Inspection on 06/04/09 for Englewood Care Home

This inspection was carried out on 6th April 2009.

CQC found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Englewood Care Home 25/01/10

Englewood Care Home 30/04/08

Englewood Care Home 24/01/08

Englewood Care Home 14/08/07

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 06/08/2009.

Key inspection report CARE HOMES FOR OLDER PEOPLE Englewood Care Home 42-44 Egerton Park Rock Ferry Birkenhead Wirral CH42 4QZ Lead Inspector Peter Cresswell Unannounced Inspection 6th April 2009 09:30 DS0000054702.V374867.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Englewood Care Home DS0000054702.V374867.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Englewood Care Home DS0000054702.V374867.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 Manager post vacant Care Home 24 Category(ies) of Dementia (24) registration, with number of places Englewood Care Home DS0000054702.V374867.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Dementia - Code DE The maximum number of service users who can be accommodated is: 24 Date of last inspection 30th April 2008 Brief Description of the Service: Englewood provides personal care and support for up to 24 older people who have dementia. The home is situated in a quiet residential area of Rock Ferry in Wirral. Accommodation is on three floors which are served by a passenger lift. The bedrooms are single and all but one of them have en-suite facilities. There is one double bedroom available for people who choose to share, such as married couples or partners. On the ground floor there is a lounge and at the rear of the building a large dining room/lounge overlooking the spacious garden. The home has a call system and mobility aids. There is a large car park at the front. When we visited, the weekly fees for the home were between £395.22 and £458.63. Additional charges are made for hairdressing, newspapers, clothing, medical requisites (other than prescribed medications) items of a luxury nature and chiropody. Englewood Care Home DS0000054702.V374867.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star. This means the people who use this service experience adequate quality outcomes. As part of this inspection we visited the home without telling anyone that we were going. During the visit we spoke to the deputy manager, most of the staff on duty, and several residents. The owner was not at the home but we did speak to him on the telephone. We toured the home, visiting all of the bedrooms in use and several which were being redecorated. We also looked at care plans, medication, fire safety records, the menu, accident records and various staffing records. Before we went the deputy manager completed an Annual Quality Assurance Assessment. This includes the provider’s own assessment of how they are meeting people’s needs as well as some statistical information. It is one of the main ways in which the Care Quality Commission secures information from registered services. We sent some survey forms to people who live at the home but none had been returned by the time we wrote this report. We did receive a number of survey forms back from members of staff. What the service does well: The deputy manager carries out assessments of prospective residents, making sure that they are only admitted if Englewood can meet their needs. People thinking of moving in and their relatives visit the home to see if it is right for them before they make a final decision. Friends and relatives are encouraged to visit at any reasonable time. The meals are appealing, freshly cooked, wellbalanced and substantial. The home is clean, homely and adequately furnished. Staff are friendly and considerate towards residents, which helps to create a pleasant and relaxed atmosphere at Englewood. A number of the staff have worked at the home for some years, so the people are cared for by staff who are familiar to them and know their needs. What has improved since the last inspection? The owner is still acting as manager but he has appointed a new deputy manager and told us that she is now in effect the ‘acting manager’. She has begun to show some leadership in developing the care provided and has introduced new care plans and assessment documents. Englewood Care Home DS0000054702.V374867.R01.S.doc Version 5.2 Page 6 What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Englewood Care Home DS0000054702.V374867.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.V374867.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5. People using the service experience good quality outcomes in this area. The assessment of new residents ensures that people are only admitted if the home can meet their needs. People can visit the home to see if it is right for them before moving in. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: We looked at the files for three people who live at the home. They had all been admitted since September last year and all had been assessed before they moved into the home to make sure that Englewood could meet their needs. The newly appointed deputy manager carries out and records the assessments, using a form which she has introduced herself. The assessments provide the basis from which a care plans are developed. Standard assessment tools are used for nutrition and skin care and the assessment of skin care requirements is transferred to the care plan. A handover book is completed each day but staff need to be careful not to include any confidential information in it. Anything of this nature can be referred to in the handover book with details in the individual file. Englewood Care Home DS0000054702.V374867.R01.S.doc Version 5.2 Page 9 Prospective residents and their relatives are able to visit the home before moving in. There is a ‘Client Welcoming Guide’ (in effect a service user guide) for new and prospective residents. The guide is now out of date and needs to be revised. Its information about activities, for instance, is not accurate. Privately funded residents have contracts on file though there were none for people funded by local authorities. Every resident should have a contract or a statement of terms and conditions. The contracts we saw referred to ‘nominal contributions to be made………….for decent living’. It is not clear what ‘decent living’ means and it needs to be clarified in contracts and in the guide. Intermediate care is not provided at the home so Standard 6 does not apply. Englewood Care Home DS0000054702.V374867.