Inspection on 25/04/06 for Eliza House

This inspection was carried out on 25th April 2006.

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 19/06/07

Eliza House 28/02/07

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 Caroline Mitchell Unannounced Inspection 02:30p 25 & 26th April 2006 th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Eliza House DS0000010670.V287699.R01.S.doc Version 5.1 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.V287699.R01.S.doc Version 5.1 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.V287699.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home must not take people who have severe dementia with challenging behaviour or nursing needs. 13th September 2005 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 own 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.V287699.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took a day and a half to complete. The home did not know the inspector was coming. A second inspector accompanied the lead inspector each day of the inspection. The inspectors spent time talking to Ms Khan, responsible person, as the registered manager was not available due to illness, and checked that the things the that the home had been asked to do at the last key inspection, in September 2005 had been completed. Various records that are kept in the home were also looked at. Due to the nature of the disabilities of most service users it was a challenge to gain their opinion on life in the home. However, the lead inspector was able to sit and talk to several service users, in some depth, and spoke privately with a number of service users’ relatives, who were visiting at the time. Generally, what they said about the home was positive. The inspectors also met a visiting Chiropodist and the Pharmacist. What the service does well: What has improved since the last inspection? What they could do better: An unannounced additional visit was undertaken of the home on 4 April 2006 by inspector Daniel Lim and Regulation Manager Hannah Hanley. The reason for the visit was that concerns had been raised about the care of two service users. The purpose of the additional visit was to assess the home against the Eliza House DS0000010670.V287699.R01.S.doc Version 5.1 Page 6 National Minimum Standards and associated regulations, relevant to the issues being raised. Three new requirements were made as a result of the additional visit. These were regarding the accuracy of service users’ assessments, the minutes of the latest social services review for one service user who is identified as having a high level of need, and ensuring the healthcare needs of this service user are met. These requirements remain within the timescales for action at the time of this inspection, and are included as part of this report. From the previous inspection, there still remains room for improvement in terms of providing outside activities for service users and ensuring that the staff’s written references are authenticated. There also remains a need to address the issue of low staff morale. From this inspection there are thirteen areas that are identified as needing improvement. These are primarily concerned with ensuring that the home is managed properly as a matter of priority, both in the longer and shorter term. Other areas that need to be addressed include ensuring that all service users’ plans and risk assessments are of a good standard. Although some were of a reasonable standard, there were a number that did not adequately reflect the service users’ needs, including health issues and needs associated with dementia care. Record keeping is identified as an area that needs to be improved upon, especially in terms of monitoring service users’ health care needs. Training, advice and support needs to be provided to staff by health care professionals, regarding specific health issues and there is room for improvement in terms of staff supervision and recruitment checks. In terms of the building, there are some areas that have been identified as needing maintenance and repair. 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. Eliza House DS0000010670.V287699.R01.S.doc Version 5.1 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.V287699.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&4 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home ensures that new service users have a basic needs assessment prior to coming into the home. However, there is still some work to be completed to ensure that the needs of service users with dementia are more fully assessed and met. EVIDENCE: Last year there was a period of several months with no new admissions due to concerns about the quality of care provided in the home. There had been improvements and local authorities had began placing people at Eliza House again. However, recent concerns have led to placing authorities taking the decision to stop further admissions until such time as they are satisfied that the concerns they have are resolved. The service users’ records reviewed by the inspectors included adequate assessment information about their needs, provided to the home prior to them being admitted. The home has recently been granted a variation to the conditions of registration to enable people over the age of sixty five with dementia to be Eliza House DS0000010670.V287699.R01.S.doc Version 5.1 Page 9 admitted. Part of the process of preparing for the variation of the conditions of registration of the home, Ms Khan was clear that a specific dementia mapping assessment and care plan were to be put in place for all service users with dementia, including a “life review” that sets out the service users’ background, likes and dislikes, activities, social interests and religious and spiritual needs. The written records for one service user, who has dementia, were examined and the “life review” was not in place for this particular service user. A requirement is made in respect of this. Ms Khan said that the process of assessing service users with dementia was being progressed and that most service users with dementia have had a “life review” completed. Eliza House DS0000010670.V287699.