Inspection on 11/07/05 for Elizabeth Court

This inspection was carried out on 11th July 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Elizabeth Court 13/12/07

Elizabeth Court 08/08/07

Elizabeth Court 28/04/06

Elizabeth Court 14/12/05

Elizabeth Court 03/11/04

Elizabeth Court 14/07/04

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Elizabeth Court Grenadier Place Caterham Surrey CR3 5YJ Lead Inspector Mr D Ramdas Announced 11 July 2005 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 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. Elizabeth Court H58_s13634_Elizabeth Court_v226396_110705_stage4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Elizabeth Court Address Grenadier Place Caterham Surrey CR3 5YJ 01883 331590 01883 347423 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) Anchor Trust Care Home 58 Category(ies) of DE(E) - Dementia over 65 (15) registration, with number of places LD(E) - Learning Disability over 65 (1) MD(E) - Mental Dissorder over 65 (15) OP - Old Age (58) PD(E) - Physical Disability over 65 (17) Elizabeth Court H58_s13634_Elizabeth Court_v226396_110705_stage4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd November 2004 Brief Description of the Service: Elizabeth Court is a care home for older people. The property is located in Caterham, Surrey and is close to the town centre and public amenities. The home offers assisted living for 58 permanent residents. Accommodation is provided on three floors, split into five independent living units. The home has a lift and stairs between floors. Each unit has a communal lounge, dining room and a kitchen for preparing hot drinks and snacks. Bedrooms have en-suite facilities. The home has a main kitchen where meals are prepared, adequate bathing and washing facilities and a laundry. There is a large mature garden that is private, secure and has wheelchair access. Private parking is available to the front of the property. Elizabeth Court H58_s13634_Elizabeth Court_v226396_110705_stage4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection carried out by one inspector over a period of 8 hours. A full tour of the premises took place, staff and service users were spoken to and care records and other documents were inspected. The inspector would like to thank the manager, staff, district nurse, and service users for their contributions during the inspection. Comment cards, feedback forms and CSCI business cards were left at the home. What the service does well: What has improved since the last inspection? What they could do better: Documentation and record keeping at the home must be improved. The complaint procedure and the statement of purpose must be updated to make it clear that a complaint could be made to the commission at any stage should the complainant wish to do so. This is to ensure up to date information is available to service users when making a decision about admission to the home. Elizabeth Court H58_s13634_Elizabeth Court_v226396_110705_stage4.doc Version 1.30 Page 6 Individual Lifestyle Plans and risk assessments must be regularly reviewed and updated by staff to ensure the needs of service users are assessed, identified and met. Where risks are identified a care plan must be put in place stating how the risk would be managed by staff in order to safeguard the well being of service users. Medications such as creams and ointments left in service users bedrooms must be risk assessed and the outcomes documented to ensure service users are not put at unnecessary risk. Reporting procedures at the home must be improved to ensure all notifiable incidents including MRSA are reported to the commission without delay. A review must be undertaken to identify the training needs of staff and to ensure a training programme is in place to equip staff with the skills to support service users, positively. Training in achieving National Vocational Qualification in Care must be made a priority. The home must increase the staffing level on the ground floor by one extra staff to ensure service users are adequately supervised and their safety maintained. 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. Elizabeth Court H58_s13634_Elizabeth Court_v226396_110705_stage4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Elizabeth Court H58_s13634_Elizabeth Court_v226396_110705_stage4.doc Version 1.30 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 standard(s) 1,2,3. Service users and prospective service users were provided with details of the services the home provides enabling an informed admission to the home. However, the complaints section must be updated. Service users were provided with written contracts to ensure the terms and conditions of their occupancy were respected. The assessment process at the home is adequate ensuring service users’ needs are assessed. EVIDENCE: The home had a Statement of Purpose and Service User Guide setting out the aims, objectives, philosophy of care, and the services and facilities on offer. The information it contained was well presented and written in plain English and described Elizabeth Court, Accommodation, Staff Team, Admission, Individual Lifestyle Agreement, Key Worker, Personal Care, Access to Health