Care Home: The Edwardian

Similar services:

• Ashlea Mews Residential Home
• Eastwood
• West Lodge
• Arran House
• Avenue Community Nursing Home
• Cosin Lodge
• Farmborough Court
• Cragston Court

What the care home does well The Edwardian provides a comfortable and homely environment for people to live. People receive good care from an experienced and committed staff team. People made comments about what was good about the home. One comments made was, “Everything, staff are so nice and there is a good group of residents, it is a well run home”. Another person said, “This is home from home and I wouldn’t want to be anywhere else”. The Edwardian DS0000000006.V377298.R01.S.doc Version 5.2 Other people said, “It is a lovely home, all the staff are really nice, and we have a good relationship with the staff. They always have time for you and don’t brush you aside”. There are good opportunities for personal development, and people are able to make decisions, have control over their lives and be as independent as possible. Really good interactions were observed between people living at the home and staff, they were clearly respectful and good relationships have been developed. Staff are well trained, 100% of the permanent staff team are trained to NVQ Level 2 or above in care, which is excellent. The Edwardian is a well managed home, with clear and effective leadership. What has improved since the last inspection? Significant improvement has been made to the environment which included the replacement of a number of window, new blinds and new furniture and also areas of the home had been redecorated and there had been new carpets laid. One requirement was made at the last inspection in regard to an ensuite facility. This had been attended to. What the care home could do better: This was a very positive inspection. A small number of areas have been identified as in need of further development. The care assessment and plans need to be strengthened further to include mental health components. Specific care plans for individual also need to be developed detailing how people are being supported to attain goals. There is also the need to develop more specific risk assessments, where certain risks are identified and to have a plan in place detailing how these risks are being managed. The medication records need to have more detail and there should be a record of all medication ordered as well as received. This will ensure that people have the medication they are prescribed and that there is always a stock of medication. This will also enable correct audit trials to take place. There is also the need to ensure that any entries that are handwritten on the Medication Administration Record (MAR) that they are countersigned. The ongoing work with regard to Quality Assurance should continue and the new system introduced.The EdwardianDS0000000006.V377298.R01.S.doc Version 5.2 Key inspection report CARE HOME ADULTS 18-65 The Edwardian 72 Yarm Road Stockton-on-Tees TS18 3PQ Lead Inspector Jackie Herring Key Unannounced Inspection 3rd September 2009 09:30 The Edwardian DS0000000006.V377298.R01.S.doc 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 home adults 18-65 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. The Edwardian DS0000000006.V377298.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 The Edwardian DS0000000006.V377298.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Edwardian Address 72 Yarm Road Stockton-on-Tees TS18 3PQ 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) 01642 634113 Mr Joseph Matthews Mrs Mary Matthews, Miss Joanne Louise Matthews Care Home 11 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (11) of places The Edwardian DS0000000006.V377298.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The number of persons shall not at any one time exceed 11 adults with mental health problems 1st March 2007 Date of last inspection Brief Description of the Service: The Edwardian provides a home for 11 residents with mental health disorder. There are nine single bedrooms, and one shared room. Nine full en-suite, one with just shower and basin. Communal space consists of two sitting rooms, one of which is a designated smoking area. The dining room is situated at the rear of the house, adjacent to the kitchen. There is an enclosed garden at the rear of the building, which has seating for the use of residents when weather permits. The home is a large, terraced property, which is in keeping with other properties in the area, and is situated in Yarm Road, approximately one mile from Stockton town centre. Yarm Road is also on a main bus route into both Stockton and Middlesbrough, both of which provide a range of leisure and shopping facilities. At the time of the inspection weekly fees were not available and needed to be confirmed. The Edwardian DS0000000006.V377298.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 two stars. This means the people who use this service experience good quality outcomes. This Key Inspection was to check that the home meets the standards that the Commission for Social Care Inspection say are the most important for the people who use the services, and that it does what the Care Standards regulations say it must. This inspection was conducted by one inspector in one inspection day. During the inspection, a number of records were looked at, including records of people who use the service, along with staff recruitment and training records. The medication systems was also looked at and discussed with the manager and her deputy. Discussions took place with several people living at The Edwardian as well as with the manager and her deputy. Time was also spent observing and interacting with the people who live at the home. The manager has completed the Annual Quality Assurance Assessment (AQAA), the services self-assessment of how well they think they are meeting standards, this AQAA was received earlier in the year for a previous inspection. This was received prior to the inspection and some of information has been reflected within the report to support the judgements made. We have reviewed our practice when making requirement to improve national consistency. Some regulations from previous inspection reports may have been deleted or carried forward into this report as recommendations, but only when it is considered that people who use the services are not being put at risk or harm. In future if a requirement is repeated it is likely that enforcement action will be taken. What the service does well: The