Inspection on 19/06/07 for Eliza House

This inspection was carried out on 19th June 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 but made no statutory requirements on the home.

Other inspections for this house

Eliza House 28/02/07

Eliza House 25/04/06

Eliza House 13/09/05

Eliza House 05/07/05

Eliza House 02/11/04

Eliza House 11/05/04

Eliza House 18/03/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Eliza House 467 Baker Street Enfield Middlesex EN1 3QX Lead Inspector Key Unannounced Inspection 29 June & 3rd July 2007 10:30 th 19 th & 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 Eliza House DS0000010670.V333345.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. Eliza House DS0000010670.V333345.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eliza House Address 467 Baker Street Enfield Middlesex EN1 3QX 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) 020 8367 8668 020 8367 2129 Peaceform Limited Mr Noah Sagnia Care Home 26 Category(ies) of Dementia - over 65 years of age (26), Old age, registration, with number not falling within any other category (26) of places Eliza House DS0000010670.V333345.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home must not take people who have severe dementia with challenging behaviour or nursing needs. 25th April 2006 Date of last inspection Brief Description of the Service: Eliza House is a purpose built care home that is registered to care for up to twenty six frail elderly people, some of whom may have dementia. There are twenty six single bedrooms and service users share a large lounge, divided into two seating areas plus a dining room, bathroom, shower room and outside seating areas. The home is operated by Peaceform UK Limited who also owns other care homes in the UK. The home is located a short bus ride away from Enfield Town and is close to a park. The fees are normally £395 to £405 for each placement, and service users are expected to pay separately for hairdressing, chiropody, and some toiletries. The provider must make information available about the service, including inspection reports, to service users and other stakeholders. Eliza House DS0000010670.V333345.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken on an unannounced basis. The inspector spent one day in the home, and returned for 2 brief visits to follow up some concerns that were raised by a person who wishes to remain anonymous. These concerns are referred to as part of this report. After a period of review, the home is now being provided with new referrals by the placing authorities, and there were 18 people living in the home at the time of this inspection, 7 of whom have been admitted recently. The manager aided the inspector during the inspection process, and the deputy manager showed the inspector around the building. The inspector was able to speak with 2 staff members in private, one of whom had worked in the home for a number of years and one who was recently recruited. The inspector met and spoke to a number of residents and several of their visitors, and was able to observe the residents eating their lunch and joining in with group leisure activities. There was a relaxed, friendly and lively atmosphere, with lots of activities going on and plenty of visitors. The information provided to the Commission by the registered persons in the form of a pre-inspection questionnaire was taken into account at this inspection and the inspector reviewed the written records for 2 of the people living in the home and 3 staff members. In following up the anonymous concerns, the inspector also interviewed two senior members of staff and the manager in private. What the service does well: What has improved since the last inspection? The manager is going through the process of applying to the Commission for registration. There has been a programme of redecoration and refurbishment that has made the home feel a nicer place to be in. In response to previous requirements the radiator cover in the first floor bathroom in Beech wing has been is repaired, the toilets near the lounge have been redecorated, the net curtains have been replaced in various shared areas and in the residents’ bedrooms, where necessary. There was no longer a smell of damp in the toilet Eliza House DS0000010670.V333345.R01.S.doc Version 5.2 Page 6 in the foyer near the lounge, or in the bathroom next to room 12, and that the water damage to the tiles in the bathroom next to room 12 has been repaired. Several residents’ bedrooms have been redecorated and feel much cleaner and fresher. Several of the carpets in the shared areas and in residents’ bedrooms have been steam cleaned and the smell is fresher throughout the home and, despite there being more residents living in the home, no unpleasant odours were detected throughout. The records for staff were available for inspection and included the necessary information regarding their recruitment. 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. Eliza House DS0000010670.V333345.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 Eliza House DS0000010670.V333345.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There is a service user guide, which provides basic information about the service and the specialist care the home offers. The guide is made available to individuals in a standard format. This would benefit by being made more accessible in the way that it is presented, and was being improved by the manager. The service consults the assessment information to see if they can meet the prospective individual’s needs before they make the decision to accept the application for admission and offer a placement. Evidence suggests that prospective people who use services have a needs assessment carried out before they are admitted to the home. The service has received copies of the summary, and care plans, from those assessments carried out through care management. Staff have the necessary specialist skills and ability to care for individuals who are admitted. EVIDENCE: The manager explained that she is currently working on improving the information included with the brochure for the home and showed the additional Eliza House DS0000010670.V333345.R01.S.doc Version 5.2 Page 9 information that she is including to be given to prospective residents. She intends to add information about the daily activities on offer, a sample of the menu, an up to date complaints procedure and details of the costs for items that are not