Inspection on 09/05/07 for Eldonian House Care Centre

This inspection was carried out on 9th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

Eldonian House Care Centre 27/04/09

Eldonian House Care Centre 02/10/08

Eldonian House Care Centre 14/04/08

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 Unannounced Inspection 09:10 9th May 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 Eldonian House Care Centre DS0000067206.V335198.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.V335198.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) 01352 755590 Raydonborne Limited Elizabeth Tracey Davies 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.V335198.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Older people with dementia (DE) (E) shall be accommodated in a self contained area of the establishment. 13 February 2007 Date of last inspection 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 and two named younger people with physical disabilities. Residents with dementia (generally referred to as EMI - elderly mentally infirm) are now located in a self contained unit - called the Seren Unit - within the home. ‘Seren’ is the Welsh word for ‘star’. At the time of the inspection there were 28 residents in the home, seven of whom were in the EMI unit. 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 is 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 Care Centre DS0000067206.V335198.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced site visit and was initially dealt with by a senior care assistant until the Registered Manager arrived. The Responsible Individual (the owner) also visited the home during the site visit and spoke to the inspector. The inspector also spoke to the senior carer on duty and several staff as well as a number of residents and five relatives who were visiting the home. He toured the home, visiting about half of the bedrooms and examined care plans, medication, fire safety records, accident book and the menu. The manager returned a detailed pre inspection questionnaire before the site visit. What the service does well: What has improved since the last inspection? What they could do better: There remained a number of minor, but persistent, errors in the recording of medication and it is essential that this matter is addressed through training and auditing of medication. The dining room needs to be redecorated. Although basic care planning is satisfactory some of the plans for new residents had not been drawn up quickly enough. Risk assessments need to be in place for all residents who use bedrails. Eldonian House Care Centre DS0000067206.V335198.R01.S.doc Version 5.2 Page 6 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.V335198.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.V335198.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, 3, 4, 5. Quality in this outcome area is good. Eldonian House’s assessment and admission procedures ensure that residents are only admitted if their care needs can be met in the home. 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: The Eldonian House has a satisfactory Statement of Purpose and service user guide. Residents are assessed before admission by the Registered Manager or other 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 of the assessment forms had not been signed or dated, another omitted the name of the resident. Although these assessments were otherwise complete it is important that such documents are accurately and fully completed, especially for future reference. Residents and their families are encouraged to visit the home before making a final decision on whether to move in but this is not always practical for residents with dementia. The care and facilities provided by the home, particularly in respect of residents with dementia, are based on the specialist knowledge of the Eldonian House Care Centre DS0000067206.V335198.R01.S.doc Version 5.2 Page 9 Registered Manager and the Responsible Individual (the owner, Pamela Haddock). Eldonian House charges fees of between £330-425 a week, depending on the needs of the resident. These fees include a ‘top up fee’ paid by the resident or their family. 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.V335198.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 adequate. Care plans and daily reports are on the whole good and help to ensure that service users receive care that is appropriate to their needs. Where they are incomplete staff do not have ready access to up to date information on how to care for the individual concerned. There were some minor, persistent discrepancies in the recording of medication which need to be addressed in order to protect the welfare of the residents. 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 set out in detail the action needed to be taken by care staff to meet the needs of the residents. The plans are reviewed regularly by keyworkers and the reviews are recorded. However, for some recently admitted residents the care plans had not yet been completed, and in one case was completely blank. This meant that some issues concerning the management of wandering at night were not fully addressed in the care plan, though there was some reference to the issue in the assessment. There was still information on the file to inform staff but the care plan should be the central reference point. They will in most cases need to be built up over the first few weeks but one care plan for someone admitted in March was still Eldonian House Care Centre DS0000067206.V335198.R01.S.doc Version 5.2 Page 11 completely blank. 