Care Home: Englewood Care Home

What the care home does well The service provides activities for individuals and enables people to maintain contact with their families. The service provides information to individuals and their families if they wish to raise concerns about the service. The service protects individuals through the way it recruits new members of staff. The financial interests of individuals are safeguarded. Comments received through surveys from staff included: `We have a 3:1 carer to service user ratio` `We provide a good quality of care` `It is a warm and welcoming home with a lovely atmosphere, the staff look after residents well. There is nothing to improve upon` `There is a low staff to resident ratio` Other surveys did not provide specific comments but indicated that they had received training to meet the needs of the people who use the service. What has improved since the last inspection? The service now refers any allegations of abuse the Local Authority. The systems has taken steps to eradicate any offensive odours in bedrooms with the fitting of appropriate flooring to these areas. What the care home could do better: This inspection found a number of deficiencies within the service and a lack of response to requirements raised from previous visits. The Annual Quality Assurance Assessment received by us prior to our visit was not detailed and did not provide us with enough information. The service does not meet people`s needs through the assessment process prior to people coming to live at Englewood. Its own assessments have been completed by an individual who is not suitably qualified and the service has failed to obtain assessment information from the authority who funds people`s care. The service still does not meet people`s needs by its failure to produce care plans for all individuals and the lack of detail contained within care plans. The service still does not meet the health needs of individuals through the lack of assessments relating to the number of falls experienced by people. The service still does not manage medication in a manner which promotes the health and safety of individuals. The service does not meet the nutritional needs of the people who use the service or cater for the dietary needs of people. The service still does not protect vulnerable adults from abuse through the lack of staff training and the lack of policies and procedures. The service does not employ ancillary staff to supplement the role of carers with the result that the needs of people are not met. The people who use the service are supported by staff who are still not trained to meet their needs or trained to keep them safe. The people who use the service still do not receive a service that is accountable through the lack of a registered manager. The service still does not serve the interests of the people who use the service given that they do not notify us of any adverse incidents that affect the wellbeing of people. The service does not promote the health and safety of people who use the service given that fire drills do not take place and fire risk assessments are not updated. The service has not enabled portable hoists to be serviced and as a result has not promoted the health and safety of the people who use the service. Key inspection report Care homes for older people Name: Address: Englewood Care Home 42-44 Egerton Park Rock Ferry Birkenhead Wirral CH42 4QZ     The quality rating for this care home is:   zero star poor service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Paul Kenyon     Date: 1 4 0 4 2 0 1 0 This is a review of 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. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 32 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. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 32 Information about the care home Name of care home: Address: Englewood Care Home 42-44 Egerton Park Rock Ferry Birkenhead Wirral CH42 4QZ 01516455064 01516455069 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Englewood Care Limited Name of registered manager (if applicable) Type of registration: Number of places registered: care home 24 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia Additional conditions: 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 Brief description of the care home 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 roomlounge overlooking the spacious garden. The home has a call system and mobility aids. There Care Homes for Older People Page 4 of 32 Over 65 0 24 Brief description of the care home is a large car park at the front. When we visited, the weekly fees for the home were between 395.22 and 458.63 pounds. Additional charges are made for hairdressing, newspapers, clothing, medical requisites other than prescribed medications items of a luxury nature and chiropody. Care Homes for Older People Page 5 of 32 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: zero star poor service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: This was an unannounced key inspection of Englewood. The inspection was spread over two days. The first day involved the examination of records, interviews with staff members, discussions with the Registered Provider, a tour of the premises and observations of care practice. For the purposes of this visit, two Inspectors visited as well as a Pharmacy Inspector who examined the management of medication. The second day of the visit was briefer and involved the gathering of further information in relation to staffing rotas and medication. The service submitted an Annual Quality Assurance Assessment prior to the visit and we received a number of staff surveys outlining staff experiences of working in Englewood. The nature of the disability of the people who use the service is such that it is not always possible to gain an indication of their experiences of living there. We were able Care Homes for Older People Page 6 of 32 to observe care practice within the service in order to gain an indication of the quality of care they were receiving. During the visit there were five people living at Englewood. Care Homes for Older People Page 7 of 32 What the care home does well: What has improved since the last inspection? What they could do better: This inspection found a number of deficiencies within the service and a lack of response to requirements raised from previous visits. The Annual Quality Assurance Assessment received by us prior to our visit was not detailed and did not