for residents and visitors. There is a small but pleasant patio area with plants and flowers where residents can sit and enjoy. The home is run in an informal manner by the owner and his wife with the assistance of three care workers. They are familiar with and are attentive to the needs of the residents and ensure that these are met. Residents receive information about the service prior to deciding if they want to move into the home. They are visited by the manager, who tells them about the home. The manager also assesses the needs of the residents to ensure that the home will be able to meet the needs of the residents, although these were not recorded for the last resident admitted to the home. The needs of residents are addressed in care plans, which are mostly kept updated and reviewed. There is evidence of some involvement of residents and of their relatives in drawing up and in agreeing the care plans. The healthcare needs of residents are well met in the home. The cultural and religious needs of residents are included in care records and addressed during the delivery of care. Medicines management in the home is generally good. Staff are aware of the social and recreational needs of residents and provide support to residents to meet these needs. Meals are provided to residents in appropriate amount and variety and according to their individual cultural needs.
Edwin Lodge, 6 Victoria Court DS0000017496.V338301.R01.S.doc Version 5.2 Page 6 Staff are provided in appropriate numbers to meet the needs of residents. They receive appropriate induction to the home and also receive the common induction standards according to the Skills for Care Council. What has improved since the last inspection? What they could do better:
The service users’ guide, while in the main is comprehensive, needs to be updated to contain information about the range of fees that it charges as per recent amendments to the Care Homes Regulations 2001. The terms and conditions/contract of stay in the home must be updated to contain all the relevant section as detailed in standard 2.2. Copies must be provided to all residents and evidence must be kept that the residents/relatives have agreed to the terms and conditions/contract of the placement. Records must be kept about the preadmission assessment of the needs of residents. The assessment of needs should include information about the psychological and mental state of residents, particularly in cases where they have dementia. Care plans are comprehensive and while some progress is noted with regards to involving residents or their relatives in drawing up and reviewing care plans, more progress needs to be made in this area. Thorough checks must be carried out prior to new members of staff starting work with residents. Full CRB checks must be undertaken and at least a PoVA first check must be received before they are allowed to care for residents, even with supervision. The work history of the applicants must be fully completed with dates of starting and leaving employment and there must be no gaps in the work history of the applicant.
Edwin Lodge, 6 Victoria Court DS0000017496.V338301.R01.S.doc Version 5.2 Page 7 Training updates must be provided to ensure that all members of staff are up to date with statutory training including manual handling and fire training. When requirements are made the manager must ensure that these are met within the timescales. Recommendations are good practice guidelines and serious consideration should be given to meeting them. The quality control system needs further development to make it a suitable tool to assess the quality of the service. The home was required to develop a fire emergency plan following the last inspection. The plan has not yet been fully prepared. The home did not have an up to date electrical wiring certificate at the time of the inspection, a copy of the new certificate was later forwarded to the inspector. 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. Edwin Lodge, 6 Victoria Court DS0000017496.V338301.R01.S.doc Version 5.2 Page 8 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 Edwin Lodge, 6 Victoria Court DS0000017496.V338301.R01.S.doc Version 5.2 Page 9 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): 1-4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ needs are assessed prior to them being admitted into the home and information is provided for them to decide if they want to move into the home. The terms and conditions of the placement are not always offered and agreed with the residents/representatives. As a result they may not always be aware of their rights and obligations. EVIDENCE: The home had a service users’ guide (SUG) in place, which was available for inspection. While mostly comprehensive, it was noted that the SUG does not yet contain information about the range of fees charged by the home. Each resident is given a file on admission which contains the SUG. This was found in the bedrooms of residents. A resident admitted in February did not yet have a copy of the terms and conditions/contract of the placement. The terms and conditions/contract were