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 some 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. All residents have single rooms with ensuite facilities and personal care is therefore provided in complete privacy. One resident tends to wander at night and has gone into other residents’ bedrooms. Although this issue was referred to in the care plan there was no detailed action plan to cope with it and this should be addressed. All of the bedrooms have locks which open in one simple movement from the inside, even when they are locked. Staff have master keys which override the locks in an emergency. Individual rooms can therefore be locked at night if necessary to ensure residents’ privacy without in any way at all restricting the resident’s liberty or freedom of movement. If this is done it should be discussed first with the resident if possible and with their family, and a risk assessment completed. 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. On the day of the site visit a chiropodist was visiting the home and residents were treated in the treatment room. It is of course understandable that occasionally the next person may need to wait outside but at one point two people were in a queue outside the treatment room. The lounges are only a short distance from the treatment room so queuing – a very institutional arrangement, at odds with Eldonian’s homely feel – should be avoided. Most medication is supplied by the pharmacist in a Monitored Dosage System and all medication is kept securely in a spacious, dedicated treatment room. We examined medication for three residents and there were several errors, as follows: * Handwritten amendments had been made to several items in the Medication Administration Record (MAR) sheets but they had not been signed or dated. It is essential that all manual entries are signed and dated. This matter was raised when the CSCI pharmacist inspected the home in February 2006 and at the last inspection of the home in February 2007. * The administration of a painkiller had not been clearly and accurately recorded, with some entries unsigned. The number of tablets given on each occasion was not always clear. This medication was to be administered in variable doses as required but although the senior carer knew when it should be administered this was not recorded. Where any medication has variable Eldonian House Care Centre DS0000067206.V335198.R01.S.doc Version 5.2 Page 12 doses or is to be given ‘as required’ (PRN) there should be written guidance as to the circumstances in which it is to be given, based on instructions from the GP or the dispensing pharmacist. * One tablet had not been signed for, possibly when the resident was in hospital. * It was not possible to account for the quantities of one medicine as it appeared that the amount to be administered had changed but had not been amended on the MAR sheet. This appeared to have been identified after a period of two weeks but this had not been recorded. The records continued to indicate that two tablets had been given each day, whereas in reality it seems almost certain that one (the correct dosage) had been given. This may have originally been a pharmacy error but it is important that staff only sign for what they have actually administered and that mistakes on the MAR sheet are corrected, accounted for and signed. 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. Eldonian House Care Centre DS0000067206.V335198.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, 15. Quality in this outcome area is good. The home arranges some activities to satisfy the residents’ needs and expectations though these could be extended. 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: Eldonian House employs an activities organiser who works at least twelve hours a week. Activities advertised in the home included reminiscence sessions, bingo, ‘hair and beauty’, cards, ‘arts and crafts’ and ‘cooking with Vera’. There is also a ‘gardening club’. Risk assessments have been completed for activities involving residents from both wings of the home. The home’s remaining cat is popular with the residents, and one resident has a budgerigar in her room. 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. Two residents have satellite TV in their rooms. The Prime Minister’s wife recently visited the home and met many staff and residents, illustrating the home’s position at the heart of the Eldonian Village and its organisations. Some of the residents had Eldonian House Care Centre DS0000067206.V335198.R01.S.doc Version 5.2 Page 14 subsequently sent her an Easter card and received a personal reply and photo from Downing Street. There is an orientation board in the Seren Unit lounge to help residents know, for instance, what day it is. As is normal at Eldonian House, several relatives visited the home during the visit and said that they had been made very welcome. Some were enjoying a tray of tea with their relative in her room. Five of them spoke to the inspector and were more than satisfied with the care given to their relatives and the meals they receive. One of them said that ‘nothing is too much trouble for the staff’. The menu is balanced and consists of meals that suit the tastes of most of the residents. The meals are largely traditional – lunch was pork ribs with cabbage and potatoes on the day of this visit,. Lunch consists of three courses and there is usually a choice of main meal at lunchtime (the main meal of the day) and the cook was preparing a chicken curry for one resident during the site visit. More usual alternatives include sandwiches, pasties, corned beef hash though the cook will – as with the curry – prepare meals to order to some extent. Residents can have a cooked breakfast if they wish and several choose to have breakfast in their room. 