provide us with enough information. The service does not meet peoples needs through the assessment process prior to people coming to live at Englewood. Its own assessments have been completed by an individual who is not suitably qualified and the service has failed to obtain assessment information from the authority who funds peoples care. The service still does not meet peoples needs by its failure to produce care plans for all individuals and the lack of detail contained within care plans. The service still does not meet the health needs of individuals through the lack of assessments relating to the number of falls experienced by people. The service still does not manage medication in a manner which promotes the health and safety of individuals. The service does not meet the nutritional needs of the people who use the service or cater for the dietary needs of people. The service still does not protect vulnerable adults from abuse through the lack of staff training and the lack of policies and procedures. The service does not employ ancillary staff to supplement the role of carers with the Care Homes for Older People Page 8 of 32 result that the needs of people are not met. The people who use the service are supported by staff who are still not trained to meet their needs or trained to keep them safe. The people who use the service still do not receive a service that is accountable through the lack of a registered manager. The service still does not serve the interests of the people who use the service given that they do not notify us of any adverse incidents that affect the wellbeing of people. The service does not promote the health and safety of people who use the service given that fire drills do not take place and fire risk assessments are not updated. The service has not enabled portable hoists to be serviced and as a result has not promoted the health and safety of the people who use the service. 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. Care Homes for Older People Page 9 of 32 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 32 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who come to live at Englewood do not have their needs met by the way the service assesses their needs. Evidence: One person had come to live at Englewood since our last visit. We looked at the way the service had assessed their needs before they had to come to live there. There was no evidence that an assessment had been obtained from the Local Authority who funds this persons care. The service had completed their own assessment on this person but this was limited in content and had been completed by a person who does not have the training to complete such assessments. Care Homes for Older People Page 11 of 32 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who live at Englewood still do not have their needs met by the way the service devises care plans and still do not have their health needs promoted. Further to this their health needs are still not promoted by the management of medication in the service. Evidence: We looked at how the service identifies the needs of people through its care plans. We looked at a sample of five care plans in total. One person had come to live at Englewood since our last visit. There was no care plan relating to this person and as a result there was no indication how this person could be supported by the service. A number of assessments had been completed relating to this person in relation to how they functioned in their daily lives yet these did not indicate how the person was to be supported. Our last visit to the service also identified that two care plans were not available for individuals using the service at that time. Other care plans outlined the needs of people but did not specify how each person could be best supported. Care plan reviews were in place for some but not for all and there was still no evidence that care plans had been signed by peoples representatives to confirm their agreement Care Homes for Older People Page 12 of 32 Evidence: with content of each care plan. We looked at how the service maintains the health of individuals. We examined information relating to five people. There was evidence that health professionals such as General Practitioners and District Nurses had visited individuals and that each person had been registered with a General Practitioner. Individuals had had their weight monitored and the likelihood of individuals developing pressure sores had been completed. There was either no or outdated information in relation to some assessments relating to the health needs of individuals. Continence assessments were not always in place so that there was no indication of what continence products were appropriate for some individuals. There was no information that the risk people faced from falls had been assessed despite this being raised as a requirement during our last visit. One person had experienced a high number of falls during the past twelve months yet there was no evidence of documentation to suggest that this had been assessed or indeed that we as the regulator had been informed of these adverse incidents. Handling risk assessments were either absent or outdated. There was also little detail in records to suggest how the oral hygiene needs of individuals could be met. In some cases, nutritional risk assessments had not been completed. We found that there was still poor practice when handling and recording medicines which meant that the health and wellbeing of people who live in the home was placed at unnecessary risk of harm. We looked at a sample of records and stock and we found that medicines had not always been given to people as prescribed or recorded accurately. We could see no evidence that medicines were given at the correct time with regard to food and drink. People are unlikely to get the best from their medication if it is not given at the correct time in relation to food and drink. Missing medicines can seriously affect a persons health and wellbeing. When the administration of medicines is not accurately recorded, people are at risk of being given the wrong amount of medicine. Some people were prescribed medicines to be taken only when required e.g. painkillers. There was no system in place for recording detailed information about how and when these medicines were to be given in peoples care plans, meaning that staff had no instructions to follow for these items. There were still no effective formal audits (checks) of