Inspection on 14/04/08 for Eldonian House Care Centre

This inspection was carried out on 14th April 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Eldonian House Care Centre 27/04/09

Eldonian House Care Centre 02/10/08

Eldonian House Care Centre 09/05/07

Eldonian House Care Centre 27/06/06

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Eldonian House Care Centre Eldonian Way Liverpool Merseyside L3 6JL Lead Inspector Peter Cresswell Key Unannounced Inspection 09:00 14 and 16th April 2008 th 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 Eldonian House Care Centre DS0000067206.V362032.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. Eldonian House Care Centre DS0000067206.V362032.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eldonian House Care Centre Address Eldonian Way Liverpool Merseyside L3 6JL 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) 0151 298 2989 Raydonborne Limited Vacant Care Home 30 Category(ies) of Dementia - over 65 years of age (16), Old age, registration, with number not falling within any other category (19), of places Physical disability (2) Eldonian House Care Centre DS0000067206.V362032.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may category/ies 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: Old age, not falling within any other category - Code OP Dementia –over 65 years of age Code(DE(E)) – (maximum number of places: 16) The maximum number of service users who can be accommodated is: 30 Date of last inspection 19th November 2007 provide the following Brief Description of the Service: Eldonian House is a purpose built care home for 30 older people. It is part of the Eldonian Village in the Vauxhall area of north Liverpool, close to the city centre. The home is near to pubs, local shops and the community facilities of the village such as the village hall. The home is registered to accommodate older people, including some with dementia. Two younger people with physical disabilities also live at the home. Residents with dementia (generally referred to as EMI - elderly mentally infirm) are located in a self contained unit - called the Seren Unit - within the home. ‘Seren’ is the Welsh word for ‘star’. All of the residents have single rooms with en suite facilities. There are two main lounges, one of which is in the Seren Unit, the other in the main part of the home and solely for the use of the other residents. Each wing has a small self contained courtyard and there is a spacious dining room which can be partitioned for separate use by the different groups of residents. The home was built by the Eldonian Community but is now run by Raydonborne Ltd who operate the home on a leasehold basis. Eldonian House charges fees of between £325-410 a week, depending on the needs of the individual. Eldonian House Care Centre DS0000067206.V362032.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 1 star. This means the people who use this service experience adequate quality outcomes. This inspection included an unannounced site visit that was largely dealt with by the senior care assistant on duty. A second visit was made two days later to check recruitment records. We spoke to the Responsible Individual (the owner) and a number of staff as well as several residents. We toured the home, visiting about half of the bedrooms, and examined care plans, medication, fire safety records, financial records, recruitment files and the menu. Some survey forms were distributed but none had been returned by the time we wrote this report. The owner had completed a CSCI Annual Quality Assurance Assessment (AQAA) some weeks before the site visit. What the service does well: What has improved since the last inspection? What they could do better: It is important that the new manager starts duties as soon as possible to provide leadership and a clear sense of direction. Staff recruitment procedures need to be fine tuned to ensure that nobody starts work before the appropriate checks have been completed. The new manager’s priorities will include reinstating a staff supervision and training programme. There needs to be a Eldonian House Care Centre DS0000067206.V362032.R01.S.doc Version 5.2 Page 6 system for the renewal of electrical and gas safety certificates. The home should keep signed copies of all residents’ contracts. 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. Eldonian House Care Centre DS0000067206.V362032.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 Eldonian House Care Centre DS0000067206.V362032.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, 4, 5. Quality in this outcome area is adequate. Eldonian House’s assessment and admission procedures ensure that residents are only admitted if their care needs can be met in the home. Residents’ legal rights are not set out in a signed contract. Prospective residents and their families are encouraged to visit the home before moving in, ensuring that the home suits their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Eldonian House has a satisfactory Statement of Purpose and service user guide. Residents are assessed before admission by senior staff, who also complete a preliminary care plan summary. Assessment documents are also obtained from other professionals, such as local authority social workers. One recent assessment form had not been signed or dated. One resident had been admitted for ‘EMI’ (dementia related) care but it was not evident from the case file why this was the case. There was a handwritten file note to the effect that the person had been diagnosed as having ‘vascular dementia’ but no actual evidence such as an assessment from a social worker’s assessment or the consultant psychiatrist. The care and facilities provided by the home, particularly in respect of residents with dementia, are based on the specialist knowledge of the owner, Pamela Haddock. Although a blank example of a Eldonian House Care Centre DS0000067206.V362032.R01.S.doc Version 5.2 Page 9 contract was available in the service user guide no copies of signed contracts for individual residents were available. Eldonian House does not provide intermediate care (though it does occasionally provide respite care) so Standard 6 does not apply. Eldonian House Care Centre DS0000067206.V362032.