Services, Complaints, Social Activities and Resident Consultation, as well as other areas. The inspector noted the complaint procedure needed updating to reflect that a complaint could be made to the commission at any stage should a complainant wish to do so. This was discussed with the manager who stated the Statement of Purpose is being reviewed. The inspector noted the Statement of Purpose was displayed in the foyer for information. The home Elizabeth Court H58_s13634_Elizabeth Court_v226396_110705_stage4.doc Version 1.30 Page 9 had licence agreements. These were sampled. The inspector noted agreements stated the bedrooms to be occupied by service users, the fees charged and were dated and signed by the service user, the deputy manager and a witness. Licence agreements were kept in the administrator’s office for safety and confidentiality. The home had a Needs Assessment and a local policy for admission. The assessment of service users was completed by the manager or the deputy and a ‘Resident Assessment Form’ was used to monitor changing needs. Elizabeth Court H58_s13634_Elizabeth Court_v226396_110705_stage4.doc Version 1.30 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) 7,8,10. There is clear consistent care planning in place to adequately provide staff with the information they need to satisfactorily meet service users needs. However, the care plans and risk assessments must be regularly reviewed to ensure service users receive appropriate care and support. The health needs of service users are well met with evidence of other health care professionals being involved on a regular basis. Personal support is offered in such a way as to promote and protect service users’ privacy and dignity. EVIDENCE: The home had service user plans. These were known as Individual Lifestyle Agreements that covered areas of health, personal and social care needs. The inspector sampled the plans and noted they had a photograph of the service user, personal details, lifestyle agreements, risk analysis, diary sheets, care plans, doctors’ visits, professional visits, hospital visits, reviews, and questionnaires. The inspector noted the recording of information and reviewing of care plans was inconsistent. It was noted service users weight was last recorded in January 2005, some assessments were not dated and signed, and reviews were not done regularly. One service user had a risk assessment that was completed on the 8th January 2005 and risk areas identified. The inspector noted no care plans were in place on how staff would manage that risk. These areas were discussed with the manager and the deputy who are working to address these shortfalls. The deputy stated the home had one service user Elizabeth Court H58_s13634_Elizabeth Court_v226396_110705_stage4.doc Version 1.30 Page 11 with MRSA. This was not reported to the Commission. Service users are registered with a local GP practice and arrangements are in place for accessing dental, chiropody and optical services. During the inspection the district nurse visited the home. She stated, communication between staff and the GP practice is excellent and that care is good. She is based at Town Hill Surgery. It was recorded in the Individual Lifestyle Agreement that the home had made referrals to the Continence Advisor. Service users were treated with dignity and respect. The inspector noted staff addressed service users by their preferred names and the Activity Co-ordinator and Senior Care Officer sought permission from service users before entering their bedrooms. Telephones were available in some service users bedrooms where calls could be taken in private. One service user stated, the staff are very good and kind hearted. They bring me a cup of tea every morning another remarked, staff look after me very well they come and see me before I go to bed. Elizabeth Court H58_s13634_Elizabeth Court_v226396_110705_stage4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,15 The appointment of an Activities Co-ordinator to the staff team is good providing service users with social, leisure and recreational opportunities. The meals are good offering both choice and variety and catering for special dietary needs. EVIDENCE: The home has an Activities Co-ordinator who works 30 hours a week. She supports service users to be involved in social, leisure and recreational activities. The home has a Weekly Activity Diary that has a list of activities available such as indoor bowls, current affairs, music and movement, board games, arts and crafts, cookery group, bingo, quiz and sherry morning. The Activity Co-ordinator circulates the information about activities to service users and keeps a record. During the inspection it was noted the Co-ordinator supporting a number of residents in playing indoor bowls. One service user stated, she is happy to sit and watch as she has breathing difficulties. The home has a Chef Manager who works full time. There is a written menu plan. The inspector sampled the plans that offered variety and choice. Three choices of different meals are available at lunch. On the day of the inspection some service users had lamb vegetable pie, others had creamy cod and cheese omelette all served with carrots and peas. Dessert was a choice of