Inspection on 25/04/07 for Elderthorpe Residential Home

This inspection was carried out on 25th April 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Elderthorpe Residential Home 01/12/05

Elderthorpe Residential Home 18/05/05

Elderthorpe Residential Home 26/01/05

Elderthorpe Residential Home 13/10/04

Similar services:

Abbey The

Snydale Care Home

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

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

CARE HOMES FOR OLDER PEOPLE Elderthorpe Residential Home 230-232 Bradford Road Shipley Bradford West Yorkshire BD18 3AN Lead Inspector Nadia Jejna Unannounced Inspection 07:30 25th April 2007 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 Elderthorpe Residential Home DS0000001144.V329513.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. Elderthorpe Residential Home DS0000001144.V329513.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elderthorpe Residential Home Address 230-232 Bradford Road Shipley Bradford West Yorkshire BD18 3AN 01274 583375 01535 583374 kevin.driscoll1@tiscali.co.uk 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) Mr Kevin Driscoll Mrs Joanne Driscoll Patricia Robertshaw Care Home 16 Category(ies) of Dementia - over 65 years of age (5), Old age, registration, with number not falling within any other category (16), of places Physical disability over 65 years of age (3) Elderthorpe Residential Home DS0000001144.V329513.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st December 2005 Brief Description of the Service: Elderthorpe is a large Victorian house in Shipley. It is not far from local shops and public houses. It is on a main road and well served by major bus routes from Shipley, Bradford, Bingley and Keighley. On road parking is provided at the back of the house. The provider intends to provide a designated parking area in the near future. The house has been converted to provide residential accommodation and personal care for sixteen people over the age of 65. Nursing care is not provided. Accommodation is provided on the ground and first floors in both double and single rooms. Stair lifts have been provided to the first floor. None of the rooms are en suite, but all have wash hand basins and commodes. There are enough communal toilet and bathing facilities for the number of people living in the home. There is ramp access to the home at the rear of the building for people with disabilities. Information about services provided at the home can be found in the Service User Guide. Copies will be provided on request. At the time of writing this report the weekly charges for services and accommodation for the year ending 31st March 2007 were from £354.75 to 369.75, but these were due to be increased. Elderthorpe Residential Home DS0000001144.V329513.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Three visits were made on 25th, 26th and 30th April 2007. The home did not know that this was going to happen. Feedback was given to the manager during and at the end of the visits. The purpose of the visit was to make sure the home was being managed for the benefit and well being of the of the people who live there and to see what progress had been made since the last inspection. Before visiting the home the inspector asked for information from the provider in the pre inspection questionnaire (PIQ). This asked about what policies and procedures are in place and when they were last reviewed, when maintenance and safety checks were carried out and by who, menus used, staff details and training provided. Comment cards were sent to the home to be given to residents, their relatives and other visitors to find out what their views of the home were. At the time of writing this report ten responses had been returned, five from people living in the home and five from relatives/visitors. In order to find out how well staff knew people care plans were looked at during the visit and people were spoken to including those who live there, visitors and staff. Other records in the home were looked at such as staff files, complaints and accidents records. What the service does well: What has improved since the last inspection? Elderthorpe Residential Home DS0000001144.V329513.R01.S.doc Version 5.2 Page 6 Work has started on making improvements to the structure of the building. The roof, guttering and some of the fascia boards were being replaced. The garden at the front of the building has been fenced to provide extra security, so that people can walk in it safely and enjoy being outside when the weather permits. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Elderthorpe Residential Home DS0000001144.V329513.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Elderthorpe Residential Home DS0000001144.V329513.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 5. People who use 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 given enough information to be able to decide that the home will be suitable for their needs. EVIDENCE: The Statement of Purpose was looked at. It provides people with information about the home and the services provided. For example it makes it makes it clear that: • They can visit to look round at any time and can stay for longer ‘trial visits’ if they want to. • The first four weeks living there are for a trial period so they can decide if it is the right place for them at the end of that time. • What services are provided at the home. Advice was given to the provider and manager about additional information that should be added to this document. Examples included: Elderthorpe Residential Home DS0000001144.V329513.R01.S.doc Version 5.2 Page 9 • • • People with dementia can be accommodated but not if they present with challenging behaviours that will be a risk to themselves, other residents and or the staff. In these cases admission may be refused or if already at the home they will be helped to find more suitable accommodation. The layout of the home and the provision of a chair lift mean that people accommodated on the first floor need to