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. The Registered Person needs to ensure that the health care needs of service users are fully addressed in their care plans and risk assesments. Every service users’ daily and health care records need to be sufficiently detailed so as to ensure that their needs are being fully met. The service users’ best interests are protected by the home’s policies and procedures for dealing with medication. There is room for improvement in terms of protecting the service users’ privacy and dignity. EVIDENCE: There had been two adult protection issues in the home prior to this inspection. These were in relation to the extensive unexplained bruising of one service user, and the death of another service user, in hospital, as the result of a pressure ulcer. At the time of this inspection these issues were being investigated by the local authority under their adult protection procedures, and this inspection did not specifically focus on the two service users concerned. However, the inspection did include a review of the way in which care is delivered and risks are managed in the home, for the more frail and vulnerable service users, with respect of their health care issues. Eliza House DS0000010670.V287699.R01.S.doc Version 5.1 Page 11 The inspectors looked at the written records for three service users, who were identified by Ms Khan as being particularly at risk of pressure sores, falls or where cot sides were in use. The inspectors noted that the standard of the service user plans was not consistent. One service user, who had high care needs, had a plan that was of poor quality, and did not reflect their changing care needs. This service user had a catheter in place. However, there was no mention of the care of this, in either their plan or their risk assessments. In addition, this service user was noted to bruise easily. However, there was no risk assessment in relation to this and no guidance for staff in moving and handling them to minimise the risks. Cot sides were being used on this service user’s bed, without adequate risk assessment in place, although there was evidence that support had been sought from an occupational therapist, whose visit was imminent. There was a written information sheet in each person’s file regarding the pressure relief equipment that was being used. However, these were not completed appropriately for each service user. Requirements and recommendations are made in respect of all of these issues. The inspectors noted that, despite staff having received training in moving and handling, there have been recent issues regarding the bruising of service users, that could be linked with the way in which they were handled by staff. It is recommended that further advice is sought and guidance provided to staff regarding this. In some instances, the inspectors noted that the standard of day-to-day record keeping was quite poor, and this did cause difficulty in tracking issues in the areas of health and care, such as tissue viability and dietary and liquid intake. A staff member had written that they had applied an emollient cream to one service user’s sacrum. There was no proper description of the condition of the service user’s skin, or explanation of why the cream was being applied. This service user was at a high risk of pressure sores, being in bed all of the time, yet no consistent records were being kept of the amounts that they drank or ate, or of their position in bed or turning by staff. A number of requirements are made in respect of this. However, in another instance, a service user’s daily records provided a clear description of the condition the service user’s wound, and clear indication of when support was sought from the district nurse. The service uses are signed up with a number of different GPS and the inspectors discussed with Mrs Khan the level of support that service users received from their GPs. During discussion a need was identified for more clarity regarding the health care input needed and scheduled for service users, particularly those who are prescribed medication, or have with other health care issues, such as diabetes. A requirement is made for a health action plan to be put in place for each service user, setting out their health needs and the Eliza House DS0000010670.V287699.R01.S.doc Version 5.1 Page 12 arrangement in place to treat and monitor these. These plans must be agreed with GPs and any other relevant health professionals. At the additional visit undertaken on 4th April 2006 the requirements made were for the registered person to ensure that assessments carried out on service users are accurate and signed by the assessor, to ensure that the minutes of the latest social services review (of the service user identified as having high needs) is forwarded to CSCI when received and to ensure that the healthcare needs of the service user identified as having high needs is met. Documented evidence that this service user has been attended to by healthcare professionals is required. At the time of this inspection these requirements remained within the timescales for action and are included as part of this report. It is also worth noting that a number of service users’ plans remained unsigned and undated at the time of this inspection. At the key inspection undertaken in September 2005 the registered person/s was required to arrange a review and update the care plan for a specified service user who has dementia. The inspector was able to confirm that copies of the reviewed assessments for three service users with