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is good. Care plans and daily reports help to ensure that service users receive care that is appropriate to their needs. Medication is safely administered. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans are drawn up by senior care staff, based on the initial assessment of the resident. The plans are called ‘strengths-based care plans’ and are a model devised by the Alzheimer’s Society. The plans are reviewed regularly by keyworkers and the reviews are recorded. Daily reports are kept on the resident’s main file and relate to elements of the care plan (when in place). The files include nutrition risk assessments and Waterlow (pressure sore) assessments. Senior care staff have in most cases produced excellent, informative, detailed life histories based on information from families and the residents themselves. These provide valuable information that can be used to develop care plans and activities as well as giving a useful picture of the resident and his or her interests and personality. Risk assessments were in place for significant risks. For instance in several cases it was recorded that the resident likes to lock the room door at night. Staff carry pass keys which provide access to all bedrooms in an emergency. However, in one case there was still no risk assessment in place for safety bed rails; it is essential that such assessments are in place for all people who have bed rails fitted. Daily Eldonian House Care Centre DS0000067206.V362032.R01.S.doc Version 5.2 Page 11 reports are rather mixed and do not always closely relate to the actual, often detailed, care plan. It may be helpful to devise care plan summaries that staff can readily consult on a daily basis, for instance when they are completing the daily report. Such reports can then provide a valuable record for planning ongoing care. All residents have single rooms with ensuite facilities and personal care is therefore provided in complete privacy. A complaint received recently did provide evidence of dignity not being respected on certain occasions. These have been investigated and addressed by the owner. All residents receive appropriate health care and are registered with local GPs. District Nurses visit the home to provide any nursing assistance that is necessary. Visits by health professionals are recorded separately on the individual resident’s case file. Most medication is supplied by the pharmacist in a Monitored Dosage System and all medication is kept securely in a spacious, dedicated treatment room. The room can be locked but when we visited the home the room was left open and unattended, though the actual medication was securely stored in the trolley or in the CD cabinet. The room should always be kept secure unless it is being used. We examined medication for three residents and it was found to be in order. Where medication is to be administered ‘as required’ (PRN) there should be a note indicating the precise circumstances in which it is to be given. We observed medication being administered and it was carried out properly. Controlled drugs are kept in a secure approved CD cabinet and their administration is countersigned by two members of staff. Medication is stored in locked cabinets in a spacious locked medication room. The temperature of the medications fridge is checked every day though there were one or two recent gaps in the recording. Eldonian House Care Centre DS0000067206.V362032.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is adequate. People’s needs and expectations are not met with an appropriate programme of activities. Visitors are welcome in the home and the home’s firm roots in the local community help residents continue to feel that they are part of the community where many of them grew up or lived before coming to Eldonian House. The balanced, varied and traditional diet includes choices and meets the residents’ nutritional needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home’s activities organiser has recently retired and has not yet been replaced. The owner said that they were advertising for a replacement to work 16 hours a week (an increase of four hours). Those residents who spoke to us said that there was not much to do in the home and could not recall any recent trips out, for instance. Some people have paid for satellite television in their room so they can watch, for instance, football. The television reception in the main lounges is not good, though the owner said that specialist engineers had been called out to try to improve it. One resident wants to move into nearby extra care sheltered housing; this had been referred to a social worker and was recorded on the file. Some residents choose to spend a lot of time in their own rooms, usually watching television, and they told the inspector that they were happy to do so. There are orientation boards in the Seren Unit to help residents know, for Eldonian House Care Centre DS0000067206.V362032.R01.S.doc Version 5.2 Page 13 instance, what day it is, but this was rather undermined by one of them being several days out of date (as was the menu board in the dining room). As is normal at Eldonian House, several relatives visited the home during the visit and one of them took her relative out. We did not manage to speak to any relatives on this occasion (though e have done so before) but distributed some survey forms for them. The menu is balanced and consists of meals that suit the largely traditional tastes of most of the residents – lunch was braised steak with vegetables and chips on the day of this visit and residents told us that it was tasty. Lunch consists of three courses and there is usually a choice of main meal at lunchtime (the main meal of the day). Usual alternatives include sandwiches, soup, pasties etc, though the cook will prepare meals to order to some extent. Residents can have a cooked breakfast if they wish and several had chose to have breakfast in their room when we visited. The evening meal is lighter but is normally also a cooked meal with sandwiches as an option and includes three courses. The residents who spoke to the inspector during the site visit were satisfied with the meals provided and enjoyed lunch in a relaxed atmosphere. One pointed out how much weight she had gained as a result of what she considered to be the excellent meals. An agency cook was doing the cooking when we visited and the quality and presentation of the meal was of a good standard. We carried out a “random” inspection in November 2007 to assess a suggestion that residents were being put to bed unduly early. This was not substantiated and residents appeared to have the freedom to go to bed when they wanted. Eldonian House Care Centre DS0000067206.V362032.