be able to manage a stair lift. The date the document was last reviewed. The provider had contacted CSCI registration unit about a variation in registration to accommodate more people with dementia. He was advised that this is not necessary as the guidance and regulations in this area would be changing in the near future. He was advised to make sure the Statement of Purpose showed clearly what areas of need could be met by the home and how it would be done. Before people are admitted to the home the provider sees them to carry out a pre admission assessment to make sure that their needs can be met. The document used covers all areas of information needed to make this decision and the provider said that further changes are going to be made to it to make it more useful. For example it will include details of when the person or their representative came to look at the home, if any specialist equipment will be needed and when a copy of the local authority care needs assessment was requested. Information from people living at the home said that: • Contracts for accommodation and services provided had been issued. • They had been given enough information about the home and the services provided before they moved in. • They were satisfied with the care and services provided. • Happy with choices made to move into the home. Information from relatives and visitors said that: • They had been given enough information about the home. • They felt that their relatives care needs were being met. • They had liked the ‘homely’ family atmosphere of the home and that the staff were caring and friendly. When asked about what the home does well comments made in the relatives surveys said that: • The home ‘provides a secure, safe environment for its residents’. • ‘The home has shown steady improvement in many areas over the years we have been coming and just needs to continue in this vein’. • ‘Try and make people feel at home’. • ‘They show great patience, humour, compassion and care in their everyday work.’ Elderthorpe Residential Home DS0000001144.V329513.R01.S.doc Version 5.2 Page 10 • ‘The staff excel in their patient and caring attitude to the residents. The residents are treated with the utmost respect. Visitors are always made very welcome.’ Elderthorpe Residential Home DS0000001144.V329513.R01.S.doc Version 5.2 Page 11 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. People who use 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 care needs are being met and evidence to show this will be clearer when the care plans contain more detailed information and guidance for staff. EVIDENCE: The manager is the main person involved with writing the care plans and staff are asked to produce a monthly written evaluation of an individuals care needs and if there are any changes. Staff had a good knowledge of people’s needs and what to do to meet them. It was clear that: • There were good relationships between people living in the home and the staff. • That peoples privacy and dignity was respected. Four care plans were looked at during the visit and three of these people were spoken with. These showed that monthly evaluations were carried out. Annual review reports were seen and it was clear that the person living in the home and their relatives were invited to be part of this process. Elderthorpe Residential Home DS0000001144.V329513.R01.S.doc Version 5.2 Page 12 The plans provided information about individual’s needs and what actions were needed to meet them in most cases. There were some areas where more detail and guidance was needed. The manager was told about this and said she would address it straight away. Examples included: • What actions staff were taking to meet an individuals pressure area care needs. Staff said they were changing people’s positions regularly; that district nurses had been involved to provide care and support as well as arranging the provision of specialist pressure relieving equipment. • More detailed information and guidance about individuals moving and handling needs and how to meet them. • Falls risk assessments have been carried out but where an individual was identified as at risk the falls prevention team had not been contacted for advice and support. The manager had spoken to the district nurses and has now been given contact details for the specialist falls prevention advisor. She and a senior member of staff have recently attended a training session about falls prevention. • A nutritional assessment was not yet being used. The manager said that those residents who could stand unaided were weighed at least monthly and that an appropriate assessment tool would be put in use as soon as possible. Information from people living at the home said that: • They got the care and support they needed. • Staff listened and acted upon what they said. • They got the medical care and support they needed. Information from relatives and visitors said that: • They were kept up to date with any issues and changes involving their relative. • Their relatives received the care and support as expected and agreed. The manager said that all senior staff who deal with medication have received appropriate training and that it is updated every year. She said the supplying pharmacist has done some of this training and more recently staff have completed a distance learning course through a local college. Medications are supplied in cassette boxes that are supplied each week. The trays in the boxes were not sealed or tamper proof. The manager was told that the pharmacist must be asked to make sure that medication cassettes provided are sealed and tamper proof. A senior member of staff is responsible for ordering repeat prescriptions, receiving and checking medications into the home. Medication records seen were up to date and correctly filled in. The procedures seen when medications were being given to residents were safe. Elderthorpe Residential Home DS0000001144.V329513.