Edwardian provides a comfortable and homely environment for people to live. People receive good care from an experienced and committed staff team. People made comments about what was good about the home. One comments made was, “Everything, staff are so nice and there is a good group of residents, it is a well run home”. Another person said, “This is home from home and I wouldn’t want to be anywhere else”. The Edwardian DS0000000006.V377298.R01.S.doc Version 5.2 Page 6 Other people said, “It is a lovely home, all the staff are really nice, and we have a good relationship with the staff. They always have time for you and don’t brush you aside”. There are good opportunities for personal development, and people are able to make decisions, have control over their lives and be as independent as possible. Really good interactions were observed between people living at the home and staff, they were clearly respectful and good relationships have been developed. Staff are well trained, 100 of the permanent staff team are trained to NVQ Level 2 or above in care, which is excellent. The Edwardian is a well managed home, with clear and effective leadership. What has improved since the last inspection? What they could do better: This was a very positive inspection. A small number of areas have been identified as in need of further development. The care assessment and plans need to be strengthened further to include mental health components. Specific care plans for individual also need to be developed detailing how people are being supported to attain goals. There is also the need to develop more specific risk assessments, where certain risks are identified and to have a plan in place detailing how these risks are being managed. The medication records need to have more detail and there should be a record of all medication ordered as well as received. This will ensure that people have the medication they are prescribed and that there is always a stock of medication. This will also enable correct audit trials to take place. There is also the need to ensure that any entries that are handwritten on the Medication Administration Record (MAR) that they are countersigned. The ongoing work with regard to Quality Assurance should continue and the new system introduced. The Edwardian DS0000000006.V377298.R01.S.doc Version 5.2 Page 7 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. The Edwardian DS0000000006.V377298.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Edwardian DS0000000006.V377298.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People needs are assessed prior to admission to the home, this ensures that their needs can be met. EVIDENCE: The AQAA detailed information about the way in which people can be admitted to The Edwardian. The admission procedure was looked at, which stated that a full assessment is carried out by the manager to assess suitability and can take up to four months, and that people are given as much time as they need. One person spoken to confirmed that they visited the home prior to their admission and that they were assured that their needs could be met. Another person said, “I met with Joanne (the manager), she explained the admission procedure, I came for a look, then a trial period, at my review I decided to stay”. Two sets of care records for people living at The Edwardian were looked at, both had lived at the home for a number of years. There was evidence of regular reviews which involved a range of social and health care professionals. The Edwardian DS0000000006.V377298.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 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): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have their needs assessed and reviewed on a regular basis, the care records do however need to be strengthened further. People are consulted about all aspects of their life and are supported to be as independent as possible. EVIDENCE: Two sets of care files were looked at in detail. The care needs assessment and plan of care are a combined document covering a range of areas of need. This included amongst others, social, personal care and sleeping. There was evidence that the peoples whose care records they were, had been involved in the assessment and review process and there was information to show that they are regularly consulted. The Edwardian DS0000000006.V377298.R01.S.doc Version 5.2 Page 11 The six monthly reviews that takes place and supporting documentation is very good, with a good level of information from a number of agencies and includes the involvement and thoughts of the person using the service. The assessment and care planning process was discussed with the manager, as the current assessment tool is based upon the twelve activities of daily living, some of which may not be relevant to this particular client group. It was identified that areas about people’s mental health needs are not being fully assessed or that plans of care are not in place to show how people are being supported in these area of need. Risks are being assessed but again in discussion with the manager, it was agreed that where specific risks have been identified there may be the need to develop a specific risk assessment and risk management plan. People living at the home confirmed that they were involved with their care needs assessment, plans of care and regular reviews. One person said, “I have regular meetings with my keyworker, we discuss how things are going”. People living at The Edwardian spoke positively about the way in which they were supported. One person said, “I am highly satisfied with all aspects of the home, staff are really approachable, always make time for you”. The Edwardian DS0000000006.V377298.