the medicines handling system in place. This meant that mistakes were not being found and acted upon to help prevent them happening again. There was no evidence of a formal system for checking and recording the competence Care Homes for Older People Page 13 of 32 Evidence: of care staff actually administering or recording medicines. Checking the competence of staff ensures they are safe to carry out their duties without supervision Care Homes for Older People Page 14 of 32 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who use the service are provided with a programme of activities and are able to maintain contact with their families. They are able to maintain a degree of independence but attention should be paid to freedom of movement they have within the building. Their nutritional needs are met although attention should be paid to the level of support they receive a mealtimes. Evidence: We looked at how activities are provided to the people who use the service. An Activities co-ordinator is available and this person works each afternoon.During this time they take responsibility for all the individuals living at the service. The activities co-ordinator maintains records of those activities that people are engaged in. A poster is on display offering details of activities on offer.The poster on display is looked at by some individuals but not all. It includes details of the activities on offer as well as photographs of people pursuing those activities. It is still recommended that the format for passing on details of activities information is devised and reviewed by the service so that people know what activities are on offer. Some people receive visitors while others do not. There was evidence through the visitors book of people visiting the service to see their relations. No one was visiting Care Homes for Older People Page 15 of 32 Evidence: on the day of our visit. We looked at how the people who use the service are offered independence in their daily lives. Families deal with the finances of people although there is provision in the service to store and account for small amounts of pocket money. A tour of the premises noted that some personal possessions were included within bedrooms such as furniture and photographs. There is no evidence that anyone receives advocacy services. An observation of care practice noted that individuals who may wish to move independently in building are prompted into areas in which staff want them to be. There appeared to be little choice given to individuals as to where they wished to go. We looked at how meals are provided in the service. We noted that nutritional assessments and information on dietary needs were incomplete. A menu is on display.For alternatives meals, people are directed to ask the cook before 10 am as to any differing meals they wish. This format does not assist people who have the communication needs that the people living at Englewood have. The kitchen has all the equipment needed to cater for people. Care staff are expected to cook meals as well as perform other roles in the service.-An Environmental health visit last took place in November 2009 and this indicated no issues. There were sufficient food stocks in place. We made some observations of lunchtime. The meal offered appeared to be nutritious. The meal was different from what was on offer in the menu. It was noted that no condiments were offered or indeed any drinks during the meal. One person needed a piece of cutlery but no staff were available to attend to this wish. Eventually everyone was offered a cup of tea but there appeared to be no choice in drinks served. Care Homes for Older People Page 16 of 32 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Information is available for people and their families who wish to make a complaint. The people using the service are not protected from abuse. Evidence: We looked at how the service deals with any complaints it receives. A complaints procedure is on display in the hallway and this includes details of how complaints would be dealt with as well as our details. Two complaints have been received by us since our last visit. We responded by incorporating the concerns within this visit. No complaints have been recorded in complaints records. A requirement from our last visit raised the need for the Registered Provider to raise any allegations of abuse through the process with the Local Authority. On this visit, the Manager stated that three referrals had been made to the safeguarding unit. Training records still suggest only some staff have been on abuse training. It is still required that this is extended to all. There is no information in the services policies and procedures on how staff can report abuse,the extent to which they should be involved in the financial interests of individuals or the whistleblowing procedure. As a result people not protected from abuse. Care Homes for Older People Page 17 of 32 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who use the service live in an adequately decorated, maintained and hygienic environment. Evidence: We looked at the environment that people are provided with. We toured the premises in order to do this. Previous issues in relation to heating and lighting in the home had improved. The tour included the lounge, dining room, kitchen, the exterior of the building and all bedrooms and bathrooms. No offensive odours were noted in the building. This was an issue at our last visit especially in two bedrooms. The Registered Providers showed us the steps taken in order to address this with the provision of new flooring in two bedrooms. There were no issues in respect of the standard of decoration in the building. A repairs record was available but this had not been completed since our last visit. External grounds are available and are accessible to those who wish to use them. The grounds did not appear to be maintained but were not overlooked. No close circuit television cameras are in place and the last Environmental health report in November 2009 did not highlight any issues. There are issues in respect of fire prevention which are explored later in this report. Care Homes for Older People Page 18 of 32 Evidence: We looked at hygiene standards in the building. Care staff are expected to perform the role of domestic staff as well as their care role and other roles. This is explored later in this report. A laundry is available in the cellar area to which the people who use these service do not