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. People who use 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 helped to exercise choice and control over their lives and to maintain contact with family and friends. EVIDENCE: The home has a very friendly, homely atmosphere. Visitors said they could call in at any time and staff made them feel welcome. Some said they had chosen the home because of this. There is a weekly activity plan displayed by the main lounge and staff on duty are responsible for making sure it is followed. It includes such things as reading the morning papers, talking about what is happening in the world, various games, watching films, going out for a walk or to one of the local pubs and listening to music. A file of special themed events is kept including photographs of people enjoying them. For example there was a St Valentines dinner dance and after Easter there was a show called the ‘Easter parade’ by an entertainment group. The manager said she was looking at different forms of activity and social stimulation that would be suitable for people with dementia. It is important that she does this and makes sure that the activity Elderthorpe Residential Home DS0000001144.V329513.R01.S.doc Version 5.2 Page 14 programme is expanded to include all people living at the home regardless of their physical and mental abilities. The manager said that links have been made with some of the local churches for the clergy to visit the home and for people who wanted to continue with their chosen from of worship. The menu was on display in the dining room. There were no choices offered at lunch and teatime but it did state that alternatives were available if people did not want was on the menu. During the visit one person chose to have a different meal at lunchtime and the cook prepared it for them. Drinks and snacks such as biscuits and homemade cakes are offered regularly through the day. The manager is looking at providing an additional supper for people to have later in the night if they want it. Staff are aware of peoples dietary likes and dislikes and this is taken into account when planning meals. The provider said that the menus are always changing as they continually try different things and add people’s suggestions about meal ideas. Two new cooks have recently started working at the home. Training about nutrition and the elderly has been arranged for them. This is good practice and they will be able to use the information to look at ways of enriching the diet for older people who are at risk of losing weight. Guidance and information produced by CSCI about meals in care homes was given to the manager. It was clear that people living in the home can choose: • When they get up and go to bed. • Where to spend their time either in their own room or in one of the communal areas. • Where they want to eat their meals. • Whether or not they want join in with any of the planned activities. Information from people living at the home said that: • They enjoyed their meals and had enough to eat. • There were usually activities planned that they could join in with. Information from relatives said that: • The needs of different people were being met as far as they knew, including race, disability, religion. • People were being supported to make choices about their daily life as much as they could be. Elderthorpe Residential Home DS0000001144.V329513.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 People who use 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. Residents feel safe living at the home. EVIDENCE: There is a complaints procedure in the brochure/Statement of Purpose. The manager was advised to revise this as it included CSCI as part of the homes complaints process and only gave them 15 days to respond to a complaint. It was recommended that the process should include acknowledging all complaints received in writing within 5 or 7 days and responding in writing in 28 days. A copy of the procedure should be displayed in the home so that all people can have to and refer to it as and when needed. Since the last inspection the PIQ said that there had been 6 complaints. 3 of these were referred to the home by CSCI. The complaints records showed that they had been investigated and responded to appropriately. Two complaints had been about no escort with people who were sent to hospital in an emergency. The manager said that it is the homes policy to contact relatives and ask them to meet the person at the hospital as staffing did not allow for them to send an escort. She said that there are information packs about the individual that would be given to the ambulance crew. This information is included in the Statement of Purpose. A copy of the local authority adult protection procedures was seen. The manager has given most of the staff training sessions around abuse using a Elderthorpe Residential Home DS0000001144.V329513.R01.S.doc Version 5.2 Page 16 video and questionnaire training system bought specially for the purpose. But she has not had formal training to do so and was advised to attend an appropriate ‘train the trainer’s’ course. Information from people living at the home said that: • They knew who to talk to if they were unhappy. • They knew how to make a complaint. • They felt safe. Information from relatives said that: • They knew what to do and who to speak to if they had any concerns. • Concerns they had discussed with staff had been dealt with to their satisfaction. Elderthorpe Residential Home DS0000001144.V329513.