Inspection on 15/08/07 for Elisabeth House

This inspection was carried out on 15th August 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Elisabeth House 05/01/09

Elisabeth House 08/01/08

Elisabeth House 30/08/06

Elisabeth House 17/01/06

Elisabeth House 26/07/05

Elisabeth House 13/01/05

Elisabeth House 01/07/04

Elisabeth House 02/03/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Elisabeth House Rhosweil Weston Rhyn Oswestry Shropshire SY10 7TE Lead Inspector Rebecca Harrison Key Unannounced Inspection 15th August 2007 09:55 Elisabeth House DS0000020684.V342009.R01.S.doc Version 5.2 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 Elisabeth House DS0000020684.V342009.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 Adults 18-65. 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. Elisabeth House DS0000020684.V342009.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elisabeth House Address Rhosweil Weston Rhyn Oswestry Shropshire SY10 7TE 01691 777563 01691 680983 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) Mrs Sonja Eckert-Hopkins vacant post Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Elisabeth House DS0000020684.V342009.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: No Conditions apply Date of last inspections 30 August 2006 – Key Inspection 2nd January 2007 – Random Inspection Brief Description of the Service: Elisabeth House is registered with the Commission for Social Care Inspection (CSCI) to provide accommodation and personal care for a maximum of nine adults with a learning disability. The registered provider is Mrs S EckertHopkins. The acting manager has been in post twelve months but an application for registration has not yet been received by CSCI. The home is located in the hamlet of Rhosweil, some 8 miles north of Oswestry in North Shropshire, in a quiet area next to a canal but within easy reach of main roads and the local towns. Elisabeth House was originally converted from a row of four cottages and provides homely accommodation on two floors in 2 double and 5 single bedrooms. A large kitchen/diner and separate lounge and dining room are provided. The home has pleasant and well-kept grounds and gardens. Information about this service is available from the Statement of Purpose and Service User Guide. Inspection reports produced by CSCI can be obtained direct from the provider or are available on CSCI’s website at www.csci.org.uk Fees charged per person range from £318.00 to £895.00 per week. Elisabeth House DS0000020684.V342009.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place on 15th August 2007 by two inspectors over five and half hours. A range of evidence was used to make judgements about this service to include information completed by the provider and sent to CSCI, discussions with service users, staff and the acting manager and a tour of the home. Inspectors also looked at a number of records and observed aspects of care provided for two people using the service. The proprietor was present for a small part of the inspection but had to attend a private appointment however feedback was given to her via telephone following the inspection. During the inspection an inspector spent time in the lounge watching how people spend their time and seeing how they are supported by staff. The inspector used the Short Observational Framework for Inspection (SOFI) to record findings. Given the nature of the service the observation was cut short and the inspector spent time instead speaking with people who live at the home. Observations and information shared with the inspector are included within the report. The purpose of the inspection was to assess all 22 ‘Key’ National Minimum Standards for Younger Adults and to review all ten requirements made at a random inspection undertaken on 2nd January 2007. A quality rating is provided throughout the report based on each outcome area for the people who use the service. These ratings are described as excellent/good/adequate or poor based on findings of the inspection. What the service does well: The people living at Elisabeth House are provided with a homely place to live. People who spoke with the inspector said that they liked living at Elisabeth House and they liked all of the staff. One person stated ‘I couldn’t wish for a better home’. The home has a committed team of staff who try hard to meet the needs of the people in their care. People are supported to maintain good relationships with family and friends. The transition for the person most recently admitted to the home was managed well with a number of visits to the home undertaken to ensure the service was able to meet her needs and for her to get to know the other people living at the home. Elisabeth House DS0000020684.V342009.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Elisabeth House DS0000020684.V342009.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Elisabeth House DS0000020684.V342009.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2,4 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are provided with the information needed to decide whether this service will meet their needs. Their needs are assessed and a contract is available which tells them about the service they will receive. EVIDENCE: The provider completed a self assessment and sent this to CSCI which states ‘ We have continued to give potential residents a genuine ‘Feel’ for the home prior to admission and believe we offer every opportunity for an informed decision’. One person has been admitted to the home since the last key inspection. The persons care file was examined and an overview assessment completed by the placing authority was available in addition to written guidance provided by a Community Nurse. The acting manager stated that she had visited the person in their former placement and undertook a needs assessment however this was not available for inspection. It was reported that the person had a number of introductory visits to the home and that the placing authority had been provided with a copy of the homes Statement of Purpose and Service User Guide prior to admission. These documents were not examined as part of this inspection however the acting manager was advised to ensure that the guide Elisabeth House DS0000020684.V342009.R01.S.doc Version 5.2 Page 9 complies with the changes in the Care Home Regulations as amended in September 2006. A blank contract was available and the acting manager was advised to ensure this is completed and signed for the person most recently admitted. Since the last inspection one person has left the service and moved into supported living accommodation at her request supported by an advocate. The home therefore has one vacancy and referrals are being sought. Elisabeth House DS0000020684.V342009.