Inspection on 05/07/05 for Eliza House

This inspection was carried out on 5th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 25/04/06

Eliza House 13/09/05

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 Jackie Izzard Unannounced 5 July 2005 @ 11:40 am 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 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 G59 S10670 Eliza House V213896 05.07.05 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Eliza House Address 467 Baker Street Enfield Middlesex EN1 3QX 020 8367 8668 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Ms Vibhuti Khan of Peaceform Limited Mr Noah Sagnia PC - Care Home 26 beds Category(ies) of OP - Old age registration, with number of places ELIZA HOUSE G59 S10670 Eliza House V213896 05.07.05 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Eliza House is registered to accommodate twentysix people over the age of sixtyfive. Three named residents who have a diagnosis of dementia may remain at the home. Date of last inspection 19 May 2005 Brief Description of the Service: Eliza House is a purpose built care home for twentysix older people. There are twentysix single bedrooms and residents 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 have other care homes in the UK. The home is located a short bus ride away froom Enfield Town and is close to a park. ELIZA HOUSE G59 S10670 Eliza House V213896 05.07.05 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place on 5 July 2005 from 11.40am until 3.10pm. The previous inspection took place on 19 May and was an additional visit due to three complaints made about the home in May. The report of this visit is available from CSCI on request. Jackie Izzard and Angela Hunt carried out this inspection. They talked to the majority of the eighteen people who were living at Eliza House. They also talked to three relatives, two staff members, the manager and the owner. As well as talking to people, the inspectors looked at various records, checked up on requirements made at the last inspection, observed residents having their lunch, observed staff giving out medication and looked at a number of rooms in the building. What the service does well: The last few months have been difficult for the home as there have been a number of concerns raised about the home and extra visits made by the CSCI which has put the manager and staff under pressure to make improvements. The staff have had to work harder but appear to have maintained good relationships with residents. A number of the residents, and two relatives, said that the staff and particularly the manager are very helpful and look after them well. One said that leaving her mother with the manager was like leaving her with one of her own family as he was “absolutely marvellous.” The other relative made similar comments. They felt that the manager pays special attention to each resident. One also praised the staff, saying that they “do above and beyond their duty.” ELIZA HOUSE G59 S10670 Eliza House V213896 05.07.05 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: The owner and manager were informed that they must immediately change the way that medication is given out. Other requirements made in this report are that they must make sure all appointments with the doctor, dentist or specialist are written in each resident’s personal file, to arrange for one resident to be given her own wheelchair, to record any injury or bruises in the accident book and daily records, to find out how one resident obtained bruises and report this to Enfield Council, to ensure the men are helped with shaving regularly, to arrange for a resident to see a social worker, to ensure all staff are told how each resident is when they come on duty and to remove wheelchairs and walking frames from the lounge and store them safely. The director of Peaceform UK Limited agreed with the CSCI in February 2005 to appoint a deputy manager to help the manager with management duties in the home. There is still no deputy manager at the home. The appointment of a deputy should lead to greater improvements in the home. ELIZA HOUSE G59 S10670 Eliza House V213896 05.07.05 Stage 4.doc Version 1.40 Page 7 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 G59 S10670 Eliza House V213896 05.07.05 Stage 4.doc Version 1.40 Page 8 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 Standards Statutory Requirements Identified During the Inspection ELIZA HOUSE G59 S10670 Eliza House V213896 05.07.05 Stage 4.doc Version 1.40 Page 9 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 standard(s) These standards were not assessed at this inspection as no new people have moved into the home since the last inspection. The home does not provide intermediate care. EVIDENCE: ELIZA HOUSE G59 S10670 Eliza House V213896 05.07.05 Stage 4.doc Version 1.40 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 standard(s) 7, 8, 9 The home has made improvements to the care plans in the last six weeks to ensure individual needs are better recorded. Improvements need to be made in recording health appointments, injuries and in the home’s medication practice in order to ensure residents’ healthcare needs are properly met. EVIDENCE: In May 2005, inspectors