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, 20, 21, 24, 25 and 26. People who use the 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 home is kept clean and tidy and people living there are satisfied with it. EVIDENCE: The building was registered before April 2002 and therefore meets the room size requirements for care homes in operation before this date. The provider is aware that the home is need of redecoration and refurbishment. He said that plans are in place to do this when the proposed building work for an extension has been completed. He said that an action plan with proposed timescales would be sent to the CSCI. Some work has already started and the roof, guttering and some of the fascia boards are all being replaced. Then a dedicated car parking area will be added. The garden at the front of the building has been fenced and made secure so residents can walk or sit there safely when the weather allows. Elderthorpe Residential Home DS0000001144.V329513.R01.S.doc Version 5.2 Page 18 There are enough bathrooms and communal toilets for the number of people accommodated in the home. One of the bathrooms has been equipped with a bath hoist and there is a shower room. None of the bedrooms are ensuite but all have wash basins and commodes. The provider said that the hot water temperatures had not been checked for a few weeks and he would make sure they were done at least once a month and records kept. People were happy with their rooms. Those seen showed that many of the period features of the house had been kept and that people had brought in some of their own belongings to personalise their rooms. The home was clean and tidy and there were no smells. The domestic had been working at the home for three weeks. They had received an introduction to the home and their role. But they were not using colour coded cloths when cleaning bedrooms and toilet areas. There is no sluice facility and staff said that commodes are emptied in the toilet and cleaned with water before being returned to the room. They should be chemically disinfected after each use. The manager was advised to contact the infection control nurse for advice and to obtain a copy of guidance that is now available about infection control in care homes. Elderthorpe Residential Home DS0000001144.V329513.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. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There is a risk that the needs of people living in the home will not always be met because the there may not be enough staff on duty with the necessary skills and knowledge. EVIDENCE: There were 16 people living at the home when the site visits were made. Staff rotas sent with the PIQ showed that there were 2 care staff on duty from 8am to 10pm and 1 waking carer on night duty from 10pm to 8am, with a person ‘sleeping in’ on the top floor in case of emergency. This arrangement has been in place since before April 2002 and had been agreed with previous registration authorities. This was discussed with the provider as the number of staff on duty at any one time must be enough to meet the needs of the residents, taking into consideration the size and layout of the building and make sure that peoples health, safety and well being can be maintained. The provider was told to provide a risk assessment showing: • What criteria were used for admitting new residents and were there any people with special needs that the home might not be able to accept, taking into account the number of staff that will be on duty? (This information should also be included in the Statement of Purpose) • How the staffing levels had been decided? • What criteria were used for deciding what an individual’s level of dependency was? Elderthorpe Residential Home DS0000001144.V329513.R01.S.doc Version 5.2 Page 20 • • What action would be taken if peoples needs increased or changed? What duties the night worker was expected to do and whether or not this would include doing laundry in the basement? Information from people living at the home and their visitors was that there were usually staff available when they needed them. Staff were attending to peoples needs and call bells were answered promptly. 3 staff files were looked at. These showed that safe recruitment procedures had been followed. Two written references and satisfactory POVA (Protection of Vulnerable Adults) and enhanced CRB (Criminal Records Bureau) disclosures were in place. The provider was advised to make sure that the application forms asked for a full employment history from leaving school and that records were kept to show that gaps in employment had been explained. The manager keeps individual training records for each care worker. These include information about what they have done and what is planned for them to do. Training materials to provide induction training to the Skills for Care common induction standards have been purchased. Other training packages bought by the home include videos and questionnaires about abuse and care of the dying. Other training courses are bought by the home and staff are sent on study days as well. It was clear from looking at records that not all staff have received training they need to maintain the health, safety and well being of people living in the home and themselves; this includes the domestic and ancillary staff. The manager has identified where the shortfalls are and said that required training will be provided. Only the manager and a senior care worker are doing any training about dementia. The manager was told that all staff must receive this training to make sure that they all understand the needs of people with dementia. Elderthorpe Residential Home DS0000001144.V329513.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. People who use 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 home is managed in the best interests of the residents. EVIDENCE: The manager has over sixteen years experience of working in care homes and looking after older people. She has successfully completed the registration process with CSCI and achieved a management qualification equivalent to NVQ level 4. The manager and provider are at the home every week day and work closely together. The provider is very ‘hands on’. He looks after financial and business matters and finds time to be with the people living in the home and their visitors. They are both focused on meeting people’s needs and making sure they have a good quality of life. The manager carries out quality assurance Elderthorpe Residential Home DS0000001144.V329513.R01.S.doc Version 5.2 Page 22 audits every three months getting the views of people who live in the home as well