have access to. Industrial appliances are installed in this facility. Care Homes for Older People Page 19 of 32 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who use the service are supported by staff whose additional roles do not ensure that the needs of people are consistently met. Recruitment does protect the people who use the service but staff are not trained to meet their needs. Evidence: We looked at staffing levels in the service and how these meet the needs of the people living there.Staff rotas indicate two members of staff on are duty during most of the day with an activities co-ordinator working during the afternoon. The service still has no cook, domestic or laundry assistant. Care staff are expected to perform these roles. There were two care staff on duty for six people. It is still required that the skill mix is improved so that care staff can concentrate on their roles. The Manager is included in the rota but did not appear to be adopting a care role during our visit. The Registered Provider was also present during the visits. There was still no evidence that staff levels deviate from two on duty and an activity co-ordinator. There remains some evidence in care files that the dependency levels of people have been assessed in the past but not an ongoing exercise. It is recommended that this is re-introduced so that the care staffing levels can be linked to the dependency needs of individuals. The rota suggested that the Registered Provider had worked as carer in the past despite not having the skills or training to perform this role. There was a suggestion from the rota that the Provider had worked in the role of a carer. The Registered Care Homes for Older People Page 20 of 32 Evidence: Provider admitted that he does not have the skills or training to do this. We conducted a further visit to determine this further. Rotas did suggest that the Registered Provider was on duty in his role as the Provider rather than a carer. The Registered Provider did state that he had had to work as ancillary staff as opposed to a carer when staffing shortages had occurred. He further stated that this was because only one carer had been on duty. Given that this staffing shortage had occurred, we were not informed of this through statutory notification as required under Regulation 37 of the Care Standards Act 2000. Information received by us prior to our visit in the services Annual Quality Assurance Assessment suggested that the majority of staff are qualified at National Vocational Qualification Level 2. This was confirmed through certificates on file and through staff interviews. We looked at two personnel files relating to staff who had started work since our last visit. These files included all checks such as references, checks against the vulnerable adult list, police checks and proof of staff identity. We looked at staff training. Training records suggested that there were still significant gaps in training received by staff in mandatory health and safety topics and training designed to meet the needs of people. Care Homes for Older People Page 21 of 32 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who use the service do not receive a consistently well managed service and the service is not run consistently in the best interests of individuals. The financial interests of people are safeguarded but their health and safety is not promoted by the service. Evidence: The service has a new Manager who has come to work at the service since our last visit. This person was previously registered with us as the Manager of a Domiciliary Care Agency.Since our last visit, no candidate has been forwarded by the Registered Provider to become registered with us. This still remains a requirement. We looked at how the service examines the quality of the service it provides. The Registered Provider stated that questionnaires sent to families and responded to. We also received surveys from the staff team in respect of their experiences working in the service. No requirements that we raised at our last visit have been responded to. For the purposes of this visit, we took copies of documentation under legislation. The Care Homes for Older People Page 22 of 32 Evidence: service co-operated with this at all times and cooperated with all our requests. We looked at how the service safeguards the financial interests of individuals. The service provides safekeeping of pocket money. These are stored securely and reinforced with the maintaining of records and obtaining of receipts. We checked two amounts of money and reconciled these with records to our satisfaction. We looked at how the health and safety of people is promoted by the service. Training records suggested that no staff had received recent health and safety training. An issue at our last visit highlighted the need to have portable electrical appliances tested. This had now been done.We noted that the service had not completed a fire risk assessment since 2007 and that the fire safety policy had only been completed at this time. This was combined with the fact that no fire drills had been undertaken in the service. This is raised as a requirement in this report. There was evidence that fire extinguishers had been serviced with fire alarms and emergency lighting being tested. Certificates confirmed that electrical wiring and gas systems had been checked but there was no evidence that portable hoists had been serviced since 2007. This is raised as a requirement. Radiators have been covered and window restrictors are in place. The service has a duty under legislation to inform us of any incident which adversely affect the well being of the people who use the service. The service has not written to us informing us of staff shortages, safeguarding referrals or the number of falls experienced by one person. Care Homes for Older People Page 23 of 32 Are there any outstanding requirements from the last inspection? Yes R No £ Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 1 7 15 The service must ensure that 26/02/2010 each person who uses the service has a care plan so that their needs can be met. 2 8 12 The service must ensure that 26/02/2010 risk assessments relating to falls are completed and provide a clear indication of the likelihood that a person will be at risk from repeated falls. so that their health and safety is promoted 3 9 13(2) Records for the receipt, 31/12/2009 disposal and administration of medicines must be complete and accurate to reduce the risk of mistakes and to help ensure medicines are given properly. 