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. People using the service experience good quality outcomes in this area. People’s needs are set out in detailed care plans, helping to ensure that they are cared for appropriately. People are protected by the home’s medication procedures though certain matters need to be improved. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: We looked at the care plans for three of the nine people who live at the home. The new deputy manager has devised a new care plan format which includes a lot of details about the individual’s care needs and how they are to be met. All of the plans include, for instance a section on skin care. There were also assessments from local authorities on file where they had arranged the admission. The deputy manager said that staff familiarised themselves with the details of the care plan and were then able to provide the care that was needed. Staff make daily reports on everyone but they are not closely linked to the essential elements of the care plan and it may be helpful to draw up a summary of the care plan to be kept alongside the daily reports for ready reference on a daily basis. The residents all appeared to be well cared for and staff have a good relationship with them. One lady was very interested in the Englewood Care Home DS0000054702.V374867.R01.S.doc Version 5.2 Page 11 way in which cleaning was carried out (harking back to her days at work) and the staff encouraged her to take an interest and gave her, for instance, a yellow duster when she asked for one. There are records visits by medical professionals such as GPs and district nurses. We checked the medication for three people and found that it was generally well organised. Medication is kept in a secure locked cabinet that is chained to a wall. The home uses a monitored dosage system where the pharmacist provides most the medication in dedicated blister packs for each individual. There were several blank spaces on the Medication Administration Record (MAR) sheets though a tablet was not in the blister pack, presumably having been correctly administered. The deputy manager said that sometimes staff will put tablets in a pot and take them to the resident with the intention of recording it when they return. This may well be the reason for the omissions and staff should take the blister packs and the MAR sheet to the resident so that it can be recorded on the spot. One tablet had unaccountably not been administered for three days. No harm had come to the person in question but care needs to be taken to avoid such errors. Some drugs were prescribed to be taken ‘as required’ (PRN). In these cases there should be details on file of under exactly what circumstances the medication is to be administered. The deputy manager did know this information so there is no reason to think that anything had been administered wrongly but it is important to have a full record to avoid any possibility of mistakes. Some medication that needs to refrigerated was kept in the food fridge in the kitchen. This type of medication should preferably be kept in a dedicated, lockable fridge, or otherwise in a lockable container in the kitchen fridge. Englewood Care Home DS0000054702.V374867.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. People using the service experience adequate quality outcomes in this area. People’s recreational needs are not met adequately but the varied, home cooked food ensures that dietary needs are met. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The deputy manager said that the care staff try to arrange activities for the residents every afternoon. These include reminiscence (using some of the residents’ old photos), exercise using a ball, dominoes, jigsaws, hoopla and nail care. Staff keep a record of the activities and which people join in. There have been no trips out for some time but the new deputy manager has plans to introduce some during the summer (should there be one). Hairdressers visit once a fortnight and children from a nearby school come in every week to help, under supervision, entertain the residents. People can get up and go to bed when they want and can stay in their room if they want to, though none were doing so when we visited. People were getting up in their own time whilst we were in the home. Visitors are welcome in the home and most people do have visitors, though nobody called in whilst we were there this time. Englewood Care Home DS0000054702.V374867.R01.S.doc Version 5.2 Page 13 There is a four week menu in place, and the main cooked meal is at lunch time. The evening meal is usually a lighter cooked meal such as quiche. There is no formal choice on the menu but the cook told us that she would cook anything that a particular resident requested and the notice board in the dining room, in addition to setting out the meal of the day, says ‘alternative meals are available on request, see cook before 10am’. On the whole the meals are largely traditional British dishes - pork casserole, mash and veg followed by spotted dick and custard when we were there. The cook said that other types of food have been tried but are generally not popular though pasta does appear on the menu from time to time. The cook and deputy manager have plans to introduce a five week menu to provide even greater variety. The cook uses fresh ingredients and makes her own pies and pastry. When we called everyone enjoyed a peaceful lunch and most ate healthy portions. Englewood Care Home DS0000054702.V374867.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18. People using the service experience good quality outcomes in this area. The wellbeing of people who live at Englewood is safeguarded by the procedures and practices for responding to complaints and safeguarding of adults issues. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home’s complaints procedure is displayed in the reception area. No complaints had been recorded in the home since the last inspection. The home has a copy of Wirral Borough Council’s adult protection procedures. No allegations of abuse have been made at the home since the last inspection. Most staff have received training around safeguarding older people from abuse. Englewood Care Home DS0000054702.V374867.R01.