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17, 18. Quality in this outcome area is adequate. The home’s policies for dealing with complaints and allegations of abuse protect the interest of the residents, though liaison with other professionals in the recent past had been inadequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Eldonian House has a complaints procedure and keeps a record of complaints, though most concerns are resolved informally. The home also has appropriate policies in relation to adult protection and whistle blowing. One complaint received since the last inspection had been referred to an adult safeguarding meeting and had been investigated by the owner, who had replied to the Commission. The complaint had raised issues about the difficulty district nurses had experienced in arranging meetings with the then Registered Manager to address their concerns. In her response the owner states that the acting manager had now arranged a meeting with district nurses and ‘will ensure that these are regular events, as they were previously’. Eldonian House Care Centre DS0000067206.V362032.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26. Quality in this outcome area is good. Residents have well furnished individual rooms with en suite facilities, ensuring their privacy and comfort. Some work and attention to detail is needed to ensure the residents’ continued comfort. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Eldonian House is a purpose built home for the care of older people. The building has two wings, with a dining room in between the two wings. One of those wings – furthest from the main entrance – is now a self-contained unit (the Seren – ‘Star’ in Welsh – Unit) for older people with dementia (‘EMI’). The doors into the unit are opened by a simple switch and all exits, including doors to the stairs, are protected by electronic number pads. The Seren Unit has a small smoking room which provides a comfortable environment for those residents who choose to smoke. The dining room is used by both wings and can be separated by a room divider if necessary. Residents are supervised when they are having their meals. Table cloths and table mats are used to give the dining room a homely appearance, but the room needs some further renovation. The carpet has Eldonian House Care Centre DS0000067206.V362032.R01.S.doc Version 5.2 Page 16 been replaced by a laminate surface and the serving counter – little used – has been removed creating additional space. The chairs are now rather scruffy and marked, and the walls need to be redecorated. All of the residents have single ensuite bedrooms, many of which are personalised and all of which have televisions. The carpet in one room in particular (15) was badly marked and worn and must be replaced as soon as possible. We did not look at every room so the owner needs to check all rooms to see if any other carpets need to be replaced. Many residents choose to spend a lot of time in their room. A number of residents have beds fitted with bedrails for safety reasons and the Registered Manager said that bedrails are only used on the recommendation of district nurses, who also do risk assessments. The inspector looked at a sample of the files for people who use bedrails and there were risk assessment on most of the files. One did not have any sort of risk assessment’ these should be carried out and recorded for all people who have bed rails fitted. Two new assisted baths have been installed and are proving popular with the residents. Magnetic closers are fitted to most of the fire doors in the home; they close automatically if a fire alarm is sounded. This allows the doors to bedrooms to be safely kept open if that is what the residents want. Some bedroom doors have ‘Dorgard’ devices, which perform the same function, if less elegantly. Eldonian House has a mobile hoist and staff were seen to be using it appropriately. The doorbell cannot be heard in all parts of the home and is a type used in domestic homes. The door was in fact answered promptly during our visit but the owner still needs to address this issue. The home was clean and was generally odour-free, but there was an unpleasant odour on the ground floor corridor which needs to be addressed. The lifting vinyl flooring in two toilets was being repaired. Eldonian House Care Centre DS0000067206.V362032.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is adequate. Residents needs are met by experienced staff but the recruitment procedures do not totally protect them. Staff’s competence would be developed by a full training programme. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is normally staffed by a senior carer and four care staff, plus the acting manager during the daytime and ancillary staff such as catering staff, domestics and the full time handyman. Night staffing consists of a senior carer who sleeps in and three waking care staff. The owner is proposing to continue to increase the number of residents with dementia, subject to protecting the tenure and quality of life of existing residents. Staffing needs to be kept under review as this process continues. Nine care staff have NVQ2 or above, still slightly short of the 50 target set out in the National Minimum Standards. Staff have recently received training in safeguarding adults and some other training does take place but there is not a full training programme in place and this should be a priority for the new manager (see next section). Seven new staff have been recruited since the last inspection and the appropriate checks had been obtained. However, in two cases the person had started work a few days before the home had received POVA (Protection Of Vulnerable Adults) clearance for them. This is not acceptable. Staff may start work before a full CRB (Criminal Records Bureau) check is received as long as they have a POVA First clearance and the home would otherwise be understaffed. In those cases the person can work under supervision. In no circumstances can a person start work in advance of POVA clearance, even by a few days. There was not a second employment reference for several of the Eldonian House Care Centre DS0000067206.V362032.R01.S.doc Version 5.2 Page 18 recruits as other employers appeared to be reluctant to give references under any circumstances, which is deplorable. In these circumstances it may be best to seek a personal reference, though unsolicited testimonials are not acceptable. The administrative officer was continuing to seek references. The employment records were not available in the home on the day of the first site visit. These records must be kept in the home. Eldonian House Care Centre DS0000067206.V362032.