the views of their relatives, GP’s and other healthcare professionals who visit people living in the home. The most recent was in April 2007. The manager said that she will collate these results and make them available to interested parties. She had a copy of a quality assurance survey carried out by the local authority for the year 2006/2007 which gave positive outcomes and comments for questions asked and indicated people were satisfied with services provided. The PIQ said that policies and procedures were in place but they have not been reviewed or revised since 2003. The provider was advised to put systems in place for making sure they are reviewed and updated as needed at regular intervals. The PIQ said that the home does not act as appointee for any of the residents. The provider said that he does hold money in safekeeping for some people. Individual records kept of monies received and returned to people were seen. The PIQ said that maintenance and annual checks of equipment, gas and electrical appliances are carried out and were up to date. The provider said that a fire safety risk assessment was in place and that the last fire safety officer’s report had been in December 2005. The manager was asked if risk assessments were in place around residents who smoke and staff carrying laundry and other items up and down the basement steps. These could not be found at the time of the visits. She said she would make sure they were in place. Elderthorpe Residential Home DS0000001144.V329513.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 Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 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 2 2 3 3 X X 3 X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Elderthorpe Residential Home DS0000001144.V329513.R01.S.doc Version 5.2 Page 24 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 OP8 Regulation 13(1)(b) Requirement To make sure that peoples health, safety and well being is maintained the manager must make sure that the care plans contain assessments, information and guidance about meeting individual residents needs relating to nutrition, pressure area care, falls and moving and handling. Where appropriate advice and support must be requested from relevant healthcare professionals. To reduce the risk of mistakes being made when dealing with peoples medication the manager must make sure that the monitored dosage system cassettes supplied by the pharmacy are sealed and ‘tamper proof’. The provider must make sure that an action plan with proposed timescales of when building works, redecoration and refurbishment of the home are expected to be carried out. Timescale for action 30/08/07 2. OP9 13(2) 15/05/07 3. OP19 23(2)(a) (b)(d) 30/06/07 Elderthorpe Residential Home DS0000001144.V329513.R01.S.doc Version 5.2 Page 25 4. OP26 13(3) In order to reduce the risk of cross infection the manager must contact the infection control nurse for advice about: * cleansing commode pots after use, * use of colour coding for cloths and equipment in different areas of the home. * up to date information about infection control in care homes. The registered provider must provide CSCI with a copy of a risk assessment showing how staffing levels in the home have been decided upon and what safeguards have been put in place to make sure that the health, safety, well being and needs of people living in the home will be maintained by the number of staff on duty at any one time. In order to make sure that staff have the knowledge and skills needed to meet peoples health, social and specialist care needs the manager must make sure that the training programme is extended to include all relevant areas and provided to all staff. In order to make sure that the health and safety of staff and people living at the home is maintained the manager must make sure that risk assessments of the building, equipment, tasks and activities are carried out and reviewed at regular intervals. 30/08/07 5. OP27 18(1)(a) (b) 30/05/07 6. OP30 18(1)(c) 30/11/07 7. OP38 13(4) 30/07/07 Elderthorpe Residential Home DS0000001144.V329513.R01.S.doc Version 5.2 Page 26 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 OP1 Good Practice Recommendations The registered provider should make sure that the Statement of Purpose and Service User Guide clearly sets out the different needs of people that can be met by the home and when they cannot, either be cause of their individual needs and abilities, the homes layout and need to be able to manage a stair lift or because of staffing levels. This will help people to make an informed choice about whether or not the home will be suitable for them. The manager should make sure that work started on making the care plans more detailed and individual to people continues. This will provide staff with more detailed guidance about individuals and what has to be done in order to meet their needs. To make sure that the social, recreational and leisure needs of people with dementia are met the manager should make sure that she gets more information and advice about planning and providing suitable activities and stimulation. The complaints procedure should be revised and make it clear that CSCI is not part of the homes complaints procedure. A copy should be displayed prominently in the hoe so that all people know what to do if they have any concerns. In order to safeguard people living at the home staff training about abuse and adult protection should be provided by somebody who has received specialist training in order to do so. So that people can access peoples views of services provided in the home the manager should collate the results of surveys carried out and make them available to interested parties. 2. OP7 3. OP12 4. OP16 5. OP18 6. OP33 Elderthorpe Residential Home DS0000001144.V329513.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Elderthorpe Residential Home DS0000001144.V329513.R01.S.doc Version 5.2 Page 28 - 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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