dementia were provided to the Commission at that time. However, at the time of this inspection there remained a small number of service users with dementia who did not have a full in-house assessment and care plan in place. This is addressed under Standard 4 of this report. A requirement was also previously made in respect of a specific service user who was not happy to take prescribed medication. The requirement was for the registered person to ensure that, if a service user is not happy to take prescribed medication, that this is clearly addressed in the risk assessment and care plan. At this inspection the notes on the service user’s records were seen and this requirement was considered to have been met. As part of the relatives’ feedback it was noted that the staff do not always pay enough attention to ensuring that the toilet doors are closed when they are assisting service users in the toilet. A recommendation is made in respect of this. The inspectors reviewed the arrangements for the storage, administration and recording of medication in the home and these arrangements were found to be of an acceptable standard. Eliza House DS0000010670.V287699.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. There is still room for improvement in terms of the activities provided to service users in the home. EVIDENCE: At the previous key inspection the registered persons were required to provide more activities, both within and outside the home, to meet the recreational needs of all service users. There is a record of daily activities kept that reflects that activities are scheduled in the home, to suit service users’ needs. However, there was very little evidence of service users being offered access to any activities outside of the home and this part of the requirement is restated. Feedback from service users and their relatives was also that there is room for improvement in bringing in entertainment and services into the home and taking service users out into the local community. Eliza House DS0000010670.V287699.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. Although service users and their relatives are confident that complaints will be listened to and dealt with, there have been a number of adult protection issues in the home that were in the process of being investigated. EVIDENCE: As stated, at the time of this inspection the Local Authority was investigating concerns regarding unexplained bruising for one service user and pressure ulcers for another, in accordance with their adult protection procedures. There was also an adult protection investigation in December 2005 regarding unexplained bruising of another service user. A number of requirements and recommendations that are relevant to these issues are made throughout this report. The inspector spoke to a number of service users and their relatives and they were clear about whom to complain to, should they have a concern about the home. They were reasonably happy that any complaints that they may have would be dealt with appropriately. At the previous key inspection the registered persons were required to ensure that all service users are protected from any possibility of financial abuse and therefore must advise the responsible local authorities of the concerns about three specified service users not being able to access their personal money. The inspectors were able to verify that this issue has been addressed. Eliza House DS0000010670.V287699.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 22 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home is clean and pleasant. Some areas have been identified as needing improvement, but generally the home feels homely and well kept. EVIDENCE: An inspection of all of the bedrooms, the lounges, dining room, gardens and health and safety records was carried out. These were clean, tidy and decorated and furnished to a satisfactory standard. However, during the tour of the building the inspectors noted that the kitchen was in need of deep cleaning and there were some small areas of peeling paint. To minimise the risk of food contamination it is necessary for the kitchen to be re-decorated. The floor covering in the laundry room was damaged, and in order to minimise the risks of accident and cross infection, this needs to be replaced. There were two external overflow pipes that were leaking and causing water damage to the brickwork, one to the kitchen drain and one high up on an external wall. These issues need to be addressed. The inspectors also noted Eliza House DS0000010670.V287699.R01.S.doc Version 5.1 Page 16 an unpleasant odour, which could possibly have been linked to the drains, in one wing of the home. There was one electric socket front, in one service user’s bedroom that was broken. Requirements are made in respect of these issues. At the previous key inspection the registered persons were required to provide a storage area for wheelchairs, walking frames and other equipment and arrange for a wheelchair user to be assessed for receiving their own wheelchair. The registered persons were also required to replace all stained and worn armchairs and to send a copy of the most recent inspection report for the gas appliances to the CSCI as evidence that this is up to date. The inspectors were able to confirm that all of these requirements had been addressed. Eliza House DS0000010670.V287699.