received a complaint that none of the residents at Eliza House had a bath for a month. An unannounced additional visit was undertaken by two inspectors on 19 May who found that this allegation was true. The bath had been out of order for at least a month. Inspectors also found that residents were not being provided with adequate personal care. Some were given a bath or shower infrequently. A number of people had dirty hair and uncared for nails. A report of this visit in letter form is available from the CSCI and the home. An immediate requirement was issued to provide regular baths, showers, hair, nail and teeth care. At this inspection, the inspectors noted an improvement in this area. Residents had been consulted about when they would like baths or showers and which they prefer. ELIZA HOUSE G59 S10670 Eliza House V213896 05.07.05 Stage 4.doc Version 1.40 Page 11 Six residents were spoken to about personal care. All six said they has recently had a bath or shower. The physical appearance of residents had improved since the last visit and a new bath chair had been purchased. The inspectors looked at two residents’ risk assessments and care plans in detail. Both residents had a review with a care manager from Enfield Council in 2005. Their care plans had been updated since their review to address changes to their individual needs. The home has introduced a new format for care plans which had been used with these two residents. The new format is clear and more comprehensive. The director told the inspectors that this new care plan format is being introduced for all residents. This is very positive. Both residents had a risk assessment updated in June. One person had fractured her leg recently and her care plan had been updated to reflect the changes in her care since the accident. The inspectors were concerned that an identified issue regarding medication was not recorded in the resident’s care plan or risk assessment and a requirement was made to include this. One person had no medical appointments recorded in her file since 2003. The manager and owner said that the appointments would be recorded in the home’s own records. A requirement was made to ensure all medical appointments and their outcome are recorded in residents’ personal files. Three requirements were made about medication practice. The home had not adhered to its own procedure of two staff recording that a controlled drug was given to a resident. The controlled drug cupboard was a cash tin stuck to the office wall. The home are required to keep the controlled drug tin securely within the medication trolley. Although inspectors have previously seen medication given out properly by staff, on this occasion this was not the case. The tablets were removed from the blisterpack in the medication trolley and taken to the residents in unlabelled plastic cups on a microwave plate cover. The manager said that he thought this practice took place at times during the day when only a small number of residents were given medication. An immediate requirement was issued stating that this practice must cease. One resident was observed by the inspectors to have some bruising to her face and an injury to her arm. There was no record of these injuries in the accident book and no explanation for all but one injury in her daily records. The resident was unable to remember how she got the bruise and the manager and owner also did not know. A requirement was made to investigate how this resident obtained bruises and report the outcome to Enfield Council and to ensure that staff record and report all injuries and bruises to the manager. A requirement is also made to ensure that the two men in the home are helped to shave on a regular basis and that this is recorded in their care plans. ELIZA HOUSE G59 S10670 Eliza House V213896 05.07.05 Stage 4.doc Version 1.40 Page 12 A requirement made at the last inspection to ensure that all staff receive a handover when they come on duty, to ensure they are fully up to date regarding residents’ needs, was not assessed at this inspection. This requirement has been restated and will be checked at the next inspection of the home. ELIZA HOUSE G59 S10670 Eliza House V213896 05.07.05 Stage 4.doc Version 1.40 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 standard(s) 13, 14, 15 Residents are enabled to see their relatives as often as they wish. They have some choice in their day to day lives. The diet is considered to be adequate. EVIDENCE: Residents’ social and recreational interests were not assessed at this inspection. Activities will be addressed at the next inspection as this is an area previously identified as needing improvement. On the day of this inspection, inspectors did observe that staff came and sat with residents to play a game and gave out colouring materials. One resident said that s/he had never coloured in pictures before but had really enjoyed it. Another resident also appeared to enjoy this activity and this is something that could be continued and developed in the home. It was positive to see staff spending time with residents. Inspectors met all eighteen residents and spoke with all those who were able to communicate clearly. In addition, three residents’ relatives were