Inspection on 20/09/07 for The Georgiana

This inspection was carried out on 20th September 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

The Georgiana 14/11/08

The Georgiana 14/01/08

The Georgiana 08/11/06

The Georgiana 12/01/06

The Georgiana 02/06/05

The Georgiana 04/03/05

The Georgiana 01/07/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Georgiana 10 Compton Avenue Luton LU4 9AZ Lead Inspector Mr Pursotamraj Hirekar Key Unannounced Inspection 20th September 2007 12:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Georgiana DS0000044852.V347432.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. The Georgiana DS0000044852.V347432.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Georgiana Address 10 Compton Avenue Luton LU4 9AZ Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01582 570650 No email yet. 3/7/2007 Heritage Care Homes Ltd Mrs Mary Ainsbury Care Home 44 Category(ies) of Dementia - over 65 years of age (12), Old age, registration, with number not falling within any other category (44) of places The Georgiana DS0000044852.V347432.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th November 2006 Brief Description of the Service: The Georgiana was located in a residential suburb of Luton within walking distance of a Leagrave train station. The amenities of the town were a short car journey away. The home had been purpose built almost three years previously to meet the environmental standards detailed by the National Minimum Standards 2001 for the care of forty-four frail older people. The proprietor was Heritage Care Homes Ltd that also operated two other care homes in the vicinity. The accommodation was distributed over three floors that were accessed via staircases and a shaft lift. The upper floor was used for administrative purposes, food storage, and preparation. The building had been designed to provide four distinct living areas. Each had a lounge/diner and convenient access to toilet and bathing facilities. Small kitchenette facilities for the use of service users were located on the ground and first floor. The home had a hairdressing room that could also be used for chiropody treatment. All of the bedrooms, which were for single occupation, were fitted with call bells and had ensuite toilet and washbasin facilities. The fee was in the range of £420/- to £450/. The Georgiana DS0000044852.V347432.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of the unannounced key inspection carried out by pursotamraj hirekar on 20/09/07 from 12.00noon to 7.00pm and by an expert by experience from 12.00noon to 2.00pm. The manager had coordinated the entire inspection. The methodologies of the inspection-included study of relevant care documents, staff records, review of outstanding requirements, pre-inspection service users questionnaires, annual quality assurance assessment – self-assessment prepared by the home, discussion with the manager, staffs and service users’. Partial tour of the home was undertaken; observations were made of staffs and service users’ interaction. What the service does well: What has improved since the last inspection? What they could do better: The home must action all the building risk assessments recommendations to ensure safety and comfortable stay of all the service users’. The home must evidence that the service user agreed and signed the care plan whenever capable and / or representative if any. The home must ensure to reflect changing needs of the service users’ in their care plan including in the medication section. The home must make suitable adaptations with appropriate equipment and facilities that are provided for all the service users’. The Georgiana DS0000044852.V347432.R01.S.doc Version 5.2 Page 6 The home must have adequate staffs’ to ensure all the assessed needs of all the service users’ were met on all the shifts. The registered person must ensure that all parts of the home to which service users’ have access are free from hazards to their safety. The home must ensure that all allegations and incidents of abuse are followed up promptly and action taken including timely reporting to the safeguarding team. The home must ensure that the staffs employed are fit to work at the care home, especially the overseas staff with student visa. The home must ensure that the overseas staff work permit details do not contravene with the terms and conditions of the employment contract. The home must ensure that there is a staff training and development programme and ensures staff fulfil the aims of the home and meet the changing needs of the service users. The home must ensure that the policies, procedures, and practices are regularly reviewed in light of changing legislations and of good practices. The home must ensure effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and statement of purpose of the home. The home must ensure that the results of service user surveys are published and made available to current and prospective service users, their representatives, and other interested parities. The home must ensure that two written references are obtained and at least one is from the previous employer before appointing a member of the staff and any gaps in employment records are explored. The home must ensure that service user are assessed, by a person trained to do so, to identify service user who are at risk of developing, pressure sores and appropriate intervention is recorded in the care plan. Please contact the provider for advice of actions taken in response to this inspection. The Georgiana DS0000044852.V347432.R01.S.doc Version 5.2 Page 7 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. The Georgiana DS0000044852.V347432.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Georgiana DS0000044852.V347432.