Inspection on 13/12/07 for Elizabeth Court

This inspection was carried out on 13th December 2007.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Elizabeth Court 08/08/07

Elizabeth Court 28/04/06

Elizabeth Court 14/12/05

Elizabeth Court 11/07/05

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 Elizabeth Court Grenadier Place Caterham Surrey CR3 5YJ Lead Inspector Jo Griffiths Unannounced Inspection 10:30 13 December 2007 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 Elizabeth Court DS0000013634.V353928.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Elizabeth Court DS0000013634.V353928.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elizabeth Court Address Elizabeth Court Grenadier Place Caterham Surrey CR3 5YJ 01883 331590 01883 347423 claire.russell@anchor.org.uk www.anchor.org.uk Anchor Trust 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) vacant post Care Home 58 Category(ies) of Dementia - over 65 years of age (34), Learning registration, with number disability over 65 years of age (1), Old age, not of places falling within any other category (58), Physical disability over 65 years of age (5) Elizabeth Court DS0000013634.V353928.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th August 2007 Brief Description of the Service: Elizabeth Court is a care home located in Caterham, Surrey in a village setting close to the local shops and public amenities. The home provides personal care for older people and the accommodation is on three floors that can be accessed by stairs or lifts. The home has communal lounges, dining rooms, toilets, bathrooms, kitchenettes and a laundry. The garden is well maintained, private and secure. Bedrooms are single and have en-suite facilities and meals are prepared in the main kitchen and served in heated trolleys. The home has private parking available to the front of the property. The home is managed by Anchor Homes. Fee levels in 2007 ranged from a minimum of £583 to a maximum of £675 Elizabeth Court DS0000013634.V353928.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘Key Inspection’. The inspector arrived at the service at 10.30am and was in the service for 8 hours. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s manager, and any information that CSCI has received about the service since the last inspection. Surveys were sent to people that use the service and their relatives. 18 of these surveys were returned. During the visit to the service the inspector spoke with 8 people that live in the care home, who gave their view of the quality of the service. The inspector had a look around the home, inspected some of the records and spoke with the Manager and staff on duty. What the service does well: What has improved since the last inspection? The care plans have been fully completed and are now meeting the health and personal care needs of the people in the home. The records relating to the care provided have greatly improved. Staff have completed more training and further training is planned. The Deputy Manager and staff have completed a project in nutrition to ensure that people in the home have their needs met in the best way in this area. The home has Elizabeth Court DS0000013634.V353928.R01.S.doc Version 5.2 Page 6 joined the Dignity project launched by the Department of Health to champion dignity in older people’s services. A new activity coordinator has been appointed. The activities in the home have improved and people are now more involved in the daily running of the home and have more control over their lives. Pictures have been placed around the home of activities taking place. The environment has been improved with new signs to ensure people can find their way round the home easily. New pathways have been added to the garden to make it easier and safer for people to walk around outside. The laundry service has improved and people know have their laundry managed individually to avoid damage and loss of items. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Elizabeth Court DS0000013634.V353928.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Elizabeth Court DS0000013634.V353928.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 Standard 6 is not applicable at this care home. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People only move into the home after they have their needs assessed and are assured they can be met by the service. EVIDENCE: The Manager and deputy Manager carry out all assessments of people wishing to move into the service. The assessment documentation was seen and this ensures that all areas of need are addressed. There is a pre-admissions assessment that is completed before the person moves to the home and a baseline assessment that is completed within 48 hours of them moving in that forms the care plan. Elizabeth Court DS0000013634.V353928.R01.S.doc Version 5.2 Page 9 The assessments for 5 of the people that live in the home were inspected in detail. These showed that people only move into the home if their needs can be fully met by the service. The Manager gave examples of where assessments have shown a person’s needs would not be met and therefore a service was not offered. Feedback from people living in the home and their relatives evidenced that they felt involved in the assessment process and felt that their views were taken into account. Elizabeth Court DS0000013634.V353928.