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People are treated with respect and their lifestyles are very much individualised and underpinned by appropriate social and recreational activities as well as the opportunities for personal development. People benefit from maintaining personal relationships and have their right respected. Meals are provided to a good standard within a suitable environment. EVIDENCE: In the care records examined, each person had a weekly activity plan showing what activities they were doing at certain times of the week. From discussion with people living at the home, staff and the manager is it clear that people have good opportunities for leading active and fulfilling lives. Everyone who lives at The Edwardian has opportunities for occupational, recreational and social activities. These are very much based upon the individual and some people have some 1:1 support for their activities. Many of The Edwardian DS0000000006.V377298.R01.S.doc Version 5.2 Page 13 the activities take place outside of the home and people attend college and day centres. One person is doing a catering course at college, while another is doing carpenter/joinery course. People go swimming, play pool, meet up with friends, go out to the pub and attend support groups. Staff spoken to confirmed that there were sufficient opportunities for occupational and leisure activities if people wanted. They also said that all of the people living at the home had opportunities for holidays and a short break to Scarborough had been arranged for a group of people. They made very positive comments about life in the home and emphasised that people had choice, were able to make their own decisions and be as independent as possible. From observations that took place during the inspection, it is clear that good relationships exist between the people living at the home and also with the staff. Over lunch there were a lot of conversations taking place and a sense that people cared about each other and took an interest in each others lives. Life within The Edwardian for people living there is flexible and very much promotes individual decision making. People have keys to their own rooms as well as the front door and are able to come and go as they choose. One person said, “It is lovely here, you can please yourself, I look after my own room, do my own ironing and look after my own finances. I can come and go as I want and am able to make all daily life decision”. People living at the home said that were very satisfied with the meals provided. Whilst there is no actual choice on the menu, it was confirmed by people living at the home and staff that people did have a choice and could have alternatives if they so chose. On the day of inspection people were observed having different meals at lunch time and different drinks. The Edwardian DS0000000006.V377298.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 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): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Peoples healthcare and personal care needs are met by staff who provide support in a sensitive and flexible manner in accordance with the wishes of the individual. The systems for managing medication are generally good although more records keeping would enhance this further. EVIDENCE: In the care files looked at there was information that showed people physical and mental health care needs are being attended to. People confirmed that their health care needs are being well met by the home and the support given by the staff. They said that if unwell they would go to their GP and that they had appointments with their Consultants on a regular basis. One person said, “I have been unwell, the staff supported me very well, they have been brilliant”. All of the staff have completed training in respect of Safe Handling of Medication and NVQ Level 3 in medication management and all are qualified to The Edwardian DS0000000006.V377298.R01.S.doc Version 5.2 Page 15 administer medication within the home. Records and storage was looked at. The medication administration records were well recorded, with no gaps. Care is however needed when items need to be handwritten on the medication administration records, there should be two signatures and the amounts received and date should also be completed. It was recommended that the temperature of the room in which medication is stored should be monitored and the medication cupboard should be strengthened. The ordering procedure does however need to be improved as currently there are no records of medication ordered and the staff at the home do not see the prescription prior to it going to the supplying pharmacist, which would enable discrepancies to be picked up at an early stage. The Edwardian DS0000000006.V377298.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 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): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at the home have access to the complaints procedure. Complaints are dealt with appropriately. Staff have had training around safeguarding adults to ensure protection of people who live at the home. EVIDENCE: The AQAA detailed the following information about complaints, “Here at The Edwardian we pride ourselves on being good listeners. Each resident is aware of how to make a complaint. We value everything our residents tell us”. Without exception people spoken to were very clear that if they had concerns they would raise them with any of the staff. One person said, “If I was unhappy I would speak to the manager or deputy, they are very approachable and they would listen”. A copy of the complaints procedure was on display in the entrance hallway. This had been updated since the last inspection and needed some slight amendment to include the Ombudsman details. It was confirmed through discussion with the deputy manager that staff have completed training on the protection of vulnerable people. Training records also confirmed this. They also said that they were in the process of rolling out this as an update via e-learning. The Edwardian DS0000000006.V377298.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 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): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at The Edwardian benefit from a warm, homely and safe environment. EVIDENCE: The Edwardian is situated near to Stockton Town Centre, close to public amenities and on a bus route. The Edwardian is a spacious, clean, well maintained and tastefully decorated home. There is a good amount of communal space as well as good personal space. There are two nicely decorated and furnished lounges and a pleasant dining room. All communal rooms within the house are accessible to all of the people who live there. There is also a rear courtyard garden available to people, which also provides a semi sheltered area for people to smoke. One of the people living at the home has been growing tomatoes in the garden. The Edwardian DS0000000006.V377298.R01.S.doc Version 5.2 Page 18 People living at the home are able to personalise their rooms. One person’s room that was visited was extremely personalised, with photographs of family members, lots of personal belongings and their own TV. The manager confirmed that there is an ongoing maintenance and refurbishment programme and plans are in place. An area that was identified at the last inspection as in need of redecoration had been attended to. The AQAA detailed a range of improvements to the home, which included the replacement of a number of window, new blinds and new furniture and also areas of the home had been redecorated and there had been new carpets laid. Everyone living at The Edwardian has a lock fitted to their bedroom doors and have their own key as well as their own key to the front door. The Edwardian DS0000000006.V377298.