Inspection on 14/08/07 for Englewood Care Home

This inspection was carried out on 14th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Englewood Care Home 25/01/10

Englewood Care Home 06/04/09

Englewood Care Home 30/04/08

Englewood Care Home 24/01/08

Englewood Care Home 21/11/06

Englewood Care Home 25/05/06

Englewood Care Home 26/01/06

Englewood Care Home 04/05/05

Englewood Care Home 20/12/04

Englewood Care Home 18/06/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Englewood Care Home 42-44 Egerton Park Rock Ferry Birkenhead Wirral CH42 4QZ Lead Inspector Beate Field Unannounced Inspection 14th August 2007 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 Englewood Care Home DS0000054702.V339911.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. Englewood Care Home DS0000054702.V339911.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Englewood Care Home Address 42-44 Egerton Park Rock Ferry Birkenhead Wirral CH42 4QZ 0151 645 5064 0151 6455069 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) Englewood Care Limited Mrs Kathleen Parker Care Home 24 Category(ies) of Dementia - over 65 years of age (24) registration, with number of places Englewood Care Home DS0000054702.V339911.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 24 service users to include:*Up to 24 service users in the category of DE (E) (Dementia over the age of 65 years). 21st November 2006 Date of last inspection Brief Description of the Service: Englewood care home provides personal care and support for 24 older people, both male and female over the age of 65, who have dementia. The home is situated in a residential area. Accommodation is provided on three floors, which are accessible by a passenger lift. The bedrooms are single with most having en-suite facilities. Residents who are related currently share one bedroom. The home has two communal areas on the ground floor. There is a lounge and a large dining room and conservatory to the rear of the building overlooking the garden. The home has a call system and mobility aids. Ample car parking is available. At the time of this inspection, the weekly fees for the home were £406.84. Additional charges are made for hairdressing, newspapers, clothing, medical requisites (other than prescribed medications) items of a luxury nature and chiropody. A service user guide and a statement of purpose, which describe the services offered is available to new residents, their relatives and professionals before a resident comes to live at the home. A copy of the most recent inspection report can be obtained from the manager or deputy manager. Englewood Care Home DS0000054702.V339911.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection is based on a site visit to the home over a 7-hour period and is also informed by information received about the service since the last inspection and by questionnaires completed by relatives and health care professionals who visit the home. During the site visit to the home time was spent in the office looking at a sample of records and policies and procedures and talking to the deputy manager. A tour of the home was undertaken. The inspector spoke with residents and staff and made observations of the care given by staff. What the service does well: What has improved since the last inspection? What they could do better: A manager with relevant experience and qualifications needs to be in full-time day-to-day control of this service to ensure that there is clear guidance and leadership available for staff. Englewood Care Home DS0000054702.V339911.R01.S.doc Version 5.2 Page 6 Staff need to receive more detailed training around caring for older people with dementia so that staff are able to better understand and fully meet the needs of the residents at Englewood. A person who has training around assessing the needs of people with dementia must complete initial assessments in order to ensure that appropriate information is gathered. The residents care plans and risk assessments must contain clear information as to the action staff are to take to meet the needs of the residents, so that their well being is promoted at all times. An assessment of the home environment should take place with a view to making the home more accessible for residents with dementia. A risk assessment of the potential hazards presented by the stairs and baths needs to be undertaken in order to ensure that the safety of residents is at all times fully safeguarded. In order to fully safeguard residents a robust recruitment procedure must at all times be in operation. There must also be a sufficient number of staff at all times to meet the needs of the residents living at the home. 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. Englewood Care Home DS0000054702.V339911.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 Englewood Care Home DS0000054702.V339911.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): 2, 3 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents’ needs would be more fully assessed if the senior staff undertaking these assessments had training around meeting the needs of people with dementia. EVIDENCE: Since the last inspection the registration of the home has changed and a service is now provided to people with dementia. There is currently no manager at the service. The deputy manager, who has little experience or training around working with older people who have dementia is carrying out initial assessments. Englewood Care Home DS0000054702.V339911.R01.S.doc Version 5.2 Page 9 Records showed that an assessment is undertaken before any resident moves to the home. The assessments of two new residents were seen. These assessments provided basic information about a residents’ physical and mental wellbeing. There was little information about the residents’ dementia and how this is presented or around their current daily life skills. There was also little information about the residents’ life before moving to the home. This information is needed so that it can inform the residents care plan and ensure that staff have the information they need to fully support residents. Relatives and staff confirmed that prospective residents and their relatives are able to visit the home on an introductory basis. During these visits they can meet staff and current residents and view the home. Records showed that residents have a contract with the home that outlines what is covered by the fees and the rights of the home and the resident. Englewood Care Home DS0000054702.V339911.