included in the charges, such as hairdressing. It was evident that the manager is limited to some extent, in the improvement that she is able to make, as she does not have access to the original formats of some of this information on the computer in the home. Recommendations are made with regard to this under Standard 37 of this report. The inspector reviewed the written records for 1 person who had been admitted to the home around 6 weeks prior to this inspection. The manager explained that she asks the placing authority for a written assessment of each persons’ needs prior to her visiting them to undertake an assessment of whether the home can meet their needs. She explained that, where possible a she likes to give a member of the senior team an opportunity to undertake the assessment with her. In this case there was clear written information about the person’s needs provided prior to the manager had visiting them, in hospital to undertake her assessment. As the resident was unable to visit beforehand, their daughter came and looked at the home and met the manager prior to the decision being made for the resident to move in. At the time of this inspection the resident had just had their 6 week placement review, and the manager reported that the social worker had expressed her thanks to the staff, as she was very happy with the care provided to the resident thus far in the placement. The home does not provide intermediate care. Eliza House DS0000010670.V333345.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. This judgement has been made using available evidence including a visit to this service. Each individual has a care plan. The plan includes basic information necessary to deliver the resident’s care and are becoming more person centred. Care plans are reviewed and updated as required by the NMS. Risk assessments are completed and are mainly focussed on keeping people who use the service safe. The home understands the need to comply with the administration, safekeeping and disposal of controlled drugs. An incident had recently occurred where medication systems had not followed safe practice guidelines and the managers in the home were investigating this issue. There is basic information available to inform individuals of their rights. Documentation is provided but often not in formats understandable to individuals. There is some evidence that individuals are involved in some decision making about the home, such as day to day living and social activities. EVIDENCE: The inspector reviewed the written records for 2 people living in the home. It was previously recommended that the registered persons review the language and format of the original care plans in order to make them more personal to Eliza House DS0000010670.V333345.R01.S.doc Version 5.2 Page 11 each individual, and generally more accessible to residents. At this inspection the inspector noted that, although the format remains the same, there has been an improvement in the way in which people’s needs are being presented in their plans, in that the language used is more person centred, and better reflects their individuality and individual needs. Again, it was evident that the manager is limited to some extent, in the improvement that she is able to make, as she does not have access to the original formats of some of this information on the computer in the home. Recommendations are made with regard to this under Standard 37 of this report. The risks had been assessed for each person in a number of areas, such as for manual handling and falls, tissue viability and nutrition. The appropriate risk assessments in place and the risks were highlighted in people’s plans so that staff were made aware of which risks were relevant to each person, and how these risks could be minimised. Monitoring records were clear in respect of each person’s health care needs and the input and treatment that they had received from the relevant health care professionals. The inspector was told by a person who wishes to remain anonymous, that an incident of liquid medication being missing had recently taken place in the home, which had not been reported to the Commission. Senior staff members confirmed this, upon the inspector’s second visit to the home. However, it was clear that the managers of the home were undertaking an appropriate investigation into this issue. A requirement is made for a written report of the incident, the subsequent investigation and outcomes is provided to the Commission, on completion of the investigation. The inspector was able to observe the interaction of staff and residents and staff were both gentle and respectful towards the people who live in the home. 1 person that the inspector spoke to said that the staff were “kind” and another said they were “very nice”. Several of the staff team have recently completed a 6 month training course in person centred working with people with dementia and the manager was enthusiastic about the insight that this has provided to staff. Eliza House DS0000010670.V333345.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. This judgement has been made using available evidence including a visit to this service. People who use services are involved in meaningful daytime activities of their own choice and according to their individual interests and capability. Residents are consulted regarding the choice of daily activity, and his process is continually being improved. People using the service are given the opportunity to take part in a variety of activities both within the home. People who use the service have the opportunity to develop and maintain important personal and family relationships. The practice of staff promotes individual rights and choice, but also considers protection of individuals, supporting people to make informed choices that are relevant to them. The home tries to be flexible and attempts to provide a service that is as individual as possible using its staff and resources effectively. EVIDENCE: A television has been donated to the home, and a library of video ‘s that are suitable for the interests of the residents are being collected, and progressing well. A massage chair has also been donated. The inspector observed the staff undertaking activities with the residents, both on an individual basis and in groups. People were playing games that helped with their memory and Eliza House DS0000010670.V333345.R01.S.doc Version 5.2 Page 13 recall, and at other times staff were doing