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 & 30 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Whereas training is provided there are still some staff who have not had all of the necessary core training. There are also a number of areas that are specific to service users’ needs, where further staff training is very important to ensure their welfare. Recruitment practice has improved, but there remains room for further improvement to ensure that the welfare of service users is maintained through best practice. EVIDENCE: Ms Khan keeps a record of the training that has been provided to staff and this indicated that, although most of the core training has been provided to most staff, there remain a number of staff that have not received all of the necessary core training, particularly, but not exclusively, health and safety and adult protection. A requirement is made in respect of this. There are also areas of training need that have been highlighted as a result of this inspection. These include tissue viability and the prevention of pressure ulcers, caring for service users who have a catheter in place, basic literacy skills and report writing training. Requirements are made in respect of these issues. At the previous key inspection the registered persons were required to ensure that every person employed in the home has two written references which the registered persons have satisfied themselves are authentic. The inspectors Eliza House DS0000010670.V287699.R01.S.doc Version 5.1 Page 18 were able to confirm that the records of recruitment of staff reflected an improvement in practice and two written references were being obtained for all applicants prior to them starting in the home. However, in some instances there was no evidence to indicate that references had been checked for their authenticity. This requirement has been restated as part of this report. Eliza House DS0000010670.V287699.R01.S.doc Version 5.1 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 & 38 Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. Given the concerns that have been raised recently about the quality of care in the home, it is a matter of priority that proper arrangements are put in place to manage the home, both in the long and the short term. In order to protect the best interest of the service users, staff need to receive proper one to one supervision more regularly. Staff morale is low and this needs to be addressed. Record keeping needs to be improved, regarding service users’ wellbeing and care. Generally the health and safety of service users and staff are promoted and protected. EVIDENCE: The registered manager was not at work due to illness, and Ms Khan was unclear as to when he was likely to be well enough to return to work. The management arrangements in the home were discussed at length and it was emphasised that this area is not satisfactory and must be addressed as a Eliza House DS0000010670.V287699.R01.S.doc Version 5.1 Page 20 matter of priority. Ms Khan was clear that a temporary manager would be recruited to cover if the registered manager was not able to return to work within a specific timescale. Throughout the inspection it was evident that a number of areas of management of the home had not been satisfactory for some time and these will need to be addressed with the registered manager upon his return. However, it is also the responsibility of the registered persons to ensure that satisfactory standards within the home are maintained, and the monthly visits should be key to this process. In order to help monitor progress in the improvement of quality in the home, it is recommended that the objectives set for the home, and any targets set for improvement be monitored as part of the monthly visits by the registered persons. It had been acknowledged that a deputy manager was a necessary addition to the management of the home after a number of complaints and an adult protection issue had arisen in the home in 2005. A deputy manager was recruited towards the end of last year, but had not worked in the home since December 2005. Ms Khan showed the inspector evidence that she has made several attempts to recruit a deputy manager. She explained that there had been difficulty in retaining them, once recruited. A requirement is made for the registered persons to ensure that proper arrangements are put in place to manage the home, both in the short term, in order to cover for the absence of the registered manager, and in the longer term in terms of recruiting to the deputy manager post. The inspectors reviewed the written records for several staff members at random and it became evident that staff were not being provided with formal one to one supervision as often as necessary and some staff had not had a recorded supervision session for several months. A requirement is made in respect of this. At the previous key inspection the registered persons were required to maintain good personal and professional relationships with staff and inform CSCI of what action has been taken to improve low staff morale. Morale is an ongoing issue in the home. The lead inspector had received feedback from an external trainer who was providing training to staff regarding working with people with dementia stating that staff are very disaffected, and are complaining of not being treated properly. Another recent incident resulted in the police being called to escort the staff member from the building. The previous requirement is reworded and restated as part of this report. As previously mentioned the standard of record keeping regarding service users was quite poor, making it difficult to track issues of health and care and a number of requirements are made in respect of this. There are two different methods of recording information regarding service users. These are the dayto-day record sheets that are completed by care staff, and the handover notes, completed by the senior staff members, which sometimes refer to individual service users. It is recommended that the use of these records be reviewed to Eliza House DS0000010670.V287699.R01.S.doc Version 5.1 Page 21 ensure that all information regarding service users’ health, welfare and care are recorded on their personal records. The inspectors reviewed the records kept in the home regarding the maintenance of health and safety. These