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are provided with information to support service users needs however failure to provide detailed risk assessments potentially places people at risk. EVIDENCE: Records evidence that a formal review was held in relation to the person most recently admitted to the home by the placing authority. The acting manager stated that four people have been formally reviewed at their day service however the acting manager was informed that all service user plans require formal review at least every six months with the service user and significant others. The self-assessment completed by the provider states ‘We have always tried to cater to individual needs, but have fallen down on paper work in the past’. Elisabeth House DS0000020684.V342009.R01.S.doc Version 5.2 Page 11 Discussions held during the inspection indicate that people are supported in decision making processes such as activities, menu planning, shopping etc however this could be better evidenced. The risk assessment file was reviewed by the inspector and found to be in urgent need of review and updating. The majority of risk assessments were very general and did not identify how risks should be managed. Individual risk assessments had not been updated and on one occasion a reference to an incident in 1999 had been carried forward as a current risk meaning that the service user did not take part in that activity. One risk assessment stated that one person needed two to one support while in the community and on the day of the inspection she attended a health appointment with only one member of staff. The acting manager attempted to justify this but additional documentation demonstrated that there were manual handling implications supporting the risk assessment. Also a direction stating that a medical reference card had to be carried at all times while out of the house had also been ignored and the card was seen on the care file. The acting manager was also advised of her responsibilities in relation to risk assessments and told that certain comments made to advise staff of consequences of certain actions were inappropriate and ultimately put people at risk. Elisabeth House DS0000020684.V342009.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people who use the service are provided with some social activity and can keep in contact with their family and friends. Social, cultural and recreational activities may not meet all service users’ expectations because of the lack of assessment, consultation and choice. Service users receive a varied diet in accordance to their personal preferences. EVIDENCE: A number of people living at Elisabeth House attend day service opportunities on different days of the week and discussions held with people indicated that they enjoy these services. There was very little information recorded on the activity sheets to demonstrate that people have good leisure opportunities and personal spending records suggest minimal opportunities to spend money. People who Elisabeth House DS0000020684.V342009.R01.S.doc Version 5.2 Page 13 live at Elisabeth House spoke of in house activities focussing around craftwork and one person showed the inspector her knitting and explained how she is currently making blankets. Records do not show active consultation regarding their choice of daily activity and no structured activities were observed taking place during the inspector’s observation although it was noted that the morning is when staff carry out their cleaning duties. One person living at the home said that she had recently been to a keep fit class and goes to a local day centre on a Thursday. Daily records contain only basic information although good cross-referencing was noted when incidents have occurred. All the people living at Elisabeth House have been on holiday this year and day trips to Blackpool and Ellesmere proved popular. The home has received input in relation to developing activities for one person living at the home although success has been limited and the health care professional commented in a letter that ‘little has changed’. The acting manager said that additional staff are available on a Monday afternoon to organise activities and this has been successful. One person’s care plan did not positively reflect that the staff are encouraging him to take part in meaningful activities. His likes were listed as ‘wandering round the house’. The inspector discussed this with the acting manager who committed to review the care plan. People are supported to maintain contact with their friends and family. During the inspection one person went out for lunch with her sister. Another service user spoke about her family and numerous photographs were seen displayed in her room. Two people spoken with reported that they help keep their room tidy. It was reported that keys to bedroom doors were provided but have been lost. People spoken with said that they like the food. People’s likes and dislikes in relation to food were available. It was reported that service users help with food shopping and basic preparation. During the inspection people were offered a choice of light lunch and choose where to eat. One woman was celebrating her birthday on the day of the inspection. It was planned that she would be having a chocolate cake for tea. Elisabeth House DS0000020684.V342009.