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 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health and social care needs of residents would be better met if the care plans and risk assessments contained more detailed information for staff to refer to and if staff were to receive greater training around caring for residents with dementia. EVIDENCE: A sample of residents’ care plans were seen. Care plans are directly available for staff to refer to. Different types of care plans are in use and some care plans contained more information than others. The deputy manager is currently updating all the care plans to ensure that one format is used. This will reduce confusion. Any care plans not in use should be removed from the Englewood Care Home DS0000054702.V339911.R01.S.doc Version 5.2 Page 11 residents’ files to further avoid confusion. The care plans indicate the basic needs of residents but do not provide sufficient information. The care plans need to give clear information to staff as to how they are to meet the needs of the resident and what residents can do for themselves. This clear guidance will enable residents to maintain their independence where this is appropriate. More detailed information on how the residents’ dementia presents and how staff are to meet this needs to be recorded. Where residents have a specific illness such as diabetes or Parkinson’s disease, clear written guidance needs to be available for staff to refer to on how these illnesses present themselves and the support staff are to provide the resident. There was limited background and social information around the lives of residents before they came to live at the home such as details of their family and work history and significant life events. This is essential for informing care planning. Staff have not received sufficient training to ensure that they can fully meet the needs of people with dementia. To date staff have only received half a days training in this area. Staff spoken with said that they did not feel they have had sufficient training to meet the needs of residents with dementia. Risk assessments in relation to falls were examined. These assessments do not provide sufficient guidance to staff on the actions to be taken to minimise the risk of falls. The assessments do not indicate how to make sure a safe environment is provided, how nutritional and medication factors may be significant. This needs to be addressed so as to provide detailed information on falls prevention. Care needs to be taken to ensure that care planning information and assessments are signed and dated. Regular management overview would ensure that this is taking place. The G.P. surgeries that returned the CSCI questionnaires stated they were generally happy with the service provided by the home. There was evidence in the files that other professionals visit the home to treat residents such as opticians, chiropodists, district nurses and community dentists. Policies and procedures for handling and recording medication are available. A sample of the medicine administration record (MAR) sheets and corresponding medications were inspected and found to be correctly maintained. Staff who administer medication have undertaken training in the safe handling and administration of medication. Staff interviewed were clear that they could not administer medication unless they had been appropriately trained. No residents manage their own medication. A record should be made of the assessed competence of staff to administer medication. Englewood Care Home DS0000054702.V339911.R01.S.doc Version 5.2 Page 12 Staff were observed to treat residents with respect. Staff were observed to speak to residents in a respectful manner. The relatives spoken with and those who returned questionnaires said that the staff respect their relatives privacy and are “polite,” and “caring.” Englewood Care Home DS0000054702.V339911.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, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s would benefit from further information being available to staff about the choices they can make in their daily lives and from a greater range of activities being offered. EVIDENCE: Records show that activities are made available for residents such as board games, sing-a-longs and armchair exercises. The activities provided seemed a bit limited given the potential activities that could be made available. The head of house is the activity co-ordinator as well as having housekeeping responsibilities at the home. It is understood that 2 hours per day are dedicated to activities for residents however this was not clear as this is not indicated in any records. Staff spoken with said that they consider that there are sufficient activities available for residents. Relatives spoken with and those Englewood Care Home DS0000054702.V339911.R01.S.doc Version 5.2 Page 14 who returned questionnaires were of a mixed opinion. Some considered that there is enough for their relatives to do and others indicating that there should be a greater range of activities and more stimulation. It is recommended that a review of activities takes place with residents, where possible and with their relatives to look at what is working well and what improvements can be made. Opportunities should be made available for residents to take part in activities outside of the home. A discussion with staff indicated that the routines of daily living are flexible. Staff said residents make decisions about their day-to-day lives at the home, such as when they will get up and go to bed and what they will do each day. Residents