spoken to at some length. The feedback from these discussions was that residents are able to maintain contact with their families and that families are welcomed to the home. ELIZA HOUSE G59 S10670 Eliza House V213896 05.07.05 Stage 4.doc Version 1.40 Page 14 Three residents were asked they felt they made choices for themselves. Two said they were concerned about their finances and requests to see social workers about this matter were passed on by the inspectors. Two said they now made choices about when and whether to have a bath, shower or wash. A recommendation is made at the back of this report for those residents who are assisted with eating to be served when staff are ready to assist them, as an inspector observed that two people were served their meal then had to wait until others had been served before they were helped to eat. This could cause frustration and the food to become cold. Three meals a day are served. Breakfast is cereal and toast, a hot main meal is served for lunch and a snack meal in the evening. Tea, coffee and a cake or biscuits are offered mid morning and mid afternoon. On this occasion, the inspectors asked three people what they thought of the food at the home. One said s/he didn’t eat much so did not want to comment. The other two did not praise the food but said they had no complaints about the food. ELIZA HOUSE G59 S10670 Eliza House V213896 05.07.05 Stage 4.doc Version 1.40 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 Inspectors did not feel able to make a judgement about how the home responds to complaints as the majority of complaints made by relatives and social workers have been made directly to the CSCI. The home has not always investigated thoroughly but there have been improvements in recent months. The home’s own complaints procedure and records will be inspected in detail at the next inspection and a judgement made. EVIDENCE: Three complaints were made to the CSCI about Eliza House between 9 and 16 May 2005. As a result of this, an additional visit was undertaken on 19 May by two inspectors. An anonymous complaint by a relative about dirty net curtains and a tumble dryer being out of action, leading to a build up in dirty laundry and a resident running out of clean underwear was considered to be upheld. Another complainant who wished to remain anonymous complained about the following matters; no handover given to junior staff, only one wheelchair was in good working order, staff wear inappropriate shoes and jewellery which could be a health and safety risk to residents, a resident who should have a commode did not have one, none of the residents had a bath in over a month, residents are not helped to have a wash in the evenings, staff speak in different languages in front of residents, residents are left unsupervised in the lounge at mealtime when staff are in the dining room, reviews of care plans have said no change continuously which did not reflect the true picture of the ELIZA HOUSE G59 S10670 Eliza House V213896 05.07.05 Stage 4.doc Version 1.40 Page 16 resident’s condition and medication was carried in small medication cups without lids and could be mixed up. An investigation of these complaints was carried out during the visit on 19 May and the outcome is that the complaint was partly upheld. It was confirmed that there is no handover period on the rota and that junior staff may not be given the handover which senior staff give. A sample of wheelchairs were checked and other than one with a broken footrest, they were in adequate condition. Discussion with all residents who are able to give reliable information and inspection of the bath/shower book showed that the complaint that none of the residents received a bath for over a month was upheld. This was of serious concern. Records showed that some people had baths in May. Inspectors were informed that the bathroom in bedroom 7 was being used, although this was clearly not suitable for all residents due to a lack of hoist. Records showed that a wheelchair user had two baths in this bathroom in May although the resident denied this when asked if this was the case. A number of residents had had showers in April but inspectors were concerned at the infrequency of showers. They looked closely at the records of baths and showers for eleven residents for April and May. The result was that the frequency of baths and showers was inadequate to meet personal care needs. Although records indicated people are being helped to wash daily, inspectors were informed by a staff member that all but three residents are incontinent at night and a number also during the day. A wash is therefore inadequate. Of the eleven people whose records were studied, the resident who had the most showers had four in the month of April and two residents had neither a bath or shower for the whole month. This is unacceptable. One resident had only one shower in over six weeks, one had one bath in that time. On the visit of 19 May, observations were made of the appearance of seventeen residents and inspectors noted the condition of their hair, clothes and fingernails. Fifty per cent (8) of residents had long and/or dirty nails and fifty per cent (9) had dirty or greasy hair. The condition of their