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had ensured to undertake need assessments, prior to the admissions of potential service users’ to the home. EVIDENCE: On this inspection, on a random basis 6 service users’ preadmission assessment were seen. The home had appropriate arrangements for the preadmission assessment. Initial, enquiry form and a pre-admission assessment tools were used for all the new admissions, as to determine whether the home can meet the assessed needs of the potential service user’s. The home did not have service users’ referred for intermediate care. The Georgiana DS0000044852.V347432.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 home had prepared care plans for the service users’ and has carried out monthly reviews. However, there was no evidence provided, how the service user, or the family member, or an advocate was engaged in the preparation and agreeing to the care plan prepared by the home. The care plan should reflect the changing needs of each individual service users’ corresponding to their mar sheet prescription. EVIDENCE: The staff and the service users’ appeared to have good working relationship that ensured the service users’ privacy and dignity; the service users spoken to confirmed this. The home had used a structured needs and risk assessment tool to arrive at a rating that determined the service provision and delivery as part of the care plan. The monthly care plan reviews consistently recorded no changes in the rating; there was no evidence to support as to how the home has arrived at a conclusion for rating without using structured tool. One service user was rated heavy for pressure sore assessment and was provided normal mattress. When The Georgiana DS0000044852.V347432.R01.S.doc Version 5.2 Page 11 asked, the manager agreed to refer to the DN and implement recommendation. The medication section of the care plan did not reflect the changing medication as prescribed on the mar sheet. There was no evidence provided, how the service user, or the family member, or an advocate was engaged in the preparation and agreeing to the care plan prepared by the home. On this inspection 6 service users’ were case tracked and their summary details are as follows: Service user – 1 care plan dated 03/08/07 covered details of general health, goal achievement, and recommendation. Monthly care plan review for May, June, and August 2007 and medication review dated 01/09/07 and 23/07/07 carried out, recorded no changes. However, the mar sheet had recorded information about glucomen test strips 50 and E45 cream and this information was not reflected in the care plan. There was no evidence on the care plan with regard to, how the home had engaged the service user and family members in the preparation of the care plans and their reviews. Service user – 2 care plan was dated 30/04/07. Monthly care plan reviews of 2/05/07, 25/06/07, 28/07/07, and 22/08/07 recorded no changes. However, when the mar sheet and care plan medication section was compared, it was found that, the mar sheet had gliclazide tabs 80mg half tablet to be taken twice a day, felodipine tabs m/r 2.5mg take one morning, furosemide – soi – 20mg one spoon daily for 10 days. These three medicines were not reflected on the care plan. Nevertheless, the medicine in the stock and the mar sheet tallied. There was no evidence on the care plan with regard to, how the home had engaged the service user and family members in the preparation of the care plans and their reviews. Service user – 3 care plan was dated 06/03/07. Monthly care plan review for 25/04/07, 25/05/07, 25/06/07 and 18/07/07 recorded no changes. However, when mar sheet and care plan medication section was compared, it was found that, the mar sheet had codeine tabs 30mg one or two to be taken four times daily, adcal d3 tabs chewable and co-dydramol tabs 10/500mg take one morning one lunch. These three medications were not reflected in the care plan. Nevertheless, the medicine in the stock and the mar sheet tallied. There was no evidence on the care plan with regard to, how the home had engaged the service user and family members in the preparation of the care plans and their reviews. Service user – 4 care plan was dated 10/05/07. Monthly care plan review for 15/05/07, 17/06/07, 17/07/07, and 28/08/07 recorded no changes in the care plan. However, when the mar sheet and the medication section was compared, it was found that, the mar sheet had` recorded to provide paracetomol as and when required, cavilon cream and prednisolone eye drops were not reflected in the care plan. There was no evidence on the care plan with regard to, how the home had engaged the service user and family members in the preparation of the care plans and their reviews. The Georgiana DS0000044852.V347432.R01.S.doc Version 5.2 Page 12 Service user – 5 is a new admission and the care plan was dated 16/08/07. No issue were identified with regard to medication section of the care plan. There was no evidence on the care plan with regard to, how the home had engaged the service user and family members in the preparation of the care plan. Service user – 6 care plan was dated 08/06/07. Monthly reviews carried on 27/07/07 and 29/08/07 recorded no changes and the property list – items received on admission had no signature of staff. No issue were identified with regard to medication section of the care plan. There was no evidence on the care plan with regard to, how the home had engaged the service user and family members in the preparation of the care plan. The Georgiana DS0000044852.V347432.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 good. This judgement has been made using available evidence including a visit to this service. The service users’ had the choice of menu and timings, and activities provided were in the interest of the service users’. EVIDENCE: The home had provided a separate room and an activity coordinator who engaged service users 4 days a week from 2.00pm to 6.00pm and for 5hours on a Saturday. The 6 service users’ those were case tracked, their activity records were seen, the activity notes indicated that the home had offered a wide range of individual and group based activities. The activity notes record provided information about the nature of activity organised and the participation of the service users’. 