would be assisted further to have their choices respected if the care plans provided further information on the skills that residents have. For example the ability to choose clothing. The residents’ bedrooms that were seen had been personalised with items brought in from their own homes. The religion of residents is documented and it is understood that a minister from a local Church of England church and a priest from a Catholic church visit the home every Saturday. Visitors are welcome at the home and observations showed that visitors call to see their relatives throughout the day. Residents can see visitors in private in their bedrooms or in the dining room. The relatives who were spoken with said they are made to feel welcome when they visit. One relative commented, “There is an openness about the place. I can visit when I want and no parts are off limits.” A four-week menu is in place. The menus showed that varied meals are provided that would meet the nutritional needs of residents. The cook was spoken with and said there is a choice of a cooked breakfast or cereal or toast and a choice of meals at teatime and for supper. At dinner time one main meal and pudding is provided. An alternative is made available for residents. Relatives who completed questionnaires said that the range and quality of food is generally good. The food provided reflected the cultural needs of the residents. Observations were made of the food provided at lunchtime and teatime. The food looked appealing and well balanced. All residents sat at the dining tables and none required assistance with eating. Residents said that they liked the food. The cook did not have an understanding of meeting the nutritional needs of older people with dementia. The cook should be provided with training in this area so as to ensure she has the information needed to meet the varying needs of individuals with dementia. Englewood Care Home DS0000054702.V339911.R01.S.doc Version 5.2 Page 15 Englewood Care Home DS0000054702.V339911.R01.S.doc Version 5.2 Page 16 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. Staff need further training in meeting the needs of older people with dementia so that they can fully support and safeguard the residents at the home. EVIDENCE: There is a complaints procedure available, which is displayed in the reception area of the home. Relatives who were spoken with and those who returned questionnaires said that they would know how to complain if they needed to and those who had raised any issues said they where given an appropriate response. No complaints had been recorded in the home’s records since the last inspection. The deputy manager and staff interviewed were aware of the action to be taken should a complaint be made to them. A complaint made to CSCI about the home is being looked in to by CSCI and has been forwarded to Wirral Borough Council’s Contract and Commissioning Department to investigate. The home has a copy of Wirral Borough Council’s adult protection procedures. No allegations of abuse have been made at the home over the past twelve months. The deputy manager and staff interviewed were very well aware of Englewood Care Home DS0000054702.V339911.R01.S.doc Version 5.2 Page 17 the procedure to follow should they suspect abuse. Staff have received training around adult protection during their NVQ training and some had received training in adult protection matters in January 2007. Staff reported that there had been incidents where a resident was aggressive towards staff. These incidents were not reported to CSCI. This resident has since left the service. Staff have received half a days training in caring for older people with dementia, this included managing aggressive behaviour, however, staff themselves identified that they need further, more detailed, training as they find some behaviours difficult to manage. It is important that staff receive this given the potential difficult behaviours some residents may display. Englewood Care Home DS0000054702.V339911.R01.S.doc Version 5.2 Page 18 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, 21, 22, 23, 24 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. An adequate environment is provided with all areas being clean and odour free. Residents would benefit from the home environment being assessed to identify further ways of helping them to find their way around the home. EVIDENCE: The home was clean with no unpleasant smells. There was evidence of decorative and maintenance works taking place in several areas. The furnishings have been replaced in one bedroom, some bedroom carpets have been replaced, new beds, mattresses and bedding have been made available, and some new windows have been fitted. As reported in the last visit to the home, some of the furniture and furnishings in the main rooms and bedrooms were showing signs of wear and tear. The carpet on the landings was showing Englewood Care Home DS0000054702.V339911.R01.S.doc Version 5.2 Page 19 signs of wear. It is understood from the deputy manager that a programme of refurbishment is being worked through by the owner that includes the replacement of worn furnishings, windows and the landing carpet. Following the inspection the owner agreed to forward a copy of this programme to CSCI. A sample of resident’s bedrooms seen had been personalised and were homely. Residents who are related are currently sharing a bedroom. It would be good practice to make a further room available for their use. There were sufficient toilets, showers and bathrooms to meet residents’ needs and there were aids such as hoists in the bathrooms to help staff assist residents to get in and out of the bath. A tour of the home showed that in general a safe environment is maintained. Tests of hot water temperature are being recorded and show that water is being delivered at a safe temperature. Radiators have a low surface temperature and window restrictors are in place. A risk assessment needs to take place of residents’ access to the stairs and to the baths that are available in some bedrooms. The deputy