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. Eldonian House Care Centre DS0000067206.V335198.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, 18. Quality in this outcome area is good. The home’s policies for dealing with complaints and allegations of abuse protect the interest of the residents. 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 none had been received since the last inspection and most concerns are resolved informally. One concern had been raised direct with the Commission and the issues raised are addressed in this report. The home also has appropriate policies in relation to adult protection and whistle blowing. Eldonian House Care Centre DS0000067206.V335198.R01.S.doc Version 5.2 Page 16 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 – has been converted into 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 was formerly the handyman’s room has been redecorated and re-furnished to create a comfortable environment for those residents who choose to smoke. It was being repainted during the site visit. Eldonian House Care Centre DS0000067206.V335198.R01.S.doc Version 5.2 Page 17 The dining room is used by both wings and is separated by a fixed room divider which allows movement between the two units. 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 now needs some renovation and redecoration. The carpet is marked and needs to be replaced, the chairs are now rather scruffy and marked, and the walls need to be redecorated. The owner said that there are plans to replace the floor with a wooden one and had some samples of the possible material to be used. All of the residents have single ensuite bedrooms, many of which are personalised and all of which have televisions. Many residents choose to spend a lot of time in their room. The walls in one bedroom (room 2) need to be repainted and as the inspector did not see all of the rooms on this occasion, the manager should check all of the bedrooms to se how many of them need such attention. 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 the file for one person who uses bedrails and there was no risk assessment of any sort in place. The damaged enamel on two of the baths – noted in previous inspection reports – has not yet been repaired, but the home has applied for a City Council grant to replace the baths. 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 to move someone in the Seren Unit lounge. The doorbell cannot be heard in all parts of the home and is a type used in domestic homes. When the inspector called nobody answered the door and a visitor called round to the kitchen so that she could be let in. This is plainly unsatisfactory and a proper doorbell needs to be fitted. The home was clean and was generally odour-free, but there was an unpleasant odour in the bathroom nearest to the dining room. The odour in the bathroom appeared to be caused, at least in part, by there being no lid for the waste bin. This was also the case at the last inspection. The toilet seat also needs to be replaced. There was also no lid to the bin in another bathroom but in this case – at the time of the visit – it had not caused a smell. The vinyl flooring in two toilets was lifting very badly and needs to be replaced or repaired. The shower on the ground floor in the Seren Unit should be regrouted if it is used; if not the space could be put to better use. The bathroom on the first floor of the Unit is used to store surplus or old furniture but had been left open. If it is to be used as a furniture store it should be kept locked; if it is to be used as a toilet/bathroom it should be safe for residents to go in. Eldonian House Care Centre DS0000067206.V335198.R01.S.doc Version 5.2 Page 18 Eldonian House Care Centre DS0000067206.V335198.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, 30. Quality in this outcome area is good. Sufficient staff are deployed to meet the needs of the residents but staff numbers need to be kept under review as more residents with dementia are admitted. Specialist training in the care of older people with dementia is carried out to equip staff with the knowledge to meet the needs of these residents. 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 Registered Manager during the daytime and ancillary staff such as catering staff (70 hours), domestics (70 hours) and the full time handyman. Night staffing consists of a senior carer who sleeps in and three waking care staff. The owner is considering the possibility of increasing the number of residents with dementia at some point. This would involve an application to change the home’s registration conditions and an increase in staffing. Nine care staff have NVQ2 or above, still slightly short of the 50 target set out in the National Minimum Standards, but two more have nearly completed the course. Two more staff have just started NVQ2 and others are doing NVQ3. Staff have received training in the care of older people with dementia; the training is delivered by PHA consultants and is based on programmes devised by the Alzheimer’s Society. Four members of staff are manual handling trainers. Other recent training has included drugs management, COSSH/Health and Safety, ‘Safer Food, Better Business’, fire safety and adult abuse. Three new staff have been recruited since the last inspection and the appropriate checks had been obtained before they started work. There was not a second employment reference for two of the recruits as other employers appeared to Eldonian House Care Centre DS0000067206.V335198.R01.S.doc Version 5.2 Page 20 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. Eldonian House Care Centre DS0000067206.V335198.