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 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): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live at the home have their needs were met by the numbers and skill mix of staff who were trained and competent to care for people who live at the home. People are generally protected by the homes recruitment procedures. EVIDENCE: Staffing levels were discussed with people living at the home, the manager and deputy manager and were considered appropriate to meet the needs of people living at The Edwardian. There was no actual duty rota, which the manager said they would put in place. It was however confirmed that there are always two staff on duty during the day and one member of staff at night. There is management cover Monday to Friday in the home but also arrangements in place for weekend and out of hours should this be needed. Two staff files were looked at in detail, and a further one briefly, which was for the most recent person employed at the home. The recruitment records were The Edwardian DS0000000006.V377298.R01.S.doc Version 5.2 Page 20 in the main in order, although one reference was missing for one member of staff who was in the process of being employed. The manager confirmed that this reference had been received. There was discussion with the manager about commencing staff prior to Criminal Records Bureau checks and POVA First. 100 of the permanent care staff are trained to NVQ level 2 in care or above. Training records were looked at and showed up to date training in respect of fire, infection control, first aid and safeguarding. There was also other training that included food hygiene and nutrition and health. The AQAA also stated that training was regularly updated. It was also confirmed through information contained within the AQAA and in discussion with the manager that staff would complete the Skills for Care Induction if they did not have NVQ Level 2 in Care. Records showed that regular supervisions take place. A staff member spoken to confirmed this and also said that everyone also has an annual appraisal. Really good interactions were observed between people living at the home and staff, they were clearly respectful and good relationships have been developed. People living at the home said, “It is a lovely home, all the staff are really nice, and we have a good relationship with the staff. They always have time for you and don’t brush you aside”. The Edwardian DS0000000006.V377298.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 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): People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager provides strong leadership to the staff team and continuously strives to improve standards within the home ensuring that people’s needs are well met. Service and maintenance arrangements are in place and in good order ensuring health and safety is promoted. Quality assurance systems continued to be developed. EVIDENCE: The manager is registered with CQC and has substantial experience in this field of care. They are highly competent to run the home. They have considerable knowledge, experience, qualification and skill to manage The Edwardian effectively. They are supported by a deputy manager who is extremely enthusiastic about their job role and who is also appropriately qualified. The Edwardian DS0000000006.V377298.R01.S.doc Version 5.2 Page 22 People made comments about what was good about the home. One comments made was, “Everything, staff are so nice and there is a good group of residents, it is a well run home”. Another person said, “This is home from home and I wouldn’t want to be anywhere else”. Quality assurance systems were discussed with the manager. They are in the process of researching alternative systems that would be more appropriate to the service. The regular review held with people living at the home form an aspect of the current system. Discussion took place about regulation 37 notifications and the manager confirmed that they would download the new form from CQC’s website. The AQAA detailed that the servicing of equipment such as fire equipment and gas safety are up to date. The Edwardian DS0000000006.V377298.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 X 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 4 X 2 X X 3 X Version 5.2 Page 24 The Edwardian DS0000000006.V377298.R01.S.doc Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 12 Requirement The records for ordering and receiving medication must be more detailed and accurately show what has been ordered and received. This will ensure that discrepancies are identified and that people have the medication needed to ensure their wellbeing. Timescale for action 31/10/09 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. Refer to Standard YA6 Good Practice Recommendations The manager should review the assessment and care plans to ensure that they are relevant and that people mental health needs are also assessed and plans in place to support people. Where specific risks have been identified, more detailed risk assessments and supporting care plans should be developed. When items are handwritten on the MAR sheet, it should be countersigned and the information regarding date, DS0000000006.V377298.R01.S.doc Version 5.2 Page 25 2. 3. YA9 YA20 The Edwardian amount received should also be completed. The temperature of the room where medication is stored should be monitored to ensure that medication is being stored at the correct temperature. The quality assurance systems should continue to be developed and introduced. 3. YA39 The Edwardian DS0000000006.V377298.R01.S.doc Version 5.2 Page 26 Care Quality Commission Care Quality Commission North Eastern Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.northeastern@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. 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. The Edwardian DS0000000006.V377298.R01.S.doc Version 5.2 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!