semolina, ice cream or fresh fruit. Apple and cranberry juice was available at lunch. Mealtime was relaxed and unhurried and meals were nicely presented. The inspector noted in the care plan of one service user that he was on a gluten Elizabeth Court H58_s13634_Elizabeth Court_v226396_110705_stage4.doc Version 1.30 Page 13 free diet. In the food trolley was a gluten free meal that was labelled and given to the named service user. One service user stated the food is excellent and she gets a choice another stated the taste is good. The Chef Manager stated, the food is good and everything is freshly made. Elizabeth Court H58_s13634_Elizabeth Court_v226396_110705_stage4.doc Version 1.30 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 standard(s) 16,18 The home has a satisfactory complaints system with complaints information available to service users. Staff have an awareness of Adult Protection issues which protects service users from abuse. However, training must be undertaken by staff to ensure they have an understanding of the procedures and are kept up to date in order to safeguard the welfare of service users. EVIDENCE: The home had a complaint policy that was dated August 2004. The manager stated the home kept a record of complaints. The inspector sampled the records and noted three complaints were recorded in 2005 and the management took appropriate action. Complaint leaflets were widely available throughout the home. The home had a rights and responsibilities policy and a whistle blowing policy that was dated 2002. The policies were in a folder and kept in the staff office. The inspector noted staff dated and signed the policy. During a meeting staff stated they were aware of the complaint and whistle blowing policies. One staff who had been in post for 4 weeks stated she read the policies during her induction. One service user stated I know what to do about making a complaint. If I have a problem I always see staff about it. During the inspection it was noted the operations manager for Anchor Homes was monitoring complaints. The inspector sampled training records and noted some staff had no training in the protection of vulnerable adults. This was a requirement from the previous inspection and not met. This was discussed with the manager. Elizabeth Court H58_s13634_Elizabeth Court_v226396_110705_stage4.doc Version 1.30 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 standard(s) 19,20,21,22,23,24,25,26. The standard of the environment within this home is good providing service users with an attractive and homely place to live. EVIDENCE: The property is well maintained. The garden is secluded, private, secure and has wheelchair access. The home has a good standard of décor throughout. On the day of the inspection the home was clean and free of mal odour. The inspector noted ventilation was unsatisfactory due to the hot weather. This was discussed with the manager who had made fans available in the lounge and other areas in the home. Furnishings and fittings were of good quality and lighting was adequate. The heating was turned off. The home was fitted with adaptations such as grab rails, assisted bath and toilets to enable service users to maintain their independence. Bedrooms had en-suite facilities were well presented and personalised with family photographs, cards, television, radio, books, and flowers. The inspector noted creams and ointments were on bedside lockers. This was discussed with the manager. Communal areas were spacious, nicely decorated and well furnished. The home had adequate bathing and washing facilities that were clean and hygienic. The laundry had two industrial washing machines and dryers and operating instructions were Elizabeth Court H58_s13634_Elizabeth Court_v226396_110705_stage4.doc Version 1.30 Page 16 displayed on the wall. There were infection control measures. The inspector noted staff washing their hands regularly and gloves and aprons were available. The inspector was asked to wear a hat and a coat before entering the kitchen area. One service user stated she had a nice bedroom that was cleaned every morning by staff another service user stated she enjoyed being in the garden and watering the tomato plants. During a meeting staff stated the environment is nice and the garden has improved. Elizabeth Court H58_s13634_Elizabeth Court_v226396_110705_stage4.doc Version 1.30 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 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) 27,28. After a period of instability in staffing there is now a good match of staff offering consistency of care within the home. The arrangement for NVQ training is adequate. However, a review must be undertaken to ensure adequate numbers of staff are being trained to support service users. EVIDENCE: On the day of the inspection the staffing level was in accordance with those previously agreed. On duty were the manager, the deputy, a senior care officer, activities co-ordinator, chef manager, receptionist, a kitchen assistant, a handyman, a domestic and four carers. The inspector checked the staff rota and noted it reflected the numbers of staff on duty. During a meeting with staff they stated the staffing levels needed to be reviewed on the ground