clothes was however generally satisfactory. A sample of care plans were inspected and these said the resident should have a weekly bath or shower. Care plans were therefore not being adhered to. It was the case that some care plans had not been updated when needs changed as alleged in the complaint. There was no evidence on 19 May to substantiate the other complaints listed above. The complaint was therefore partly upheld. At this inspection, inspectors observed that the alleged poor practice regarding medication was seen to be substantiated and an immediate requirement is made in this report to cease the poor practice. Inspectors saw on 19 May that records of meals eaten have improved and are now providing detailed information about the diet eaten at Eliza House. ELIZA HOUSE G59 S10670 Eliza House V213896 05.07.05 Stage 4.doc Version 1.40 Page 17 They also noted that resident records do appear to be made after lunch now instead of before as discussed in previous inspection reports,. The television in the lounge next to the office had inadequate reception despite a requirement being made on this on 3 November 2004 and 3 April 2005. For this reason, an immediate requirement was made to improve the reception of this television. When inspectors arrived, they were very concerned to see a portable television balanced on top of the other television which was an obvious health and safety hazard. The manager did remove this when asked to by inspectors. Since then, a proper aerial has been provided. Despite requirements being made previously to secure the home from access by unauthorised people, inspectors observed the door to be unchained five times out of the six times they checked during the morning on 19 May at Eliza House. This has now been addressed as the registered persons have fitted a security keypad after an immediate requirement was issued to do so. Inspectors also observed that a number of armchairs had soiled arms and ten had no seat cushion in. The registered persons have since cleaned the chairs when required to do so. It is positive that the registered person have taken action to address the above complaints and have made the improvements needed to rectify the problems. The inspectors spoke with three residents’ relatives . One said that the home has responded well to a complaint and rectified the problem identified. Another said that the manager is very helpful and that any request is dealt with promptly. The complaints book was not inspected on this occasion. ELIZA HOUSE G59 S10670 Eliza House V213896 05.07.05 Stage 4.doc Version 1.40 Page 18 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 standard(s) 22, 25, 26 The registered persons need to ensure that each resident has any specialist equipment that they may need, including individual wheelchairs. The home appears safe, comfortable and clean. EVIDENCE: The inspectors saw that there were seven wheelchairs and seven walking frames stored at the back of the lounge. It is a requirement that this equipment is kept in a storage area. Inspectors observed that one resident was assisted into a wheelchair which was not hers. A second resident was using a wheelchair which was communal property. When asked where her personal wheelchair was, this resident said she did not have one. This was despite being a full time wheelchair user. A requirement was made to request that this resident is assessed for her own personal wheelchair. ELIZA HOUSE G59 S10670 Eliza House V213896 05.07.05 Stage 4.doc Version 1.40 Page 19 A requirement was made at the last inspection of the home on 19 May 2005 that the registered persons arrange an assessment of the bath facilities by an Occupational Therapist and inform the CSCI of the date of this assessment. They have told the CSCI that the assessment took place. A requirement is made to send a copy of the assessment to the CSCI. Inspectors did not look at the whole building on this occasion. They did inspect the lounge, dining room, bathrooms, toilets, laundry room, corridors and a sample of bedrooms. These rooms were all clean and safe. Armchairs have recently been cleaned. The safety of residents has recently been improved as the front door of the home has been made secure so that unauthorised people cannot gain access to the home. ELIZA HOUSE G59 S10670 Eliza House V213896 05.07.05 Stage 4.doc Version 1.40 Page 20 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 Residents are looked after by staff who know them well and staffing levels are high enough to meet their needs. EVIDENCE: The Commission for Social Care Inspection has required Eliza House to have four staff on duty throughout the day and evening. Inspectors found four staff on duty when they arrived at the home unannounced. Staffing levels are satisfactory to meet the needs of the people currently living at the home. Inspectors asked four people how they felt they were being looked after. All said that staff were busy but did their best to look after everybody. Two of the three relatives spoken to said that they were happy with the way staff looked after their relative in the home. Inspectors saw that staff had time to sit and talk or play a game with residents which is very positive. Domestic staff are employed to cook, clean