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9, 10 and 11 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People have a care plan that meets their personal care and health needs, but they would benefit from more detailed plans and better record keeping ensuring their social needs are met. People are safeguarded by the homes procedures for managing their medication. The people that live in the home are generally treated with respect and their right to privacy is maintained. People know that they will be supported sensitively at the end of their life. EVIDENCE: Each person has an individual care plan that is based on the assessment of their needs. The home uses a care plan system provided by the Anchor Trust. Elizabeth Court DS0000013634.V353928.R01.S.doc Version 5.2 Page 11 This has been recently introduced in the home and was at its early stages at the last inspection. The care plans for 5 of the people that live in the home were inspected. These have now been completed and it was noted that they have been written in a way that incorporates individual’s choices and preferences. For example, it is recorded what time people prefer to go to bed and whether they like to receive a hot drink in bed in the morning. People have signed to agree their own care plans. Individual’s preferences of the gender of the staff that support them with their personal care have been included in the care plan. The care plans cover all the needs identified on the pre-admissions assessment and the baseline assessment. The health needs of individuals are addressed through the care plan and records of visits to GP’s and other healthcare professionals are now being maintained consistently. Feedback from healthcare professionals was positive about the home. People that live in the home said that they are supported to see a GP when they need to and that they felt the care staff responded to their health needs quickly. The records relating to the personal care given to people in the home have improved, but further work is needed to ensure the records are used correctly and that they evidence that agreed support in the care plan is being given. The night time care plans are detailed and show where risks have been identified and assessed. There was evidence in the care plans that people had been consulted about the support they would like during the night and that this had been agreed in the care plan. The records of checks made at night are now being maintained properly to ensure that people are having their needs met. The care plans for people’s social needs could be further expanded to ensure that people are supported to maintain contact with their family and friends and that they are enabled to undertake activities or hobbies that are important to them. Where people need support to remember important events and family birthdays this should be included. The records relating to people’s social needs are not maintained in a way that would allow the manager to assess if they are being met consistently. For example, one persons care plan states they are to be supported to walk to the shops for a magazine each week, but there was no records to evidence that this was taking place. The care plans are reviewed monthly by the keyworker and changes are made as necessary. Risk assessments had been completed for each person and reviewed. The Moving and handling assessments had not been reviewed as frequently as the other risk assessments. The Manager said this was because the back care coordinator for the home had required update training and now that this had taken place all the moving and handling assessments were being reviewed to ensure people are being moved safely and comfortably. Elizabeth Court DS0000013634.V353928.R01.S.doc Version 5.2 Page 12 The medication procedures and practice have been reviewed since the last inspection. There are now daily and weekly audits of medication by Team Leaders and the Deputy Manager to ensure that all medicines have been given correctly and signed for. All staff that administer medication have completed two training courses, one on medicines and one on the Monitored Dose System. All staff have had a competence assessment and reassessments are planned at six monthly intervals. The Manager and Deputy are now trainers in medication so will carry out the reassessments of competence. The temperature in the medication cupboards was being monitored, but the records showed the temperature on occasions had exceeded the recommended storage temperature for medicines. The Manager said that air cooler units had been ordered to reduce the temperature. The Manager was advised to ensure there is clear guidance for staff so they know when PRN medication is to be given. For example, for medication that is to be administered when a person is in pain there needs to be clear guidance on how pain is assessed for those that do not communicate verbally. There was evidence within the care plans of consultation with people about the times they prefer to take their medication. The Manager and Deputy Manager have recently completed a train the trainer course in end of life care. Training will be delivered to all staff in January 2008. It is then planned that the care plans will be further developed to address people’s needs and wishes in this area. Feedback from people that live in the home showed that they were happy with the level of support they receive for their personal care. The hairdresser visits twice a week. Comments from people in the home included. “Couldn’t better this place” and “The carers are very patient and kind”. Staff were observed to treat people with respect and to support them at their preferred pace. However, there was one example of poor practice seen where a gentleman was seated away from his peers as he is considered noisy. This is described further under standard 15. Staff were seen to respect the privacy of peoples’ rooms and belongings. The Deputy Manager and some of the staff have joined as champions for the Dignity project that was launched through the Department of Health. The ‘Journal of Dementia Care’ has produced a toolkit for finding out the things that are important to people with dementia in their lives. This is being used by Keyworkers with their residents. The Deputy Manager has an excellent understanding and knowledge of Person Centred Support for people with Dementia. Elizabeth Court DS0000013634.V353928.