7-service users were taken on a holiday to Norfolk for 5 days accompanied by staff members as well. The service users were encouraged to have their choice when decorating bedrooms and bring in their personal belongings to personalise their rooms, one service user had owned a cat. Visiting during lunch time by friends and /or relatives was discouraged by the home, so that the staff could concentrate on giving help to those who needed it. This in fact was taking place. Visits could take place if arranged with the staff in charge at the time. One service user visiting his wife was actually having lunch with her and said he did this quite regularly. He said The Georgiana DS0000044852.V347432.R01.S.doc Version 5.2 Page 14 the meals were very nice and his wife was being well looked after although he was sorry he could no longer do this himself. There was a choice of menu, which was given as it was served. If given the day before many would have forgotten or changed their mind. Those that were spoken to say they were enjoying their meal and that the food was good with good variety and choice. The menus where up in the kitchen and ran on a four week cycle. The kitchen and staff had recently received five stars and a certificate for hygiene. The Georgiana DS0000044852.V347432.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home’s complaints policy, procedure and practice has not ensured the service users’ were protected from abuse; especially, timely reporting of incidents to the safegaurding team. EVIDENCE: The manager had dealt with the complaints received appropriately, for example, one family member complained about the missing teeth, the shaver, medication tablet belonging to another service user and inhalers. The manager had held a senior staff meeting and has rectified and has written a letter to the complainant. Another service user’s family member complained about personal hygiene and communication with family regarding the activities undertaken by the home. The manager had a staff meeting addressed the concerns made in the complaint and had replied to the complainant on the actions taken. However, the home had an alleged incident regarding a service user and a night staff on the 23/01/07. The staff member in question was suspended from duty until the allegation has been investigated, and the alleged incident was not reported to the safeguarding team at the time, and the commission had not received Reg 37 notification as well. When asked the manager had said that she was not aware of the incident, until a family member of the service user had written to the manager, dated 12/02/07. Also, after 12/02/07, the commission had not received Reg 37 notification. In the visit meeting by the community care worker on the 15/02/07 to the service user, it was found that The Georgiana DS0000044852.V347432.R01.S.doc Version 5.2 Page 16 the service user had a fall in her room and was not recorded in the personal record book. The home had a complaints policy and procedure that was reviewed on the 03/01/07, which was not robust and was scheduled for an update before 27/09/07, the manager informed. The home must maintain an appropriate complaints log/incident log for all the service users’. The Georgiana DS0000044852.V347432.R01.S.doc Version 5.2 Page 17 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, 22 and 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home must complete the impementation of the recommendations made in the report by the Occupational Therapist to ensure service users live in a safe and well maintained environment. EVIDENCE: The home was maintained clean, pleasant, hygienic, and there was no offensive odours. The home had also undertaken redecoration and repair work in few rooms, toilets and office room. The home had been taking weekly hot water temperature and has maintained a record of the same. The home was in the process of installing a new spa bath. The Letter from the manager received by the commission in the form of a fax on the 24/05/06 which said ‘Building risk assessment carried out by the Occupational Therapist in June 2005, still to action the recommendations as set out in the report. Suggessted to complete over the next two months’. In the random inspection report of The Georgiana DS0000044852.V347432.R01.S.doc Version 5.2 Page 18 26/07/06 under environment it was stated - A requirement was made in the previous inspection report that the home must action all recommendations of the building risk assessment before 30/07/06. None of the recommendations were actioned as on 26/07/06 and the manager suggested a time extension until end of September 2006 for completion. However, a requirement was made with another extension of time 31/10/06. The home must action all the building risk assessments recommendations to ensure safety and comfortable stay of all the service users’. The manager had sent in a letter dated 13/11/06 saying that ‘ I confirm that all toilet hand rails where the walls are able to take them will be completed by the end of December 2006, and where it is not possible to fit these a free standing raised toilet seat with hand rails will also be in situ by the end of December 2006’. On this inspection a tour of the premises was undertaken, in response to the requirement made in the previous inspection report, it was found that some of the recommendations made in the report by the Occupational therapist have been actioned. However, the manager said, that all the recommendations could not be implemented because of the untimely death of the maintenance person. This must now be actioned as a matter of priority. The Georgiana DS0000044852.V347432.R01.S.doc Version 5.2 Page 19 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 home had a good skill mix of staffs and work as a team. The home must have adequate staff to ensure all the assessed needs of all the service users’ are met on all the shifts. The home must have a