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 24, 25, 26. People using the service experience good quality outcomes in this area. People live at Englewood in a safe, clean and well maintained environment. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: We had a look at all of the rooms in the home apart from those bedrooms that are not being used at the moment. The home was clean with no unpleasant smells apart from in one bedroom. The deputy manager has a schedule for repairs. The home no longer has a ‘handyperson’’ but the owner does some of the repairs and hires external workers for bigger or specialist jobs. Some of the bedrooms are being redecorated and people had been moved out of the second floor bedrooms to enable some of the corridor handrails were repaired. The rooms they were in are in fact just as good as those they moved from. As reported on the last three inspections some of the furniture and furnishings in the communal rooms and bedrooms is showing signs of wear and tear. For instance, the dining room furniture serves its purpose but appears rather worn and one of the bedroom cabinets was very scruffy. We looked at all of the Englewood Care Home DS0000054702.V374867.R01.S.doc Version 5.2 Page 16 bedrooms currently being used. All but one of the bedrooms have en suite facilities. Many of them were personalised with the resident’s own belongings and photographs. The bedrooms are spacious and bright. One of the bedrooms suffered from a malodour, which the deputy manager said she would sort out, and this was not the case anywhere else in the building. The same room had torn wallpaper and a broken toilet seat. The toilet itself was not clean. Some of the bedroom carpets needed to be thoroughly cleaned or replaced. showed staining due to wear. Again, this was not typical of the other rooms but should not be the case anywhere. There are sufficient toilets, showers and bathrooms to meet people’s needs and there were aids such as hoists in the bathrooms to assist people to get in and out of the bath. The deputy manager and the owner have prepared an ‘Englewood Improvement Action Plan’ which sets out the repairs, upgrading and improvements that are planned for the fabric of the home. The spacious dining room/conservatory overlooks the garden and has a separate lounge/TV area. There is a separate lounge at the front of the building, also with a television. If the home was full the lounges may be rather crowded but this was not an issue when we visited. The kitchen was spotlessly clean and well organised. We checked a number of hot water taps and they were providing water at a safe temperature. Radiators have a low surface temperature and window restrictors are fitted. There are photographs of residents next to some of the bedroom doors. There is however scope to make the home, which is after all especially for people with dementia, easier for people with dementia to cope with Anyone who wants to smoke has to go outside to do so. This is not ideal for people with dementia but this is set out in the service user guide (“Client Welcoming Guide”). At the time we visited only one person in the home smoked at all. The enclosed garden at the back of the building is big, centred on a mature tree, and has seating areas for people to use in the warmer weather. There is a variety of plants and bushes and a bird table as well as a paved path around the grass. It is secured by gates and lit by security lights. Englewood Care Home DS0000054702.V374867.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. People using the service experience adequate quality outcomes in this area. Staff are competent, qualified and experienced but need to have some training updated. Recruitment checks ensure that suitable people are employed. Care staff sometimes have to carry out other duties which could affect the care given to residents. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: There are two care staff on duty at all times, including at night, when one member of staff sleeps in. This is a reduction from the last time we visited when both night staff were awake. The cook is on duty every weekday from 9:00 am to 13:00, a laundry assistant/domestic assistant for five hours on three weekdays. On other days care staff do the cleaning. It would be sensible to have domestic staff in every day. The home no longer employs a maintenance worker and the owner, Mr Bukhari either does repairs himself or employs an outside contractor. Previous reports have said that extra staff were needed but as only nine people were living in the home during this inspection the basic number of care staff is now adequate for the present. However, the deputy manager is one of the carers as well as having management duties. A few hours are set aside for her to carry out distinct management duties and it would help the running of the home if this could be extended. Mr Bukhari still carries out some management functions. The absence of a member of staff to organise activities puts an extra burden on the care staff as does the lack of domestic staff or a cook at weekends. Staffing, including night cover, does need, therefore, to be kept under review and in Englewood Care Home DS0000054702.V374867.R01.S.doc Version 5.2 Page 18 particular a member of staff needs to be made responsible for cooking at the weekends. We checked the recruitment files for staff who had started at the home since last September. The home had arranged for the appropriate checks to ensure that suitable people were employed and they all had proper references and a record of the interviews. They had been checked for criminal records though one person had started work, under close supervision, having received clearance from the Protection of Vulnerable Adults (POVA) register. There was a note to this effect but no documentation from POVA or the umbrella body they use to carry out the checks. The owner must insist that the umbrella body that obtains the POVA and Criminal Records Bureau certificates also provides written, dated evidence of POVA clearance. Seven of the nine care staff have NVQ2 or above, well in excess of the National Minimum Standard. There is now a training plan in place but it needs to be developed to include regular updates of training moving and handling, health and safety and safeguarding adults. The deputy manager told us that an external training agency is being used to provide training on dementia care and safeguarding though there were no dates to start the dementia training. This is especially important given that the care of people with dementia is the home’s primary function. Englewood Care Home DS0000054702.V374867.