Edwin Lodge, 6 Victoria Court DS0000017496.V338301.R01.S.doc Version 5.2 Page 10 also examined and were noted to be lacking. For example information about what is covered in the provision of services such as board and lodging, meals and other additional services covered by the placement were not addressed. There was little information about notice periods and situations where notice could be given. I also noted that the responsibility of the provider in terms of the provision of a service was not detailed enough in the terms and conditions/contract. The care records of the new resident were inspected. It was noted that the needs assessment of the funding authority was available on file and some information from the resident’s previous place of stay. The manager stated that he and his wife visited the resident prior to admission to assess the needs of the resident and to provide information about the service that they provide. They however did not record their findings and information about the assessment that they carried out was not available for inspection. The manager and his staff understand the needs of the residents who are accommodated in the home well. All residents looked well cared for during the unannounced inspection and they all appeared comfortable. A review meeting about the care of a newly admitted resident showed that the needs of the resident were being met very well. Staff were aware of the cultural and religious aspects of the care of residents. These issues were addressed in care plans and actions were identified to meet these. Meals for example were provided to take account of the cultural needs of the residents. Edwin Lodge, 6 Victoria Court DS0000017496.V338301.R01.S.doc Version 5.2 Page 11 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): 7-11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ personal and healthcare needs are met and are addressed in care plans. At times evidence was lacking about the consultation and involvement of residents/representatives about the care of the residents. EVIDENCE: Three care plans were inspected. The needs of residents were generally assessed comprehensively. Care plans were formulated and clear actions were identified that should be taken to meet the needs of residents. However the psychological needs of residents and information about behaviour and mental state could have been more comprehensive, particularly for those residents in the home who have early dementia to ensure that all their needs were fully identified. A range of risk assessments were in place including risk assessments for falls and there was evidence of control measures being put in place in cases where
Edwin Lodge, 6 Victoria Court DS0000017496.V338301.R01.S.doc Version 5.2 Page 12 high risks have been identified. It was noted that there have been some involvements of relatives in drawing care plans and risk assessments but more progress could be made in this area. In cases where the care of residents is discussed and agreed with the residents or their relatives, residents or their relatives should be encouraged to sign the care plans and risk assessments or a note made in the care plan when this is not possible. All residents presented as appropriately dressed and appeared well cared for. There were records about the personal care that residents receive, which showed that the personal care offered in the home was of a good standard. There was information on file to show that residents receive appropriate healthcare. They were seen by the GP as required and there was evidence of the optician visiting, continence advisor and district nurse. Records about the multidisciplinary input into the care of residents were good. The management of medicines was inspected. The manager and two other members of staff were responsible for the administration of medicines and they all have had medication training. The manager has made arrangements to record the balance of medicines when transferring the records to a new medicines administration chart, but the balance of medicines was not always recorded to facilitate audit. This was particularly obvious in cases where medicines were prescribed to be administered, as required. The instructions on the chart for a medicine differed slightly from the instructions on the label of the medicine’s container but there was no evidence that the resident was receiving the wrong a dose. Care plans contained some information about managing the death of residents and the funeral arrangements. The manager stated that where possible he has tried to address these issues with residents and/or their relatives Edwin Lodge, 6 Victoria Court DS0000017496.V338301.R01.S.doc Version 5.2 Page 13 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): 12-15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to lead a fruitful life and to be engaged in the local community according their wishes. Meals are provided to suit the needs of the residents. EVIDENCE: During the course of the inspection residents were observed reading books, watching TV, listening to music and one was observed playing a music instrument. They were also encouraged to go outside in the patio area. The social and recreational needs of residents were addressed to a certain extent in care records and the manager stated that his staff and himself were still working to produce a ‘life history’ of residents. Out of the care records of the three residents inspected, one had a life history. There was therefore room for progress as some information about residents was also available from the needs assessment of the placement authority and could have been transferred to the life history. Edwin Lodge, 6 Victoria Court DS0000017496.V338301.R01.S.doc Version 5.2 Page 14 Care plans were in place addressing the social and recreational needs as well as the cultural and religious needs of residents. In one case however the religion of a resident was not clearly identified. There was evidence that residents were supported in meeting their religious needs by assisting them to go to places of worship or by supporting representatives of the local churches to visit the residents in the home. The inspector asked about the involvement of residents in the local community. He was informed that few of the residents wish to go out for shopping or for walks and that only one resident wanted to go out. It seems that the manager and