CARE HOMES FOR OLDER PEOPLE
Edwina House 64-66 Grovelands Road Palmers Green London N13 4RJ Lead Inspector
Tony Brennan Unannounced Inspection 3rd October 2005 10:30 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 Edwina House DS0000027807.V251026.R01.S.doc Version 5.0 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. Edwina House DS0000027807.V251026.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Edwina House Address 64-66 Grovelands Road Palmers Green London N13 4RJ 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 8886 6658 020 8882 6265 Mr Sooreeadeo Hurree Mrs Elizabeth Ann Hurree Mr Sooreeadeo Hurree Care Home 22 Category(ies) of Past or present alcohol dependence (0), registration, with number Dementia (0), Old age, not falling within any of places other category (0), Physical disability (0) Edwina House DS0000027807.V251026.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Where service users are admitted only for intermediate care, dedicated accommodation is provided. 14th July 2005 Date of last inspection Brief Description of the Service: Edwina House is owned and managed by Mr Sooreeado Hurree and Mrs Elizabeth Hurree. The home is registered to care for twenty-two service users. The home is comprised of two semi-detached two-storey houses, which are joined and extended. There are fourteen single and four double bedrooms. There are two communal areas for sitting and dining. The home has a passenger lift. There is a garden to the rear of the property. The home is within walking distance of shops and public transport links. The home aims to provide a supportive and caring environment for those who use the service. Edwina House DS0000027807.V251026.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken as part of the annual inspection process. The inspector also sought to confirm that the ten areas for improvement found at the last inspection were addressed. The inspection took place over one day. The registered person assisted the inspector. The inspector spoke with two service users and two staff. The inspector observed practice. The inspector toured the building and examined a range of records relating to the care and management of the home. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection.
Edwina House DS0000027807.V251026.R01.S.doc Version 5.0 Page 6 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Edwina House DS0000027807.V251026.R01.S.doc Version 5.0 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 Edwina House DS0000027807.V251026.R01.S.doc Version 5.0 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): N/A None of these standards were inspected on this occasion. EVIDENCE: Edwina House DS0000027807.V251026.R01.S.doc Version 5.0 Page 9 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): 8 9 10 Service users tissue viability needs are not recorded and reviewed. Photographs of pressure sores should be obtained with the agreement of service users and their representatives. Service users are protected by safe procedures for handling medication. Service users privacy is maintained. EVIDENCE: Since the last inspection a recording system has been put in place to record when service users are turned. The inspector found that there were no detailed care plans of the treatment of pressure sores. This was discussed with the registered manager who agreed to ensure that care plans detail the dressings to be used and types of pressure relieving equipment to be used. The inspector found that photos were not taken of pressure sores to monitor the effectiveness of treatment. The registered manager has developed a risks assessment of falls. The inspector found that there were a number of service users who were at risk of falling but no assessments and care plans had been developed. The registered manager agreed to develop care plans based on risk assessments of falls to ensure that falls are prevented. The registered manager had provided evidence to show that all staff had been trained in the safe administration of medicines. Service users said that staff respect their privacy and always knock on their bedroom doors. Service users also said that staff take time to ask how they wished to be assisted.
Edwina House DS0000027807.V251026.R01.S.doc Version 5.0 Page 10 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): 12 13 14 Service users are provided with sufficient and varied activities to meet their needs. Service users are supported to maintain contact with relatives and other representatives of their choice. Service users are able to make choices about how they live in the home. EVIDENCE: Service users said they had been provided with activities and entertainment. The interests of service users had been recorded and activities that had been provided were recorded. Service users spoken to confirmed they had a choice as to whom they wished to see. Service users spoken to confirmed that they could make choices and control their lives. One service user said he had a choice of when to go out and other service users confirmed that a choice of food was provided. Edwina House DS0000027807.V251026.R01.S.doc Version 5.0 Page 11 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): N/A None of these standards were inspected on this occasion. EVIDENCE: Edwina House DS0000027807.V251026.R01.S.doc Version 5.0 Page 12 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): 19 Service users live in a safe environment. EVIDENCE: The inspector found that regular maintenance was taking place. The home has been regularly decorated and the garden was tidy. Edwina House DS0000027807.V251026.R01.S.doc Version 5.0 Page 13 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): 28 29 30 Qualified staff are registered with the appropriate professional bodies to ensure that service users are safeguarded. Staff do not have the skills to meet all the needs of service users. EVIDENCE: Training records showed that the home needs to get 50 of staff to achieve NVQ in care. Records showed that staff need training in food hygiene and manual handling. Records showed that staff had received training in care planning. The registered manager had produced evidence that all qualified nurses have an up to date professional registration. The required documentation is being maintained on all staff recruited to work at the home. Edwina House DS0000027807.V251026.R01.S.doc Version 5.0 Page 14 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): 33 35 38 Service users are consulted about the quality of the service provided and encouraged to make suggestions for improvement. Service users financial interests are protected by the home’s procedures. The risk of fire needs to be assessed and regularly reviewed to protect service users. EVIDENCE: The inspector found that there were systems in place to ensure that service users and relatives are consulted about the quality of the service provided. Actions to improve the service are identified. The registered manager explained that the survey was being repeated and a copy of the results will be sent to the Commission. The registered manager explained that money is only held for one service user. Either relatives or social service departments manage all other service users’ money. The inspector found that the money of the service user held by the home was accounted for and a record of expenditure and receipts was maintained. Records showed that fire equipment was tested regularly and maintained. Drills were taking place. The fire risk
Edwina House DS0000027807.V251026.R01.S.doc Version 5.0 Page 15 assessment was not detailed and needs to be updated and regularly reviewed to ensure that all potential risks of fire are addressed. Edwina House DS0000027807.V251026.R01.S.doc Version 5.0 Page 16 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 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X X X STAFFING Standard No Score 27 X 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 2 Edwina House DS0000027807.V251026.R01.S.doc Version 5.0 Page 17 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 OP8 Regulation 13(4b,c) 15(1) Requirement The registered persons must ensure that risk assessments and prevention plans are in place for those service users at risk of falling. The registered persons must ensure that with the agreement of service users and their representatives a pictorial record is established of any pressure sores service users may have. The registered persons must ensure that care plans detailing the treatment and prevention of pressure sores are in place and that they are reviewed monthly. The registered persons must ensure that training is provided on the following topics; Food hygiene Manual handling. The registered persons must ensure that a comprehensive fire risk assessment is in place and that the risk assessment is reviewed annually. The fire officer must be consulted regarding the contents of the fire risk assessment.
DS0000027807.V251026.R01.S.doc Timescale for action 01/12/05 2 OP8 12(1)(a) 01/12/05 3 OP8 12(1) 15(1) 01/12/05 4 OP30 18(1) 01/01/06 5 OP38 23(4)(a) 20/11/05 Edwina House Version 5.0 Page 18 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 OP28 Good Practice Recommendations The registered persons should ensure that 50 of staff achieve NVQ in care at level 2. Edwina House DS0000027807.V251026.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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