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs however closer monitoring of peoples physical health and wellbeing must be further developed to ensure peoples health is appropriately maintained. The acting manager understands the need to comply with safe medication systems however current medication procedures and lack of monitoring potentially place people at risk. EVIDENCE: The recording of medical appointments was seen to be good. Records are detailed and enable staff to follow up on previous information and share new information with the staff team. At the time of the inspection a staff member completed two of these forms on her return to the home following a medical appointment and later told the inspector that she found the records to be useful. Elisabeth House DS0000020684.V342009.R01.S.doc Version 5.2 Page 15 Physical health and wellbeing records had not been completed on files reviewed and the acting manager could not evidence when people had last attended routine health care appointments, in particular dental check ups and hearing tests. The home has actioned the requirements of a recent Occupational Therapy assessment for one person living at the home and have ordered equipment to assist her mobility. A referral for an additional assessment has also been made. There was no manual handling risk assessments seen on files reviewed by the inspector. Medication procedures were reviewed. Records seen on one persons file evidence that the evening staff had failed to administer prescribed medication to one service user which resulted in the acting manager having to attend the home during the night for the safety of service users and the lone worker. The acting manager was unable to evidence the action taken as a result of this and CSCI were not notified under Regulation 37. The random inspection undertaken on 2.01.07 also identified medication errors however appropriate action had been taken. A medication policy and procedure was available however this was not examined on this occasion. Medication procedures were discussed with the acting manager who reported that ten members of staff have undertaken accredited training via the distance-learning route and that a medication audit had been undertaken in February by the dispensing pharmacist however she was unaware of the outcome. No written procedures were available for individuals requiring PRN medication. There was evidence available that competency assessments have been undertaken for staff responsible for administering medication however these were not at the required frequency. The acting manager committed to ensuring these are undertaken at the earliest opportunity. Elisabeth House DS0000020684.V342009.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People who use the service and their representatives have access to a complaints procedure, which enables their views to be listened to. The lack of robust financial procedures and staff training in safeguarding adults potentially places people at risk. EVIDENCE: The home has a complaints procedure in place however this is in need of updating to reflect the regulatory body’s change of name. A complaint book was not available however during the inspection the acting manager found an appropriate book to record any future compliments or complaints. Service users spoken with had an understanding of what to do if they were unhappy with the service received. The acting manager stated that no complaints had been received since the last key inspection. No complaints or concerns have been received by CSCI in the last twelve months. A copy of the local safeguarding adult protection policy and procedure was available however only two staff had signed to confirm that they have read this as instructed. During a review of incidents within the home in 2007 there was a record of an adult protection issue. When questioned the acting manager said that she did not refer the incident but upon reflection she should have done. She later stated that she has received training in adult protection. Elisabeth House DS0000020684.V342009.R01.S.doc Version 5.2 Page 17 It was reported that no staff have received training in physical intervention or behaviours that challenge even though records identified that some individuals can at times challenge the service. Information was provided to the acting manager at the time of the inspection in terms of whom to contact for advice and relevant training. The cashbooks of two people who live at Elisabeth House were seen by the inspector. Records reflected the amount of money held for each person and receipts supported spending. However an error was noted in one cashbook but it had not been picked up during the double signatory monitoring system. It was also found that people who live at the home pay for staff meals when they go out. There is no policy to support this practice and the acting manager stated that it is not identified in contracts that this happens. The policy to support ‘Residents pocket money’ was seen to need review and updating to reflect that people should have a choice in what they spend their money on. The policy is ‘institutional’ in its content and this was discussed fully with the acting manager who agreed to re write it. Elisabeth House DS0000020684.V342009.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people living at Elisabeth House are provided with a clean, comfortable and homely place to live. EVIDENCE: Elisabeth House is beautifully located in the hamlet of Rhosweilin, next to a canal and provides homely accommodation over two floors in double and single bedrooms. A large kitchen/diner and separate lounge and dining room are provided. The acting manager reported that she is seeking screening for the people sharing a room. Service users spoken with said that that like living at the home. Bedrooms were very personalised and the person most recently admitted to the home was involved in choosing the décor of her room. Since the last key inspection the lounge has been redecorated and new flooring fitted to the lounge and dining room. Two bedrooms have also been redecorated. Gardens are well maintained with adequate outdoor seating provided. A service user spoken with stated ‘I couldn’t wish for a better home’. Elisabeth House DS0000020684.V342009.R01.S.doc Version 5.2 Page 19 The home was found clean and tidy during this unannounced inspection. A service user told the inspector that she helps keep her room clean with the support of staff. The manager was requested to review the infection control procedures regarding shared use of bathmats and to ensure that liquid soap and paper hand towels are available in all areas requiring them to minimise the risk of cross infection. Substances hazardous to health are appropriately stored and data sheets available. Elisabeth House DS0000020684.V342009.