manager agreed to attend to this without delay. An assessment of the environment should take place by an individual with experience in dementia care with a view to making the home environment more accessible. At present photographs of residents have been placed next to their bedrooms. Further aids such as this should be made available. The laundry is sited in the basement of the premises, accessed by a flight of stairs and is kept locked to prevent residents entering and putting themselves at risk. The laundry is equipped with modern facilities; there is a copy of the COSHH regulations pinned to the wall for the laundry assistants to refer to should they need to some advice on how to handle hazardous substances. There is a private enclosed garden with seating areas for the residents and their visitors to use in the warmer weather. The garden had a variety of plants and bushes and a bird table as well as a paved path around the grass. The garden is secured by gates and lit by security lights. Englewood Care Home DS0000054702.V339911.R01.S.doc Version 5.2 Page 20 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 and 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The training provided to staff and the recruitment practices do not ensure that residents are fully supported and safeguarded. EVIDENCE: The rota for the week of this visit shows that during the week from 8am – 5pm there are two care staff and the deputy manager providing care to residents with sufficient catering and domestic staff. An activities coordinator/housekeeper is also available. During the evenings there are two care staff available and at the weekends there are three care staff available throughout the day but due to a vacancy for a cook one of the care staff is carrying out catering duties. At the time of this visit there were 19 residents with dementia living at the home. Given the needs of the residents and that the home is a large building and has 3 floors two care staff are not sufficient. During the week the deputy manager is assisting with meeting the care needs of residents however she is currently also covering the managers position. This leaves less time for Englewood Care Home DS0000054702.V339911.R01.S.doc Version 5.2 Page 21 managerial duties. The staff and deputy manager spoken with said that they consider the staffing levels to be manageable but that the staffing levels would need to increase should further residents come to live a the home. An assessment needs to take place of the current staffing arrangements and sufficient staff need to be available at all times to meet the needs of the residents. This assessment needs to consider the size and layout of the home. There are currently vacancies at the home for a weekend cook and weekend cleaner and for two care staff. These vacancies have been advertised and applications received. Three staff files were examined during the inspection. One file did not contain any references. References were of varying quality which is due mainly to the reference request forms used which ask for limited information and provide no place to sign or date the reference. No contract, evidence of qualifications or that an induction has been provided was available on one file. Staff have not had sufficient training to meet the needs of residents with dementia. The deputy manager reported that the owner is addressing this with a view to providing relevant training. This training is needed as a priority. Staff need to have access to a more thorough induction, which meets the standards of Skills for Care. A more detailed evidence based recording system should be put in place to identify that the Skills for Care workforce training targets have been met and any learning needs identified for staff. Records showed that staff receive a brief induction. This covers the home’s policies and procedures, day-to-day routines; resident’s care plans and health and safety issues. Records show training is provided to staff around health and safety matters such as first aid, infection control, food hygiene, fire awareness, moving and handling and whistle blowing. The staff training records showed that updates are needed in this training. The deputy manager reported that this is being addressed. Staff are encouraged to undertake an NVQ in Care of the Elderly. It was reported that over 50 of staff have received this training. A sample of training certificates were seen. Staff interviewed said that they enjoy working at the home and are well supported by the deputy manager. Staff said that they would benefit from further training in meeting the needs of older people with dementia. Staff were observed to be friendly and polite towards residents. This creates a pleasant and relaxed atmosphere within the home. Relatives who returned questionnaires and those spoken with described staff as “keen,” “caring and friendly,” they said, “ my relative seems happy and well cared for. Staff listen to what my relative says” and” the staff seem to be a good team who work well together”. Englewood Care Home DS0000054702.V339911.R01.S.doc Version 5.2 Page 22 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 poor. This judgement has been made using available evidence including a visit to this service. The management arrangements are not sufficient to meet the needs of the residents. EVIDENCE: The management arrangements at the home are not sufficient. There is currently no manager at the service. A manager has not been available for 6 weeks. The deputy manager, who has little experience or training around working with older people who have dementia is managing the service. The Englewood Care Home DS0000054702.V339911.R01.S.doc Version 5.2 Page 23 deputy manager also provides care to the residents, which means there is less time available to carry out managerial duties. It is essential that there is an individual who is in full time day to day control of the home who has the experience and qualifications necessary to ensure that the home operates in the best interests of the residents. The home has systems in place