beauty treatment with people. There is a hair dressing room on the first floor and, on the day of the inspection the hairdresser was visiting and styled several people’s hair. The manager said that the foot spa is another resource that is well used, and enjoyed by the residents. A table has been set aside for activities equipment in the main lounge and there were games and equipment, which were available for staff to use to engage and stimulate the residents’ minds. There was also a library of books, which have been carefully chosen, to reflect the particular interests of the residents. There were also lots of magazines available for residents to choose from. There are some residents who are from Irish backgrounds and the inspector noted the Irish music tapes in the tape library, which is also developing nicely. The inspector noted that the seating in the second lounge has been reorganised into smaller groups and this is where people tended to sit with their visitors and chat. There were a lot of visitors on the day of the inspection, and this lounge was being well used. The inspector was able to talk to 2 residents who have become very close to each other and the manager talked sensitively about how best to support and protect their best interests in their developing relationship. The manager discussed the provision of meals with the inspector as she wishes to introduce a contact provision of meals. The manager is weighing the advantages and disadvantages of this in a careful and considered way and has an intention to review further with the support of the responsible person before making a final decision. The inspector is concerned that, now that more residents are living in the home, the cooker, which was installed as a temporary replacement for the previous range cooker, is not suitable for the purpose. It is necessary for the issue of how food is provided to residents adequately and safely now needs to be addressed as a matter of priority. A requirement is made in respect of this issue. The inspector was able to observe the residents whilst they were having their lunch and noted that they sat together in small groups, and that there was a convivial atmosphere with people chatting together and with staff. The staff who were supporting people who needed help to eat were doing so in a discrete and gentle manner. People were able to eat their meals at their own pace and were encouraged, rather than rushed or pressured. The inspector noted that the there was a need to replace some items such as saucepans and wooden spoons. The chef had given a list of equipment that needs to be purchased and the manager had passed this to the registered persons to be purchased. It did seem a slow and onerous method of purchasing small items of equipment for the home, as some items could, more quickly have been bought in local shops and used immediately. The manager Eliza House DS0000010670.V333345.R01.S.doc Version 5.2 Page 14 is also enthusiastic about obtaining further small items of equipment that would further support the reminiscence work that is being done with residents and is somewhat restricted in access to funds in order to achieve this. The manager is sensible, competent, and has dealt with purchasing equipment, and budget monitoring in previous posts. Requirements and recommendations are made in respect of this issue under Standard 34 of this report. Eliza House DS0000010670.V333345.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 adequate. This judgement has been made using available evidence including a visit to this service. The service has a complaints procedure. The procedure was being updated, but is not yet available in alternative formats. Some people say they know how to make a complaint. Staff are aware of the complaints procedure. Staff have had training around Safeguarding Adults. EVIDENCE: As noted, the manager is updating the complaints procedure to ensure that the contact information is up to date; although her not having access to the original format on the computer in the home was making this somewhat of a challenge. The manager reported that no complaints had been received in the home since the last inspection and that no adult protection issues had arisen. Records reflect that staff have had training in safeguarding adults. Eliza House DS0000010670.V333345.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, 21, 24, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that meets the specific needs of the people who live there. The home is comfortable, and has a programme to improve the decoration, fixtures and fittings. Occasionally there is slippage of timescales and maintenance has tended to be reactive rather than proactive. People who use services can personalise their rooms. They also say they the home is clean, warm, well lit and there is sufficient hot water. There has been some consultation with service users about the décor, especially for their own rooms. Toilets for the use of people using the service are easily accessible and in sufficient numbers. EVIDENCE: At the previous inspection the registered person was required to ensure that further remedial action is taken regarding the external tap that is leaking on the outside kitchen wall, to ensure that the smell of damp in the toilet in the foyer near the lounge, is properly investigated and the necessary remedial Eliza House DS0000010670.V333345.R01.S.doc Version 5.2 Page 17 action taken to address the issue, to ensure that the two toilets in the foyer near the lounge are redecorated and refurbished, that the radiator cover in the first floor bathroom in Beech wing is repaired, net curtains are replaced in the dining room and in the residents’ bedroom, where necessary, to ensure that the smell of damp in the toilet in the foyer near the lounge is addressed, to ensure that the smell of damp and the water damage in the bathroom next to room 12 is addressed, and that the water damage to the tiles in the bathroom next to room 12 is repaired. At this inspection the inspector noted that all of these issues had been addressed. The registered person was also previously required to ensure that the water damage around a pipe in the bathroom with linen store is addressed. This has not yet been achieved and this requirement is restated as part of this report. Several of the carpets in the shared areas and in residents’ bedrooms have been steam cleaned and the smell is fresher throughout the home and no unpleasant odours were