records were found to be in good order and all necessary checks and maintenance had been undertaken. Eliza House DS0000010670.V287699.R01.S.doc Version 5.1 Page 22 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 X X 3 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 2 X X X X X X 2 STAFFING Standard No Score 27 X 28 X 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 X 3 2 2 3 Eliza House DS0000010670.V287699.R01.S.doc Version 5.1 Page 23 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 13(1)(b) 15(1) Regulation Requirement Timescale for action 2 OP7 15(1) 17(1)(a) 3 OP8 12(1) The registered person must ensure that assessments carried 03/05/06 out on service users are accurate and signed by the assessor. (This requirement was within the timescale for compliance.) The registered person must 13/05/06 ensure that the minutes of the latest social services review (of the service user identified as having high needs) is forwarded to CSCI when received. (This requirement was within the timescale for compliance.) The registered person must 13/05/06 ensure that the healthcare needs of the service user identified as having high needs is met. Documented evidence that this service user has been attended to by healthcare professionals is required. (This requirement was within the timescale for compliance.) The registered persons must 30/06/06 ensure that a GP referral is made for the service users who are prone to bruise easily for DS0000010670.V287699.R01.S.doc Version 5.1 Page 24 4 OP8 13 12(1) Eliza House 5 OP8 13 6 OP8 17(1)(a) Schedule 3(3)(n) 18(1)(c) (i) 7 OP30 8 OP8 15 (1) 9 OP37 18(1)(c) (i) 16(2)(n) 10 OP12 diagnosis and advice. Where service users bruise easily, risk assessments must be in place that properly reflect the risks and set out appropriate interventions to minimise these risks. The registered persons must ensure that all service users for whom cot sides are being used have been appropriately assessed (i.e. specialist help and advice must be sought and in instances where people are at risk of falling from bed the reasons must be fully investigated) and that appropriate risk assessments are in place regarding their use. The registered persons must ensure that a record is kept with regard to pressure relief equipment and the treatment provided for each service user. The registered persons must ensure that care staff are provided with up to date training regarding tissue viability, the prevention of pressure ulcers and catheter care. The registered persons must ensure that a health action plan be put in place for each service user, setting out their health needs and the arrangement in place to treat and monitor these. These plans must be agreed with GPs. The registered persons must ensure that staff receive training in basic literacy, recording and report writing as necessary. The registered persons must provide more activities, outside the home, to meet the recreational needs of all service users. (The previous timescale of 30/11/05 was DS0000010670.V287699.R01.S.doc 30/06/06 30/06/06 30/08/06 30/06/06 30/10/06 30/08/06 Eliza House Version 5.1 Page 25 not met). 11 12 OP19 OP19 23(2)(d) 23(2)(b) The registered persons must ensure that the kitchen is deep cleaned and re-decorated. The registered persons must ensure that the issue of the two external overflow pipes that were leaking is addressed. The registered persons must ensure that one electric socket front; in one service user’s bedroom is replaced. The registered persons must ensure that the unpleasant odour evident that was possibly linked to the drains in one wing of the home is investigated and addressed. The registered persons must ensure that the floor covering in the laundry room is replaced. The registered persons must ensure that every person employed in the home has two written references which the registered persons have satisfied themselves are authentic. (The previous timescale of 13/09/05 was not met). The registered persons must ensure that appropriate arrangements are put in place to manage the home. The registered person/s must submit details in writing to the Commission as to how they plan to address this. The registered persons must ensure that all staff are provided with regular formal one to one supervision (in accordance with the National Minimum Standards this should be at least six times per year.) The responsible person inform CSCI of what action has been taken to improve current low DS0000010670.V287699.R01.S.doc 30/06/06 30/06/06 13 OP19 23(2)(c) 13(4) 16(2)(k) 30/06/06 14 OP19 30/07/06 15 16 OP26 OP29 23(2)(c) 13(4) 19(1)(c) 30/07/06 30/06/06 17 OP31 8 14/06/06 18 OP36 18(2) 30/06/06 19 OP32 12(5)(a) 30/06/06 Eliza House Version 5.1 Page 26 staff morale. (The previous timescale of 13/11/05 was not met). 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 OP8 Good Practice Recommendations It is recommended that the registered persons seek advice from the appropriate health care professionals regarding the moving and handling of people who are prone to bruising. It is recommended that staff be reminded about the home’s values regarding upholding the privacy of service users. Particularly in respect of ensuring that toilet doors are closed when they are assisting service users in the toilet. It is recommended that the use of the current written records be reviewed to ensure that all information regarding service users’ health, welfare and care are recorded on their personal files. It is recommended that the objective set for the home, and the targets set for improvement are monitored as part of the monthly visits by the registered persons. 2. OP10 3. OP37 4. OP33 Eliza House DS0000010670.V287699.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA National Enquiry Line: 0845 015 0120 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. 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