4 9 13 The Registered Person must 31/12/2009 ensure that regular audits (checks) are undertaken on all aspects of medicines management within the service. Findings and actions taken as a result of these audits should be recorded. Care Homes for Older People Page 24 of 32 Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action 5 9 13 Medication must be 31/12/2009 administered as prescribed and at the correct time with regards to food and drink, in order to ensure that the medicine works properly. 6 27 18 The registered person must 31/12/2009 ensure that there are sufficient staff available to meet the needs of the service users at all times, including cleaning, laundry and catering. An assessment must take place of the current staffing arrangements given the number and needs of the residents, size and layout of the home. This requirement was made at an earlier inspection and was to be met by 01/09/2009. 7 38 37 The service must inform the Care Quality Commission of any incident that adversely affects the well being of the people who use the service so that their best interests are served. 17/02/2010 Care Homes for Older People Page 25 of 32 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 3 14 The Registered Person must ensure that any assessments completed prior to a person coming to live at Englewood are completed by a suitably qualified person so that the needs of people are fully met. 14/05/2010 2 3 14 The Registered Person must ensure that a copy of Local Authority assessments are available prior to a person coming to live at the service so that their needs can be fully met. 14/05/2010 3 7 15 The Registered Person must ensure that care plans include specific details of how individuals can best be support in their daily lives so that their needs can be met 14/05/2010 Care Homes for Older People Page 26 of 32 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 4 7 15 The Registered Person must ensure that care plans are available for all people who use the service so that their needs can be met Previous requirement not met by timescale of 26/3/2009 14/05/2010 5 8 13 The Registered Person must 14/05/2010 ensure that risk assessments relating to falls are completed and provide a clear indication of likelihood that a person will be at risk from repeated falls so that their health and safety is promoted. Requirement not met 26/02/2010 6 9 18 Medication must only be 14/05/2010 administered by staff who have undergone training and been assessed as competent to handle medicines safely. in order to protect the health and wellbeing of people living in the home. This requirement was made a previous inspection and was to be met by 31 December 2009. Care Homes for Older People Page 27 of 32 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 7 15 15 The Registered Person must ensure that information on the dietary needs of people is available so that the nutritional needs of individuals are met 14/05/2010 8 15 17 The Registered Person must ensure that nutritional assessments are completed so that the nutritional needs of individuals are met 14/05/2010 9 18 18 The Registered Provider must provide information to staff on their involvement in wills and receiving gifts. receipt of gifts and wills so that people can be protected from abuse Previous requirement not met 26/02/2010 14/05/2010 10 18 13 The Registered Person must provide information to staff relating to the whistleblowing procedure so that people can be protected from abuse Previous requirement not met 26/02/2010 14/05/2010 11 18 18 The Registered Provider 14/05/2010 must consistently provide safeguarding training to staff Care Homes for Older People Page 28 of 32 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action so that people can be protected from abuse Previous requirement not met 31/3/2010 12 27 18 The Registered Provider 14/05/2010 must ensure that sufficient staff are employed to ensure that care staff can concentrate on their roles as carers to ensure the needs of people are met Previous requirement not met 31/12/2009 13 30 18 The Registered Person must 14/05/2010 ensure that staff are provided with mandatory health and safety training such as First Aid, Fire Awareness, Infection Control and Food Hygiene. so that the health and safety of individuals is promoted. Previous requirement not met 31/03/2010 14 31 8 The Registered Person appoint an individual to manage the service so that the people who use the service receive care that is accountable. 14/05/2010 Care Homes for Older People Page 29 of 32 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Previous requirement not met 31/12/2009 15 38 13 The Registered Person must ensure that portable hoists are serviced periodically so that the health and safety of individuals is promoted 16 38 37 The Registered Provider must inform us of those events which adversely affect the well being of the people who use the service so that their best interests are served Previous requirement not met 17/02/2010 17 38 13 The Registered Person must 14/05/2010 ensure that fire drills are undertaken periodically and that the fire risk assessment is updated so that the health and safety of individuals is promoted Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 14/05/2010 14/05/2010 1 7 The Registered Person should ensure that the representatives of the people who live at Englewood sign to confirm the content of care plans so that they are involved in the care of their relatives. Care Homes for Older People Page 30 of 32 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 2 12 The format of the activities programme must be reviewed to take the needs of people into account so that they are aware of what activities are on offer. The Registered Person must review the practices of staff to ensure that people go where they wish to go to within the building provided that it is safe. The Registered Perons should review the level of staff support at mealtimes as well as review the choice people receivein respect of drinks and availibility of conidments offered with their meals so that they are provided with choice The Registered Provider should recommence the assessing of the dependency levels of individuals so that the staffing levels can be adjusted to meet the dependency of individuals. 3 14 4 15 5 27 Care Homes for Older People Page 31 of 32 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. 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