detected. The toilets in the foyer near the lounge have been redecorated. Several residents’ bedrooms have been redecorated and feel much cleaner and fresher. It was previously recommended that the armchairs in the lounges be steam cleaned. The registered person has provided new chairs, and although the manager said that they are not as attractive as the previous ones, that they are quite practical as they can be kept clean more easily. The handy person has decorated the corridor in Cedar wing, but unfortunately further water damage has occurred since this was done, and this needs to be investigated and remedial action taken to address the issue. A requirement is made in respect of this. The inspector noted that residents’ names and photos had been put on their doors to help them to recognise their bedrooms. Eliza House DS0000010670.V333345.R01.S.doc Version 5.2 Page 18 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, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are enough competent and experienced staff to meet the health and welfare of people using the service. Staffing rotas take into account the needs and routines of the people using the service, although now that the numbers of residents are increasing the registered person needs to consider the employment of further ancillary staff. The service recognises the importance of training, and tries to delivers a programme that meets any statutory requirements and the National Minimum Standards. The manager is aware when there are identified training needs for staff and plans training with this in mind. The service has a recruitment procedure that meets the regulations and the National Minimum Standards. The procedure is followed in practice and there is accurate recording of the process. EVIDENCE: A copy of the staffing rota was provided to the inspector for the week of the inspection. This indicated that there are 3 staff rota’d to be on duty during the daytime and a chef and kitchen assistant each day. Now that there are larger numbers of residents living in the home, it is necessary for the registered person to consider reinstating the arrangements for a cleaner that were previously in place and a recommendation is made in respect of this. The inspector reviewed the written records for 3 staff members. This included the 2 files that had not been available at the previous inspection, and for 1 Eliza House DS0000010670.V333345.R01.S.doc Version 5.2 Page 19 staff member who had recently joined the staff team. Each file included the necessary information regarding the pre-employment check undertaken prior to their employment including references and CRB checks. The manager told the inspector that staff are more enthusiastic about attending training sessions and will come in on their days off and that 11 staff had attended the recent training provided regarding risk assessment and food hygiene. Additionally, funding has recently become available for medication training at NVQ level 2 and most of the staff team have put their names forward to attend this. Records reflect that the staff receive the necessary core training. The manager explained that 1 member of staff has recently been awarded private funding to undertake training at NVQ level 3, and that 2 staff, having completed NVQ 2, are now undertaking NVQ 3 at Tottenham College. Eliza House DS0000010670.V333345.R01.S.doc Version 5.2 Page 20 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, 32, 34, 36, 37 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager is qualified and has the necessary experience to run the Home; they are aware of and work to the basic processes set out in the NMS. The manager is aware of the need to keep up to date with practice and continuously develop management skills. The manager develops staff who are generally competent and knowledgeable to care for the people who use the service. The service is planned to be user focused, to take account of equality and diversity issues, and generally works in partnership with families of people who use the service and professionals. The manager is improving and developing systems that improve accessibility of documents, support staff, and monitor practice and compliance. More work is needed in these areas. The service provider takes responsibility for the home’s accounts and business development, but there is room for improvement in providing the manager more involvement in both planning the budget, and day-to-day access to funds. Checks show that records are generally up to date, although some gaps were found in reporting incidents to the Commission. Eliza House DS0000010670.V333345.R01.S.doc Version 5.2 Page 21 EVIDENCE: The manager is undertaking the process of applying to the Commission for registration she explained that she is looking into doing the Registered Managers’ Award. She is competent, open, and committed to improvement. It is evident that she and her team are, working hard to improve the quality of life of the people who live in the home. The manager told the inspector that staff morale continues to improve and showed a new staff allocation plan which she has introduced in order to ensure a more equitable system of allocation of work for staff and easier monitoring of the quality of the service delivered to residents. However, one staff member told the inspector that they had been subjected to some bullying by other staff members. It is recommended that the manager discuss this issue further with the staff member to ensure that they are clear regarding the action that has been taken in order to address this issue. At the previous inspection the registered persons were required to ensure that the manager is provided with formal one-to-one supervision at least six times a year and to ensure that a record of this is made available for inspection. The manager explained that she had received formal supervision from the responsible person and that they have additional regular opportunities to discuss the running of the home, when he undertakes his monthly visits. As part of the inspection the inspector telephoned the responsible individual to discuss concerns regarding the introduction of a maintenance co-ordinator into the home, who was alleged to have referred to a resident in insulting terms, in the resident’s presence. The responsible individual reassured the inspector that this person would not be visiting the home in the future as they had been found to be unsuitable, and were no longer employed