and manage the laundry. The majority of staff on duty have worked at the home for some times and are familiar with residents’ individual needs, which is really positive. ELIZA HOUSE G59 S10670 Eliza House V213896 05.07.05 Stage 4.doc Version 1.40 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33 The manager appears to be highly regarded by residents and their relatives as somebody who cares for the residents and tries to ensure their individual needs are met. The CSCI inspectors consider that residents would benefit from an experienced deputy manager to support the registered manager with the management duties of the home. The management of the home will be assessed at the next inspection. A quality assurance exercise has been undertaken and the CSCI look forward to reading the summary of this audit. EVIDENCE: Due to concerns over previous months about the number of complaints and concerns about the home, an agreement has been made between the CSCI and the registered persons that they will employ a deputy manager to support the manager in running the home. ELIZA HOUSE G59 S10670 Eliza House V213896 05.07.05 Stage 4.doc Version 1.40 Page 22 The registered provider has reported to the CSCI that a deputy manager has been identified but this person has still not started working at the home. Quality assurance questionnaires have been sent out to residents, relatives and professionals and returned to the registered persons and the CSCI will be given a copy of the summary of the quality assurance audit once the registered persons have written one. The result of the survey is not yet known. Inspectors did not assess the management of the home, finances or health and safety matters on this occasion. ELIZA HOUSE G59 S10670 Eliza House V213896 05.07.05 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x x x x 2 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 3 COMPLAINTS AND PROTECTION x x x 2 x x 3 3 STAFFING Standard No Score 27 3 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x x x 3 3 x x x x x ELIZA HOUSE G59 S10670 Eliza House V213896 05.07.05 Stage 4.doc Version 1.40 Page 24 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 9 Regulation 13 (2) Requirement The registered persons must ensure that medication is administered safely and properly at all times. The practice of removing medication from a controlled dosage system to unlabelled plastic cups must cease. This is an immediate requirement. The registered persons must ensure that the homes procedure of two staff signing for the administration of a controlled drug is adhered to. The registered persons must provide the correct required storage for controlled drugs. The registered persons must ensure that all medical appointments are recorded in each residents file along with the outcome of the appointment, as evidence that residents have received proper health care. Records for 2004 must be made up to date for every resident. The registered persons must ensure that, if a resident is not happy to take prescribed medication, that this is clearly addressed in the risk assessment Timescale for action 6 July 2005 and from then 2. 9 13 (2) 11 July 2005 and from then on 31 July 2005 31 August 2005 3. 4. 9 8 13 (2) 13 (1) (b) 5. 7 12 31 August 2005 ELIZA HOUSE G59 S10670 Eliza House V213896 05.07.05 Stage 4.doc Version 1.40 Page 25 and care plan. 6. 8 37(1)(e), 13(1)(b) The registered persons must investigate the cause of the bruises sustained by one resident and report their findings to Enfield Council and send a copy to the CSCI. The registered persons must ensure that staff record and report all injuries and bruises to the manager at all times. The registered persons must ensure that a handover is carried out at every shift change to ensure all staff are fully up to date regarding residents’ needs. This reuirement is restated (timescale not yet reached and not checked at this inspection.) The registered persons must provide a storage area for wheelchairs, walking frames and other equipment. The registered persons must arrange for a wheelchair user to be assessed for receiving her own wheelchair. The registered persons must send the CSCI a copy of the assessment recently carried out on the bath facilities by an Occupational Therapist. The registered persons must ensure that the mens careplans include the frequency of which they would like to shave and ensure staff follow this plan. 15 August 2005 7. 12()1(a) 13(4)(c) 1 August 2005 8. 22 23(2)(m) 30 September 2005 1 August 2005 31 August 2005 9. 22 23(2)(n) 10. 22 23(2)(n) 11. 7 12 1 August 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations ELIZA HOUSE G59 S10670 Eliza House V213896 05.07.05 Stage 4.doc Version 1.40 Page 26 1. 15 A recommendation is made that residents who need assistance with feeding are not served their meal until staff are ready to feed them. ELIZA HOUSE G59 S10670 Eliza House V213896 05.07.05 Stage 4.doc Version 1.40 Page 27 Commission for Social Care Inspection 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. Extracts may not be used or reproduced without the express permission of CSCI ELIZA HOUSE G59 S10670 Eliza House V213896 05.07.05 Stage 4.doc Version 1.40 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!