for reviewing and improving the quality of care provided at the home. Questionnaires are sent to relatives. Questionnaires should also be sent to visiting professionals as to how the home is achieving goals for residents. Staff meetings are held on a regular basis. The deputy manager is compiling part of the monthly visit reports on behalf of the owner. The owner or their representative who is not employed at the home need to carry out these assessments to ensure objectivity. There was evidence of other systems in place for quality assurance, which have been developed but not kept up to date. These systems should be revisited as they provide a good way of assessing the operation of the home. Further work should also take place around obtaining the views of the residents’ as there was little evidence available to show how this takes place. The financial affairs of residents’ are managed by the residents themselves, or by their family or a solicitor. The home looks after monies deposited by relatives or advocates. The records of this were seen and were found to be in order. Residents are able to bring personal possessions to the home. Safety certificates were seen for the gas, electrical wiring, lift and contractors checks of the fire safety systems and alarm call. Records show that the fire alarm is being tested weekly. There was no recorded evidence of a fire drill since August 2006 and the emergency lighting was being tested on a 3 monthly rather than a monthly basis. Englewood Care Home DS0000054702.V339911.R01.S.doc Version 5.2 Page 24 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 3 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X 3 3 3 3 X 3 STAFFING Standard No Score 27 1 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 X X 2 Englewood Care Home DS0000054702.V339911.R01.S.doc Version 5.2 Page 25 Yes Are there any outstanding requirements from the last inspection? 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 The registered person must ensure that a full assessment of a prospective residents needs is carried out by a suitably trained person. The registered person must ensure that the residents care plans contain clear information as to how staff are to meet the residents personal, social and health care needs. The registered person must ensure that risk assessments in relation to falls are comprehensive in order to provide clear guidance to staff around what they need to do to prevent a fall. The registered person must ensure that CSCI are notified of any event in the care home that adversely affects the well-being or safety of any resident. The registered person must ensure that a risk assessment is DS0000054702.V339911.R01.S.doc Timescale for action 14/09/07 2. OP7 15 14/09/07 3. OP7 15 14/09/07 4. OP18 13 14/08/07 5. OP19 13 24/08/07 Englewood Care Home Version 5.2 Page 26 undertaken of the possible hazards presented by the stairs and take appropriate action to manage any risks identified. 6. OP19 13 The registered person must ensure that a risk assessment is undertaken of the possible hazards presented by the baths available in resident bedrooms and take appropriate action to manage any risks identified. The registered person must ensure that there are sufficient staff available to meet the needs of the residents at all times. An assessment must take place of the current staffing arrangements given the number and needs of the residents, size and layout of the home. The registered persons must ensure that all staff are provided with appropriate training for the work they perform. The registered persons must ensure that robust recruitment practices are in place in order to protect the vulnerable people being cared for at the home. The registered person must ensure that there is an individual who is in full time day to day control of the home who has the experience and qualifications necessary to ensure that the home operates in the best interests of the residents. The registered person must ensure that the fire equipment in the care home complies with the recommendations of the local fire authority. Drills must occur DS0000054702.V339911.R01.S.doc 24/08/07 7. OP27 18 14/09/07 8. OP27 18 14/11/07 9. OP29 19 14/08/07 10. OP31 9 14/09/07 11. OP38 13 & 23 14/08/07 Englewood Care Home Version 5.2 Page 27 at regular intervals and emergency lighting tested on a monthly basis (outstanding from previous inspection). RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP7 OP9 OP12 Good Practice Recommendations Any care plans not in use should be removed from the residents’ files to avoid confusion. A record should be made of the assessed competence of staff to administer medication. A review of the activities currently available should be undertaken with residents, where appropriate and their relatives/advocates with a view to providing a greater range of activities that meet the preferences of the current residents. The hours that activities are provided by the activities coordinator are to be documented in the rota and job description. The cook should be provided with training around meeting the nutritional needs of older people with dementia so that they have the information needed to meet the varying needs that will be presented. Where residents are sharing a bedroom it would be good practice to make a further room available for their use. An assessment of the environment should take place by an individual with experience in dementia care with a view to making the home environment more accessible. Staff should have access to a more thorough induction, which meets the standards of Skills for Care. 4. OP12 5. OP15 6. 7. OP19 OP19 8. OP30 Englewood Care Home DS0000054702.V339911.R01.S.doc Version 5.2 Page 28 9. OP33 Further work should take place around ways of obtaining the views of the residents. Englewood Care Home DS0000054702.V339911.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Englewood Care Home DS0000054702.V339911.R01.S.doc Version 5.2 Page 30 - 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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