robust staff recruitment policy and practice and training that ensure the protection of the service users’. EVIDENCE: On the day of this inspection the home was accommodating 42 service users’, of whom 12 have dementia. The home operates a three-shift staff model. Shift one was from 7.00am to 2.00pm with 7 staff members, shift two was from 2.00pm to 9.00pm with 7 staff members and night shift from 9.00pm to 7.00am with 3 walking staff plus 1 staff on call. The manager said that, the additional staff member would be deployed, as and when the service users occupancy increased to 43 or 44, to meet with the appropriate staff ratio. The home need to revisit this assessment and consider the deployment of staff against the assessed needs of the service users, the size, and layout of the home to ensure there are sufficient staff on duty at all times. The home had staff recruitment policy and procedure, which was reviewed on the 03/01/07. The policy clearly stated that the ‘home’s manager will be responsible for the employment and recruitment of new staff’. However, this did not happen in practice when overseas staff are employed. The manager has no control over the process of recruitment, and there were gaps found in these recruitment processes, when asked for information on the gaps, the The Georgiana DS0000044852.V347432.R01.S.doc Version 5.2 Page 20 manager was not aware, and said the provider was directly dealing with the overseas staff recruitment. However, in the capacity of a Registered Manager must assure herself, that the provider had followed appropriate recruitment procedures prior to the employment of the staff members. The recruitment process, summary details of 2 overseas staff members and 1 local staff is as follows: Staff member – 1 was working as a care assistant from the 07/08/07, POVA first clearance was obtained on the 31/07/07, CRB clearance was obtained on 10/09/07.The staff member was on a student visa and was contracted for 35hrs per week. The references provided do not match with the previous employer as stated in the job application. Staff member – 2 references provided do not match with the previous employer as stated in the job application. The staff member was on a work permit which stated salary annual salary and designated as senior carer. Where as, the staff member was contracted for, to work as a carer with, 42hrs per week, on an hourly rate. Staff member – 3 had been working since the 10/09/07, had POVA clearance, CRB clearance awaited, references received and employment contract was not signed yet, the manager informed that she was waiting the staff to complete 6 weeks of work prior to signing the employment contract. However, there was no mention about this in the home’s recruitment policy and procedure. Staff monthly supervision was carried out regularly which was task specific and the annual appraisal was comprehensive in nature. The manager informed on the inspection that the home was in the process of introducing six monthly appraisals from October 2007 for all the staff members. The staff handover notes used during change of shifts, that was an important communication channel for the staff to refer and act upon was stopped from the 19/02/07 and this has been one of the concerns raised by a family member of a service user. The manager informed on this inspection that the staff hand over notes during the change of shifts would be reintroduced soon. The home had arranged for staffs training in manual handling, Safeguarding adults, dementia, food hygiene, bereavement, health and safety, continence, infection control, first aid and medication. However, as per the training records provided on the inspection, only 2 staff members have received training in risk assessment. The manager informed on this inspection that, she was in the process of developing a training calendar for all those staff, those who have not had the opportunity to complete all the mandatory training, including refresher courses as required. The Georgiana DS0000044852.V347432.R01.S.doc Version 5.2 Page 21 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 home manager had made efforts to ensure the service users’ assessed needs are met. However, the non – compliance of environment standards, staff recruitment practices, care plan updates and inadequate policy and procedures are a cause of concern for the service users’ safety and well being. EVIDENCE: The manager had made significant efforts to improve the service provision and delivery. However, due to lack of adequate support and compliance by the provider to meet the outstanding environment requirements and staff recruitment practices, the management outcome group is judged as poor. Please refer to details under environment and staffing outcome groups of this report. The Georgiana DS0000044852.V347432.R01.S.doc Version 5.2 Page 22 Given the size and nature of service users’ needs, the home had made some improvements with regard to the redecoration and repair work of the premises and has carried out regular monthly care plan reviews, although need to improve these, please refer under health and personal care outcome group of this report, for details. The home had planned to introduce a policy and procedure for the management of the service user’s money before 27/09/07. However, the current practice was to record date, amount, source of money, withdrawal, balance of money, and two staff signatures. The home had used the quality assurance audit tool, which was developed by Mulberry House, as per the record provided on this inspection the following were audited on: statement of purpose dated 21/11/05 and 24/11/05, care plan dated 01/01/06, handling enquiries dated 24/11/05, service user guide dated 12/12/05, trial visit dated 06/01/06, confidentiality dated06/01/06, activities dated 12/12/06, and meals dated 12/12/06. The manager said that they were due for review every year. The home had initiated service users’ and relatives meeting. The meeting of 08/07/07 minutes provided on this inspection