floor. Staff remarked they had raised the issue of staffing levels at team meetings. The inspector noted there was 1 senior care officer and 2 care assistants to support 21 service users on the ground floor. This was discussed with manager who stated she had identified the shortfall in staffing and would increase the staffing levels. The inspector noted a deputy manager and an activity coordinator joined the team recently. The home has an ongoing NVQ training programme. During a meeting staff stated training had improved. The inspector spoke to staff on duty one of whom had completed NVQ Level 2, one had a Diploma in Care and two had started NVQ Level 2. NVQ training was discussed with the manager who stated she would undertake a review to assess the current level of training and take the appropriate action. Elizabeth Court H58_s13634_Elizabeth Court_v226396_110705_stage4.doc Version 1.30 Page 18 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) 31,32. The manager has a clear vision for the home, which she has effectively communicated to service users, staff and relatives. The management arrangement at the home ensures service users, staff and relatives affect the way in which the home is managed. EVIDENCE: The home has a manager who was appointed in October 2004. She is currently working towards the completion of the Registered Managers Award and is an NVQ assessor. The manager communicates a clear sense of direction and leadership to the staff team. The home has regular team meetings for senior care officers and care staff. The inspector sampled minutes of meetings and found they were appropriate and well attended. The senior care officer meeting held on the 18th May 2005 was attended by eight staff. A care staff meeting was held on the 16th June 2005 and attended by eleven staff. The inspector noted a ‘Residents Meeting’ was held on 23rd June 2005 where the manager had discussion with service users and relatives and kept them informed of changes and developments at the home. During an interview staff stated there Elizabeth Court H58_s13634_Elizabeth Court_v226396_110705_stage4.doc Version 1.30 Page 19 had been management instability at the home that resulted in low morale amongst staff. However, things have improved recently with the return to work of the manager and the appointment of a second deputy. Staff remarked the current management is open, approachable and easy to talk to. One staff would like to have meetings every two weeks to discuss and review service users care and to have more contact with the management. This was discussed with the manager who stated she is making operational changes to the home by having unit managers who would provide regular supervision and support to the staff team. Elizabeth Court H58_s13634_Elizabeth Court_v226396_110705_stage4.doc Version 1.30 Page 20 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 2 3 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 2 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 3 x x x x x x Elizabeth Court H58_s13634_Elizabeth Court_v226396_110705_stage4.doc Version 1.30 Page 21 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 NMS18 Regulation 19(1)(a) (5) Requirement The registered person must ensure that all staff are trained in the protection of vulnerable adults. Previous timescale of 28.2.05 not met. The registered person must ensure that the complaint procedure is updated to reflect that a complaint could be made to the commission at any stage should a complainant wish to do so. The registered person must ensure Individual Lifestyle Agreements are regularly reviewed and updated, at least monthly. The registered person must ensure where risk assessments are completed they are dated and signed and where a risk is identifed a care plan must be put in place to state how the risk would be managed by staff. The registered person must ensure that all notifiable incidents including MRSA are reported to the commission without delay. The registered person must increase the staffing levels on Timescale for action 01.10.05 2. NMS1 4(1)(c) Schedule 1(14) 01.08.05 3. NMS7 14(2)(a) (b) 15(2) (a) 14(2)(a) (b) 15(2)(a) 01.08.05 4. NMS7 01.08.05 5. NMS38 37(1)(b) 01.08.05 6. NMS27 18(1)(a) 12.08.05 Page 22 Elizabeth Court H58_s13634_Elizabeth Court_v226396_110705_stage4.doc Version 1.30 7. NMS27 13(4) the ground floor by rostering one extra staff on each shift during the day to ensure the safety of service users and staff. In view of the registration of this home to care for service users with dementia the registered person is required to risk assess the practice of leaving creams and ointments in service users bedrooms. 01.08.05 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 NMS28 Good Practice Recommendations The registered person shall undertake a training needs analysis for staff to assess progress towards gaining the National Vocational Qualification. Elizabeth Court H58_s13634_Elizabeth Court_v226396_110705_stage4.doc Version 1.30 Page 23 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Elizabeth Court H58_s13634_Elizabeth Court_v226396_110705_stage4.doc Version 1.30 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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