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 and 36 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The people who use the service are supported by a committed staff team however continued poor recruitment practices and lack of staff training and supervision potentially place them at risk. EVIDENCE: Staff were seen to interact with service users in a positive manner throughout the inspection and considered they are provided with adequate information to support the needs of the people accommodated. Two service users spoken with said that the staff are very nice and that they are well looked after. Of the eleven support workers employed it was reported that five have obtained an NVQ award and a further three staff are currently undertaking NVQ training. The team consists of the proprietor, an acting manager, one senior and ten support workers. The acting manager reported that the staffing ratio is two staff to support nine service users although a third staff member is on duty every other Monday afternoon to support evening activities, meals out etc. The staffing rota seen during the inspection was not an accurate reflection of the staffing provided in terms of staff on duty, sickness and cover Elisabeth House DS0000020684.V342009.R01.S.doc Version 5.2 Page 21 arrangements, which was fully acknowledged by the acting manager. The level of staffing restricts the ability of the service to deliver person centred support. The acting manager was strongly advised to review staffing levels based on a risk assessment due to the increased needs and additional support requirements of one person in particular. Requirements have been made at three previous inspections for staff files to contain the relevant documentation as required by Schedule 2, of The Care Homes Regulations 2001, as amended. Although staff files are much improved in terms of presentation and CRB checks are now being undertaken, significant shortfalls were found in the pre-employment checks for four staff employed post December 2006. Only one file evidenced that two written references had been obtained prior to staff commencing direct work with service users and not all references had been obtained from a previous employer as required. There was no evidence that managers had questioned gaps in applicants’ employment history and health declarations had not been obtained. In addition to these shortfalls there was no personnel file available for a member of staff on duty although she confirmed to the inspector that she had completed an application form, submitted references and applied for a CRB check prior to commencing work. There was evidence of in-house induction training however this fails to meet the required specification. One person’s records evidenced that she had attended a half-day training course on LDAF Continuum of Learning Disability. The requirement previously made for each staff member to have an individual training profile has been met however training records seen on the staff files examined were out of date. With this and the absence of a clear team-training matrix, it was very difficult to establish which staff had attended training in safe working practices or service specific training. This was fully acknowledged by the acting manager. A training and development plan as required by the previous inspection was not available. It was reported that the proprietor is currently developing this. Of the four personnel files examined only one formal supervision record was available on each file. Therefore staff are not receiving supervision at the required frequency to provide support, discuss work related issues, identify training needs and professional development. Minutes of one staff meeting were available and the acting manager stated that a further staff meeting is scheduled shortly. Elisabeth House DS0000020684.V342009.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39, 41 and 42 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Management and leadership of the home are lacking which does not benefit service user care. The lack of quality monitoring and current working practices does not fully promote the health, safety and welfare of service users and staff potentially placing people at risk. EVIDENCE: Mrs Sonja Eckert-Hopkins is the registered provider and previously managed the service prior to appointing an acting manager in July 2006. It was reported that the proprietor is at the home three days a week. The acting manager is employed full time and her time is shared working in the office and providing direct care to service users. A requirement was made at the previous Elisabeth House DS0000020684.V342009.R01.S.doc Version 5.2 Page 23 inspection for an application to be submitted to CSCI to register the manager. It was reported that this had recently been undertaken however records held by the Commission indicate this has yet to be received. Slow progress has been made regarding the leadership, training, development and supervision of staff who are directly involved in service user care. The inspection overall evidenced that the service is drifting and lacks purpose and direction. Records required by regulation for the protection of service users and for the effective and efficient running of the home were not in good order despite a requirement being made at the previous inspection. Discussions held indicated that the home currently does not have any formal quality assurance and quality monitoring systems in place. With the absence of this and the lack of formal reviews undertaken by the home, it proves difficult to assess how this