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 38. People using the service experience adequate quality outcomes in this area. The home is receiving guidance and leadership in social care from the deputy manager and is run in the best interests of the people who live there. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The owner, Mr Bukhari, continues to act as the manager though when he spoke to us he did describe the deputy manager as the ‘acting manager’ and indicated that he is planning for her to apply for registration as the manager at some point. Mr Bukhari does work at the home most days, carrying out administrative duties. Mr Bukhari is highly qualified and is an experienced businessman but he has no qualifications in social care. The appointment of a manager with experience in social care would be a step forward for the home and the deputy manager has already introduced some changes and leadership in the home. Englewood Care Home DS0000054702.V374867.R01.S.doc Version 5.2 Page 20 Englewood does not use an accepted external quality assurance system but it does consult relatives through questionnaires with a view to reviewing and improving the service it provides. The deputy manager showed us copies of the most recent surveys and they were generally positive. She said that when they have all been returned she would prepare a review of the service in response to meet any comments made. Englewood would benefit from an external quality assurance mechanism such as Investors In People. The deputy manager and the owner have started a fresh programme of staff supervision, though as yet this is in its infancy. The home looks after the personal allowances for a number of the residents and keeps a record of any money that is spent (mainly on hairdressing and chiropody). If too much cash is accumulated relatives are asked to make arrangements for its safekeeping. The home has had a recent electrical safety check though the certificate has not yet been delivered. There was an up to date gas safety certificate in place. The food safety programme Safer Food, Better Business is used in the kitchen and was properly recorded. The most recent Environmental Health report was from November 2008 and stated that the kitchen was ‘clean and well run’. We inspected the kitchen and food storage areas and found that food was safely stored and rotated. Fire safety records were properly maintained and fire drills were properly recorded. Accidents are recorded properly but the forms need to be kept in a separate file in accordance with the Data Protection Act. Relevant incidents, such as accidents which require medical intervention must be notified to the Care Quality Commission. One recent incident had not been so reported. Following the visit we sent the deputy manager a copy of the Commission’s guidance on the notification of incidents. Englewood Care Home DS0000054702.V374867.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 x 3 3 3 3 STAFFING Standard No Score 27 2 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 x 3 2 x 3 Englewood Care Home DS0000054702.V374867.R01.S.doc Version 5.2 Page 22 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 OP9 Regulation 13(2) Requirement The registered person must make arrangements for the recording and storage of medication and must therefore: *ensure that all staff properly record the administration of all medicine; *review the way in which medication is administered; *securely store any medication that needs to be refrigerated in a dedicated fridge or lockable container in a normal fridge. The registered person must provide facilities for recreation and activities. The appointment of a part time activities organiser would help to achieve this. (This was originally required by 24/02/08) The registered person must ensure that the Care Quality Commission is notified of any event in the care home that adversely affects the well-being or safety of any resident. (This requirement was originally required to be met by 01/08/08) Englewood Care Home DS0000054702.V374867.R01.S.doc Version 5.2 Page 23 Timescale for action 01/06/09 2. OP12 16(2)(m) 01/07/09 3. OP18 37 01/07/09 4. OP26 23(2)(d) The registered person must ensure that all parts of the home are kept clean and reasonably decorated and must therefore: *replace the identified toilet seat; *ensure that the toilet is kept clean at all times; *clean or if necessary replace stained bedroom carpets. 01/05/09 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. 4. 5. Refer to Standard OP1 OP2 OP9 OP19 OP27 Good Practice Recommendations The service user guide should be updated. All residents should have a contract or statement of terms and conditions. Where medication is to be administered ‘as required’ (PRN) there should be written details on file of the circumstances in which the medication is to be given. The building would benefit from additional signs, colour schemes and other measures to make it easier for people with dementia to navigate. Staffing should be reviewed with a view to giving the deputy manager more time to spend on management duties, ensuring that sufficient cleaning /domestic time is provided, having a member of staff to cook at weekends and having adequate night cover. When POVA clearance has been obtained for a new member of staff the original record of that clearance should be kept on file. The staff training programme needs to be developed further to make sure that all staff receive training identified in one to one supervision, including dementia care and updated training on moving and handling. The registered person should arrange for the appointment of a manager who is experienced and qualified in the filed of social care. Using a national quality assurance system would provide a better framework for quality assurance in the home. DS0000054702.V374867.R01.S.doc Version 5.2 Page 24 6. 7. OP29 OP30 8. 9. OP31 OP33 Englewood Care Home 10. OP36 The programme of one to one staff supervision needs to be fully carried out over the next twelve months. Englewood Care Home DS0000054702.V374867.R01.S.doc Version 5.2 Page 25 Care Quality Commission Care Quality Commission Unit 1 Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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