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38. Quality in this outcome area is adequate. The home does not at present have the leadership of a Registered Manager. Residents’ interests are protected by quality assurance and financial procedures. Staff are not appropriately supervised. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Registered Manager recently left the home’s employment. A new manager has been appointed and will start work in June. In the meantime a team leader has been appointed as acting manager. Staff use wheelchairs to move residents around the home and during this site visit were seen to be using footplates to protect residents. The owner operates a quality assurance system based on detailed audits carried out every three months. She was in the process of carrying out such an audit when we visited. The owner formulates an action plan after each audit. She also carries out visits to comply with Regulation 26 of the Care Eldonian House Care Centre DS0000067206.V362032.R01.S.doc Version 5.2 Page 20 Homes Regulations. Staff get informal feedback from talking to residents and their relatives. Financial and administrative matters in the home are currently dealt with by a person from an external agency, who does the work on the premises. The home deals with the personal allowance of a small number of residents and the records were found to be in order. Staff are not receiving one to one, recorded supervision and this should be one of the new manager’s priorities. The home had electrical and gas safety certificates but the gas certificate was several months out of date and the expiry date of the previous electrical safety certificate was not recorded. It is essential that up to date safety certificates are in place at all times. Fire safety checks are carried out by the maintenance worker and were up to date. Records of fire drills should include the names of the staff who took part. Some old chairs and cardboard boxes full of incontinence pads were stored in the stairwells. No combustible material should be kept in areas such as this as they represent a potential fire risk. The kitchen was clean and well organised. The home uses the Food Standard Agency’s ‘Safer Food, Better Business’ programme to manage its food safety arrangements though it was not apparent that the records were fully up to date. Eldonian House Care Centre DS0000067206.V362032.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 2 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 2 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 2 x 2 Eldonian House Care Centre DS0000067206.V362032.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14 Requirement The registered person shall only admit someone to the home when they have been properly assessed and that assessment must be fully recorded and signed. The registered person shall provide facilities for recreation and therefore needs to provide a programme of activities for residents, including if necessary the appointment of an activities organiser. The registered person shall ensure that the home is kept clean and reasonably decorated and must therefore replace the carpet in the identified room and replace the dining room furniture. The registered person must ensure that unnecessary risks to residents are eliminated and must therefore ensure that all bed rails are fully assessed and copies of the assessments are kept on file and regularly DS0000067206.V362032.R01.S.doc Timescale for action 01/07/08 2. OP12 16(2)(n) 01/07/08 3. OP24 23(2)(d) 01/07/08 4. OP22 13(4) 01/06/08 Eldonian House Care Centre Version 5.2 Page 23 reviewed. 5. OP28 19 The registered person shall not employ a person unless they are fit to do so and must therefore obtain POVA clearance before anyone starts work at the home. Records for people employed in the home as set out in Schedule 2 must be kept in the care home. The registered person shall ensure that all staff are appropriately supervised and must therefore arrange for a programme of recorded one to one supervision for all staff. 14/04/08 6. OP28 17(2) Schedule 2 18(2) 14/04/08 7. OP36 01/10/08 8. OP38 23(4) The registered person must take 01/05/08 adequate precautions against the risk of fire and must therefore ensure that: * up to date gas and electrical safety certificates in place; * combustible materials are not kept in stairwells. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP2 OP9 Good Practice Recommendations The home should have a copy of the contract for each resident. Criteria for the administration of ‘when required’ and variable dose medication should be clearly defined and recorded for all service users prescribed such items. Eldonian House Care Centre DS0000067206.V362032.R01.S.doc Version 5.2 Page 24 3. 4. OP26 OP28 All parts of the home should be kept free from offensive odours at all times. The Registered Person should continue with the training programme to enable the home to meet the standard of 50 of care staff with NVQ2. The doorbell should be clearly audible in all relevant parts of the home. The dining room furniture needs to be replaced and the Registered Person should review all bedrooms to establish where redecoration is needed. Records in respect of the food safety programme should be kept fully up to date on a daily basis. 5. 6. OP19 OP19 7. OP38 Eldonian House Care Centre DS0000067206.V362032.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Regional Contact Team Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries.northwest@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. 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