his staff were ready to support residents if they wanted to go out. For example the manager was applying for a Disabled Permit to enable him to take one of the residents out. On the day of the inspection residents were offered a meal of quiche, potatoes, cauliflower and beans. There was yogurts and ice cream for deserts. A resident received fish with potatoes and vegetables and another resident was offered curry and rice. Records were kept about the meals cooked into the home and the inspector noted that these were on whole suitable for the residents. Records were also available of the temperatures of the fridge and freezer. The kitchen was appropriately equipped and maintained to ensure that food was appropriately prepared and served to residents. Edwin Lodge, 6 Victoria Court DS0000017496.V338301.R01.S.doc Version 5.2 Page 15 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 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although there are no records of complaints and allegations of abuse, there is confidence that the manager and his staff take these issues seriously and that they will be able to deal with these appropriately. Personnel checks were not always carried out thoroughly to ensure that residents were safe at all times. EVIDENCE: The home has not had any complaints since the last inspection. Copies of the complaints procedure were available in the residents guide and offered to all residents. A copy was also available in the foyer. There was evidence that care staff have had training on safeguarding adults issues. Either the manager or his wife are present on a shift and will make the necessary decisions when faced with any allegations or suspicions of abuse. They were both aware of the procedure to follow in these circumstances. One member of staff did not have the results of CRB check or a PoVA first check. This is poor practice and could be putting residents at risk and must therefore be addressed without delay. The manager and his wife stated that they work together with the care worker to supervise her. Edwin Lodge, 6 Victoria Court DS0000017496.V338301.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, 24 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care home provides a homely, clean and suitable environment for the care of the residents. EVIDENCE: The front of the home was tidy and clean. The exterior of the building was maintained and looked in good condition. The patio garden at the back of the home was well maintained and a lot of flowers were in bloom. There was patio furniture to enable residents to sit out. The inside of the home was warm, airy and clean. The communal areas were comfortable and residents were sitting in a range of suitable and comfortable chairs. There was adequate space for all of them. A television and a music system were in place for the residents to enjoy. One of the residents preferred to stay in her bedroom.
Edwin Lodge, 6 Victoria Court DS0000017496.V338301.R01.S.doc Version 5.2 Page 17 The bedrooms were well personalised, maintained, comfortable and clean. Furniture was suitable for the residents’ use. Residents were encouraged to bring personal items such photos, pictures and items of decorations to personalise their bedrooms. The home is commended for this. The manager stated that both residents who stay on the first floor are able to manage the stairs with assistance and that one of them comes down everyday. The home has minimal aids as most of the residents have some degree of mobility, but this should be kept under constant review with the changing needs of the residents. Edwin Lodge, 6 Victoria Court DS0000017496.V338301.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): 27-30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Adequate numbers of staff are provided to care for residents, but checks before they start work in the home were not always thorough and therefore potentially putting residents at risk. EVIDENCE: The staff group consisted of five persons. The manager, his wife and three care workers. They were organised so as to ensure that two members of staff were on duty during the day and a sleeping member of staff at night. These numbers were appropriate to meet the needs of the residents. Four of the five members of staff have been working in the home for more than a year and were therefore familiar with caring for the residents who are accommodated in the home. The training records of three members of staff were inspected. A training plan has also been prepared. There was evidence that all staff have completed or are in the process of completing the Common Induction standards from Skills for Care. Members of staff also receive induction about the service and its aims and objectives. The inspector noted that staff were mostly up to date with regards to food hygiene training but noted some lacking with regards to fire and manual handling training. The manager said that he has been trying to arrange training in clinical areas for staff such as in dementia care. He added
Edwin Lodge, 6 Victoria Court DS0000017496.V338301.R01.S.doc Version 5.2 Page 19 that 3 out of the 5 members of staff who work in the home have at least an NVQ level 2 qualification in care. The personnel records of two members of staff were inspected. It was noted that dates were not available with regards to the work history of one of the applicants. One applicant did not have evidence of eligibility to work in the UK on file and has not yet had the results of a CRB check or a PoVA First. The manager and his wife stated that they are always working with the new care worker and that the latter does not work on her own. Edwin Lodge, 6 Victoria Court DS0000017496.V338301.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): 31,33,35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager is aware of his responsibilities with regards to running a care home. Attempts have been made to evaluate the quality of the service but the results of these were not very clear. Residents’ personal money is managed appropriately. The management of health and safety in the home was not as comprehensive as it should have been. EVIDENCE: The manager has recently completed the Registered Managers’ Award. There was evidence that he has enrolled on other courses to keep himself updated. The manager is assisted by his wife and is training one of the care staff to be