in this role. He also indicated to the inspector that he was considering engaging the support of a quality consultant in order to make improvements in the quality assurance systems in the home. As it was not available in the home at the time of the last inspection, the registered persons were also required to provide a copy of the insurance certificate for the home to the Commission and this was completed within the given timescale. The home has had a number of new admissions. There is consequently less concern about of the financial pressure that the home has been under. Whereas the manager is responsive to the needs of the residents, staff and of the home generally, the system that is in place for purchasing and replacing small items of equipment does not support her in this as well as it could. A recommendation is made for the manager to more involved in the budget Eliza House DS0000010670.V333345.R01.S.doc Version 5.2 Page 22 management of the home, in order to afford her more flexibility in replacing and acquiring equipment for use in the home. A requirement is made for an appropriate amount of money to be made available in the home at all times, in the form of a petty cash fund, to enable the manager more flexibility in making small purchases, and better respond to people’s needs. The inspector was told by a person who wishes to remain anonymous, that incidents had recently taken place in the home, which had not been reported to the Commission. Senior staff members confirmed this, upon the inspector’s second visit to the home. In one instance a resident, who had recently been admitted, went missing and was returned to the home. A requirement is made for all such incidents to be reported to the Commission under Regulation 37 of the Care Homes Regulations 2001. As noted throughout this report, the manager continues to ensure that there is improvement in the written information given to residents; their assessment and care plan information, and the written records of their day-to-day welfare. However, there is further room for improvement in the basic formats that are used by the company. Unfortunately, the manager does not have access to the information on the computer in the home, to enable her to amend, update or to print it in a larger print for residents. Her having the formats would help to her to further improve this information. It is recommended that the registered person undertake a review of all of the written material that the people who use the service would normally have access to, such as their care plans and risk assessments, and the written material that is for residents’ information and guidance, such as the complaints procedure. This is in order to ensure that information is provided to people in an accessible format, to further enable the residents to be involved in the decisions made about their lives. Eliza House DS0000010670.V333345.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 2 X 3 X X 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 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X 2 X X 3 X 3 STAFFING Standard No Score 27 2 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X 2 X 2 2 X Eliza House DS0000010670.V333345.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 OP9 Regulation 13 (2) The registered persons must ensure that a written report is provided to the Commission detailing the incident of missing medication, the investigation that is undertaken and of the outcomes. 2. OP15 16 (2)(g) The registered persons must ensure that a review is undertaken of the way in which catering is organised in the home, in order to ensure that residents are provided with a wholesome, nutritious and healthy diet, which meets their individual choices and nutritional and cultural needs. 3. OP19 23 (2) The registered persons must ensure that the water damage in Cedar wing is properly investigated, the necessary remedial action taken to address the issue, and that the area is redecorated. 01/08/07 01/08/07 Requirement Timescale for action 01/08/07 Eliza House DS0000010670.V333345.R01.S.doc Version 5.2 Page 25 4. OP21 23 (2) The registered persons must ensure that the water damage around a pipe in the bathroom with linen store is, is properly investigated and the necessary remedial action taken to address the issue, and that the area is redecorated. The previous timescale of 01/05/07 was not met. 01/09/07 5. OP34 25 The registered persons must ensure that an appropriate amount of money be made available in the home at all times, in the form of a petty cash fund, to enable the manager more flexibility in making small purchases. 01/08/07 6. OP37 37 The registered persons must ensure that all incidents are reported to the Commission, referred to under Regulation 37 of the Care Homes Regulations 2001. 01/08/07 Eliza House DS0000010670.V333345.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP19 Good Practice Recommendations It is recommended that the registered persons continue with the schedule of repair and refurbishment of the building to include the re-decoration of the corridors, and in particular the corridor of Beech wing. 2. OP27 It is recommended that the registered person undertake a review of the arrangement for providing adequate numbers of staffing hours, in order to maintain acceptable levels of cleanliness in the home. 3. OP34 It is recommended that the manager be more involved in the budget management of the home, in order to afford her more flexibility in replacing and acquiring equipment for use in the home. 4. OP36 It is recommended that the manager discuss the issue of bullying within the staff group further with one staff member to ensure that they are clear regarding the action that has been taken in order to address this issue, and clear that they will not be subjected to further incidents of this nature. 5. OP37 OP1 OP7 OP16 It is recommended that the registered person undertake a review of all of the written material that the people who use the service would normally have access to, such as their care plans and risk assessments, and the written material that is for residents’ information and guidance, such as the complaints procedure. Eliza House DS0000010670.V333345.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Harrow Area Office Fourth Floor Aspect Gate Harrow HA1 1BH 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 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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