service is achieving and meeting outcomes for service users. It was established that the acting manager had no input into drawing up the Annual Quality Assurance Assessment (AQAA) forwarded to CSCI prior to the inspection of this service. Policies and procedures seen by the inspector were in need of review and update to reflect current best practice and legislation. For example the Complaints procedure refers to the NCSC. As previously stated the acting manager had not worked within the homes policies and procedures in relation to adult protection guidelines and notifications of incidents to CSCI. Health and safety procedures were reviewed. As previously stated with the absence of a team-training matrix and outdated training records it was very difficult to establish which staff had attended training in safe working practices. The two staff on duty at the time of the inspection had not received training in manual handling despite evidence to suggest one person’s mobility has deteriorated and requires assistance in this area. The acting manager has since sourced training and this was confirmed to take place shortly. As previously stated risk assessments for safe working practices were available but in need of urgent review. Not all certificates for the servicing of equipment were readily available and health and safety files were found very disorganised, which was fully acknowledged by the acting manager. It was not possible to test bath water temperatures, as a thermometer was not available. The acting manager committed to action this as priority. Inspectors were invited into the home by a man who lives at the home. There were no staff downstairs at this time. This in addition to the office being found open poses an issue with security and the acting manager agreed to review this. Window restrictors are not fitted to first floor windows therefore the acting manager was strongly advised to explore other options based on a risk assessment. The acting manager committed to undertake a first aid risk assessment to meet new guidelines. Elisabeth House DS0000020684.V342009.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 x 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 1 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 1 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 2 x 1 x 2 1 x Elisabeth House DS0000020684.V342009.R01.S.doc Version 5.2 Page 25 YES Are there any outstanding requirements from the last inspection? 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 YA9 Regulation 13 (4)(b) Requirement Timescale for action 28/09/07 2. YA20 13(2) 3. YA23 13(6) 4. YA34 19 (1) All identified risks, to include manual handling, must be assessed and regularly reviewed to ensure service users are not placed at risk of harm or neglect. Medication procedures must be 28/09/07 reviewed and competency assessments be undertaken to ensure staff are competent to handle and administer medication to service users at the prescribed time and that staff have a procedure to follow for people prescribed PRN medication. The procedures for the 28/09/07 management of service users’ finances must be reviewed to ensure service users and staff are safeguarded. Two written references must be 28/09/07 obtained before making an appointment and any gaps in the employment record explored in order to safeguard people living at the home. (This requirement is outstanding and was made following the inspection on June 1st 2006). DS0000020684.V342009.R01.S.doc Version 5.2 Elisabeth House Page 26 5. YA35 18 (1) (c) 6. YA35 18 (1) (c) 7. YA39 24(1) 8. YA41 17 9. YA42 13 (4) All staff must receive structured and recorded induction in line with the homes policies and procedures that meet LDAF specification. (This requirement is outstanding and was made following the inspection on June 1st 2006). The home must have a training and development plan, dedicated training budget and designated person with responsibility for the training and development programme to ensure staff receive the necessary training to support the needs of the people accommodated. (Previous requirement of 01/02/07 not met). Quality assurance and monitoring systems need to be developed to measure the homes success and assist with planning for the future. All records required by Regulation must be available for inspection to ensure the effective and efficient running of the home for the safety and wellbeing of service users and staff. (Previous requirement of 03/01/07 partly met). Health and safety procedures must be reviewed to ensure safety checks are carried out, service certificates are available and that staff receive training in safe working practices for the health and welfare of service users and staff. 26/10/07 28/09/07 31/10/07 28/09/07 28/09/07 Elisabeth House DS0000020684.V342009.R01.S.doc Version 5.2 Page 27 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 YA14 Good Practice Recommendations People should be provided with greater opportunities to partake in structured activities both in-house and the community in accordance with their preferences, ability and choice. Staff should be provided with training in safeguarding adults to ensure they are familiar with the process of recognising potential abuse and the formal referral process. Staffing levels should be reviewed based on a comprehensive risk assessment to establish if staffing levels are adequate based on the increased needs of service users. Arrangements should be made to ensure that all staff receive formal supervision at the required frequency to ensure they are provided with the necessary support they need to carry out their jobs. Management arrangements should be reviewed and an application be submitted to CSCI to register an experienced manager. Policies and procedures should be reviewed and updated to reflect current best practice and legislation. 2. YA23 3. YA33 4. YA36 5. 6. YA37 YA41 Elisabeth House DS0000020684.V342009.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Elisabeth House DS0000020684.V342009.R01.S.doc Version 5.2 Page 29 - 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. 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