indicated that the home had provided clarification to the participants with regard to activities, food menu, personal care, and hygiene, and the bedrooms. This was a good beginning to assess the care provision and delivery to meet the needs of the service users’. The manager said that the responses received from the service users, their family members and others have not been analysed and the outcomes have not been shared with the service users’ families. Regulation 26-provider visit reports were seen for 30/04/07 and 25/05/07 that recorded no issues identified, and there was no other report provided on this inspection after the 25/05/07. The manager also provided information with regard to weekly checks carried out regarding mar sheet and control drugs, however the system and procedures used were not enough to evidence how the checks were carried out and what remedial action would be taken when errors identified, across each service user, including cross referencing with the care plan under medication section. The home had also introduced night shift hourly checks to monitor whether the service user was awake and asleep, the home need to further improve upon the monitoring practice to check service user and record, when any need identified and action taken during the night shift hourly checks. The home had undertaken reviews of policy and procedures. However, some of them were outstanding and some needed update. For example, the smoking policy was dated 03/01/07 and has not taken into account the recent changes made by the government. Complaints policy and procedure was reviewed on the 03/01/07 and needed amendments, please refer complaints outcome group of this report for details, employment and recruitment policy and procedure review was dated 03/01/07 and needed amendments, please refer The Georgiana DS0000044852.V347432.R01.S.doc Version 5.2 Page 23 staffing outcome group of this report for details, infection control policy was dated 20/10/05 and reviewed on 02/01/07 and recorded no changes, the manager was asked to contact the health protection agency and make suitable amendments to the policy and procedures of practices. The Georgiana DS0000044852.V347432.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 X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 2 X X 1 X X X 3 STAFFING Standard No Score 27 2 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 X X 1 The Georgiana DS0000044852.V347432.R01.S.doc Version 5.2 Page 25 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 OP22 Regulation 23 (2)(5) Requirement The home must action all the building risk assessments recommendations to ensure safety and comfortable stay of all the service users’. (Previous time scales 30/07/06, 31/10/06 and 30/12/06 – partially met). Timescale for action 30/12/07 2. OP7 15 (1), (2) (a) (c) (d) 15 (2) (b) (c) 23 (2) (n) 3. OP7 4. OP19 The home must evidence that 15/11/07 the service user agreed and signed the care plan whenever capable and / or representative if any. The home must ensure to reflect 31/10/07 changing needs of the service users’ in their care plan including the medication section. The home must make suitable 30/12/07 adaptations with appropriate equipment and facilities that are provided for all the service users’. (Previous time scale 30/12/06 partially met) The home must have adequate staffs’ to ensure all the assessed needs of all the service users’ are met on all the shifts. (Previous time scale 15/12/06) DS0000044852.V347432.R01.S.doc 5. OP27 18 (1) (a) 31/10/07 The Georgiana Version 5.2 Page 26 6. OP38 13 (4) (a) The registered person must ensure that all parts of the home to which service users’ have access are free from hazards to their safety. (Previous time scale 30/12/06 – partially met) 30/12/07 7. OP18 13 (6) 8. OP29 9. OP29 10. OP30 11. OP33 12. OP33 13. OP33 The home must ensure that all allegations and incidents of abuse are followed up promptly and action taken including timely reporting to the safeguarding team and Reg 37 notification to the commission. 19 (1) The home must ensure that the staff employed is fit to work at the care home, especially the overseas staff with student visa. Schedule The home must ensure that the (2) overseas staff work permit details do not contravene with the terms and conditions of the employment contract. 18 (1) ( c) The home must ensure that there is a staff training and development programme and ensures staff fulfil the aims of the home and meet the changing needs of the service users. 12 (1) (a) The home must ensure that the policies, procedures, and practices are regularly reviewed in light of changing legislations and of good practices. 24 (1) (a) The home must ensure effective (b) quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and statement of purpose of the home. 24 (1) (a) The home must ensure that the (b) results of service user surveys are published and made available to current and DS0000044852.V347432.R01.S.doc 15/10/07 15/10/07 15/10/07 15/10/07 15/11/07 15/11/07 15/11/07 The Georgiana Version 5.2 Page 27 14. OP29 15. OP8 prospective service users, their representatives, and other interested parities. 19 (b) ( c) The home must ensure that two written references are obtained and at least one is from the previous employer before appointing a member of the staff. And any gaps in employment records are explored. Schedule The home must ensure that 3 (3) (n) service user are assessed, by a person trained to do so, to identify service user who are at risk of developing, pressure sores and appropriate intervention is recorded in the care plan. 15/10/07 15/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP16 Good Practice Recommendations The home should maintain appropriate complaints and incidents records for all the service users’. The Georgiana DS0000044852.V347432.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Georgiana DS0000044852.V347432.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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