Edwin Lodge, 6 Victoria Court DS0000017496.V338301.R01.S.doc Version 5.2 Page 21 the deputy manager. A few requirements imposed during previous inspections remain to be fully met. More could be done to ensure that previous requirements are met within the timescales. Satisfaction surveys about the service are conducted annually. The results of the last survey was however not available in the form of a report to inform future plans with regards to developing the service. As a result the inspector was unable to see the impact of the survey. The quality assurance procedure of the service also mentions that six monthly audits in key areas are to be conducted. There was evidence that the manager has started to work on a format for the audit, although there was evidence of some audits such as health and safety, environment and catering, no audit has yet taken place about the standard of care that the home provides. The manager stated that the home does not manage the personal money of residents. The home however keeps a small sum of money for one of the residents for day-to-day personal expenses. The money was not kept separately but receipts and separate records were kept for reconciliation of the expenses. The personal money of the other residents was managed by their relatives. The home had good health and safety records. A health and safety risk assessment and a fire risk assessment were carried out monthly and fire detector checks were on the whole carried out weekly. A gas safety certificate was available for inspection but an up to date electrical wiring test certificate was not available. The manager stated that he would arrange for one as soon as possible and a copy was later forwarded to the inspector. There was a previous requirement for the home to develop a fire emergency plan describing all the actions that should be taken in case of a fire. The plan was not yet completed. Training records also show that members of staff have not always been having update training on health and safety issues such as manual handling and fire training (see previous section). Edwin Lodge, 6 Victoria Court DS0000017496.V338301.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 2 2 2 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Edwin Lodge, 6 Victoria Court DS0000017496.V338301.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 OP1 Regulation 5 Requirement The residents’ guide must include information about the range of fees charged by the home to ensure that people are fully informed before they move into the home. All residents must be offered a statement of the terms and conditions/contract of the placement. This must be reviewed to make them more comprehensive. The manager must ensure that records are kept about the preadmission assessments of the needs of prospective residents. Care plans must be agreed and reviewed with the residents or with their representatives. A record must be made when this is not possible (Repeated requirement-timescale 15/10/06 not fully met). The registered person must ensure that all new employees have the necessary information as detailed in Schedule 2 of the Care Homes Regulations 2001
DS0000017496.V338301.R01.S.doc Timescale for action 31/07/07 2 OP2 5(1)(c) 31/07/07 3. OP3 14 31/07/07 4. OP7 15(1) 31/07/07 5 OP29 19(1)(b) 31/07/07 Edwin Lodge, 6 Victoria Court Version 5.2 Page 24 6 OP30 OP38 18(1)(c) 7. OP33 24(1) 8. OP38 23(4) before they are offered employment (Previous requirement- timescale 28/02/06 and 15/10/06 not met). New members of staff must at least have a PoVA first check before they start work with residents. The work history of applicants must also be completed comprehensively. The registered person must ensure that members of staff receive training updates in statutory areas such as fire training and manual handling in a timely manner. The registered person must ensure that the home has an effective quality management system with clear standards against which the service can be measured (Repeated requirement-timescale 31/10/06 partly met). The home must have a fire emergency plan (Repeated requirement-timescale 15/10/06 partly met). 31/07/07 31/07/07 31/07/07 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 OP7 Good Practice Recommendations It is recommended that the manager carry out an assessment of the psychological and mental health needs of residents who have dementia and addressed any identified care needs in care plans. The amount of all medicines brought forward on new medicines charts should be recorded to facilitate audit. The instructions on the labels of medicines and on the
DS0000017496.V338301.R01.S.doc Version 5.2 Page 25 2 OP9 Edwin Lodge, 6 Victoria Court 3 OP12 medicines charts should be the same. It is recommended that the manager develop a section of the care plan on the life history of residents to provide additional information on the background of the residents Edwin Lodge, 6 Victoria Court DS0000017496.V338301.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 Edwin Lodge, 6 Victoria Court DS0000017496.V338301.R01.S.doc Version 5.2 Page 27 - 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!