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, 38. Quality in this outcome area is good. The home has quality assurance procedures to monitor the level of service to the residents. There are adequate safety procedures to protect the safety of the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Registered Manager is qualified and experienced. She is qualified as a Registered Mental Nurse though she is not of course practising as such in Eldonian House, which is not registered for nursing care. Details of accidents are properly recorded. 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 has a quality assurance system based on detailed audits carried out every three months. The owner and the Registered Manager formulate an action plan after each audit. The owner also carries out visits to comply with Regulation 26 of the Care Homes Regulations and sends copies to the Eldonian House Care Centre DS0000067206.V335198.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection. The manager gets informal feedback from talking to residents and their relatives. Financial and administrative matters in the home are currently dealt with by an external agency, who do the work on the premises. The home had up to date electrical and gas safety certificates. Fire safety checks are carried out by the maintenance worker and were up to date. The kitchen was clean and well organised, though one or two flavourings and condiments had been kept beyond their ‘use-by’ date. The cook disposed of them whilst the inspector was there. The hot water urn was broken and the one in use did not have an automatic cut off when it boils dry. This was potentially unsafe and the owner told the inspector that a replacement was to be fitted during the week of the site visit. The home uses the Food Standard Agency’s ‘Safer Food, Better Business’ programme to manage its food safety arrangements and the records were up to date. Cleaning materials had been left unsecured in the Seren Unit. No residents were around at the time so no risk was involved at this time but cleaning materials must always be kept secure. Eldonian House Care Centre DS0000067206.V335198.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 x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 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 3 3 3 3 2 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 2 Eldonian House Care Centre DS0000067206.V335198.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 15 Requirement Timescale for action 01/07/07 2. OP9 13(2) Sch. 3 (i) The Registered Person must prepare and keep under review a care plan as to how the resident’s needs are to be met. Such plans should be prepared as soon as possible following admission and should deal with how staff will address issues such as wandering at night and how to keep residents’ safe in their rooms. The Registered Person must 01/06/07 ensure that full and accurate records are kept of all medicines administered by staff in the home. There must be a full record of all medication currently prescribed for each resident and how it is to be administered. (Originally required by 04/09/06) The Registered Person must ensure that all parts of the home are reasonably decorated, therefore the lifting vinyl flooring in the identified toilets must be affixed or replaced. The Registered Person must ensure that unnecessary risks to DS0000067206.V335198.R01.S.doc 3. OP21 23(2)(d) 01/07/07 4. OP22 13(4) 01/07/07 Eldonian House Care Centre Version 5.2 Page 25 residents are eliminated and must therefore ensure that: * bed rails are fully assessed; * copies of the assessments are kept on file and regularly reviewed. 5. OP26 16(k) The Registered Person must 01/06/07 keep the home free from offensive odours and make suitable arrangements for the disposal of waste, therefore the waste bins in bathrooms must be fitted with lids. The Registered Person must 01/06/07 ensure that all parts of the home to which service users have access are free from hazards to their safety and must therefore: * rooms containing unused equipment are kept secure at all times; * ensure that hazardous chemicals and cleaning materials are secured in compliance with COSSH Regulations. (Originally required by 13/02/07) 6. OP38 13(4) 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 OP9 Good Practice Recommendations *Criteria for the administration of ‘when required’ and variable dose medication should be clearly defined and recorded for all service users prescribed such items. *Verbal dose changes and new medication should be accurately entered onto Medication Administration Record charts with staff signature, date and authority where appropriate. Verbal dose changes should be confirmed in DS0000067206.V335198.R01.S.doc Version 5.2 Page 26 Eldonian House Care Centre writing by the prescriber. *A second member of staff should witness/countersign all hand written entries on Medication Administration Record charts. 2. 3. OP10 OP19 Residents should not be asked to queue outside the treatment room when waiting to receive treatment. The dining room needs to be redecorated and the Registered Person should review all bedrooms to establish where redecoration is needed. The identified toilet seat needs to be replaced. 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 home should have a doorbell which is clearly audible in all relevant parts of the home. 4. OP28 5. OP19 Eldonian House Care Centre DS0000067206.V335198.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Eldonian House Care Centre DS0000067206.V335198.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. 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!