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. People have the opportunity to participate in a range of activities within the home and the community, but they would benefit from clearer planning and recording to ensure the Manager can monitor that their social needs are fully met. The people that live in the home are supported to exercise control over their lives. People that use the service say they enjoy the meals. They benefit from a balanced and nutritious diet. EVIDENCE: Since the last inspection a new activity coordinator and assistant have been appointed covering 40 hours per week between them. The hours are flexible to cover evening and weekend activities. The activity coordinator is booked to attend training with the National Association for Provision of Activities (NAPA) for older people. They also attend regular practice sessions for activity Elizabeth Court DS0000013634.V353928.R01.S.doc Version 5.2 Page 14 workers held by Anchor. NAPA have worked with the home on an activities project to provide a benchmark practice guide for Older People’s services. Information about this is displayed in the entrance hall. There were numerous photographs displayed around the home showing people that live there enjoying various activities. They include photos of people doing household activities, such as hanging out their washing, baking cakes and gardening. The home has a Wii (Interactive Computer Games Console). The people that live in the home use this to play games such as tennis and golf. This has been particularly successful for people that used to enjoy these sports as a hobby. The feedback from people in the home was positive about this and photographs of people playing and laughing were seen. During the inspection people were seen to be supported to prepare vegetables for their lunchtime meal, to go for a walk in the gardens and to make cups of tea when they wanted them. One persons care plan included being supported to do some of their personal laundry. There are books around the communal areas of the home for people to read. Activities are available in the home and some are planned individually. For example, one person is being supported to go to football match of the team they support. A group trip to London to see the Christmas lights had been booked for the day following the inspection. It is planned that the staff will undertake some training in activities for older people to help them meet people’s social needs. As reported above it would benefit people if their care plans were expanded to include the support they may need to maintain their role in their family. The records of activities do not reflect the activities that people that live in the home said they were doing. People said that there were more activities in the home now but they would like to see more outings. Staff need to record the activities that are provided so that the Manager can monitor that people’s social needs are being met. This should include any individual activities that are part of the care plan. The home has recently completed a project on the nutritional needs of the people with Dementia in the home. Research, as part of this project, showed that having the main meal in the evening helped some people to sleep better at night. Everyone in the home has since been consulted about the times they would prefer their main meal and half of the people in the home have said they would like it changed to the evening. The chef has arranged for this to take place for those who have requested it. There is a 4-week menu for the home and this varies depending on the seasons. The inspector spoke with the chef Manager who said that he meets Elizabeth Court DS0000013634.V353928.R01.S.doc Version 5.2 Page 15 with people when they move in to discuss their likes, dislikes and dietary requirements. There are always two choices per meal and the choice of a cooked or cold breakfast. People are supported to make their choice from the actual meals in front of them rather than pre order. They can always have something else from the kitchen if they do not like the choices available. In addition to the main meals provided there are always fresh fruit, biscuits and other snacks on each unit. The chef makes homemade cakes daily for afternoon tea. Each unit has a water cooler and a fresh fruit juice machine. The chef Manager hopes to extend the kitchen service to provide a 24-hour meal service. The staff have access to the kitchen when the chef is not there to prepare any snacks people would like. The menus are displayed in the entrance hall and on a board in each unit. It may benefit people with Dementia or visual impairments if the menu was displayed in an alternative format. Feedback from the people in the home showed they enjoyed their meals and felt they had sufficient choice. Two of the people that live in the home are Polish and therefore some Polish staff are employed. A Polish themed evening is planned along with themed evenings from other countries. The mealtimes were generally seen to be relaxed, with the exception of one unit where a gentleman was seated alone, away from the main table. When questioned about this the staff said he can be noisy and disturb other people. Whilst the staff were meeting the needs of other people in the unit they failed to recognise that they were not fully meeting his needs. The gentleman was clearly unhappy about this arrangement. The Manager sent a team leader to support the staff in this unit immediately and said the staff would be spoken with about the incident. Elizabeth Court DS0000013634.V353928.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People that use the service know how to make a complaint and can be assured their concerns will be taken seriously. People in the home are safeguarded from abuse and harm. EVIDENCE: The home’s complaints procedure is displayed in the entrance hall alongside ‘how to complain’ leaflets. Feedback from people that live in the home shows that they know how to make a complaint and they feel they will be listened to. There have been four complaints received by the home since the last inspection. The Manager has investigated these under the home’s complaints procedure and has sent a written response to the complainant. All the complaints have been resolved satisfactorily and recorded appropriately. Changes were seen in the care plan in response to a complaint received to ensure risks in relation to a resident smoking were being appropriately managed. There have been no complaints received by CSCI in relation to the home. Some letters of compliment were also seen. One stated about the home; “Exceptional care, all staff are wonderful” Elizabeth Court DS0000013634.V353928.R01.S.doc Version 5.2 Page 17 The Manager and Deputy Manager have a copy of the Surrey Adult Protection Policy and have completed training in this area. All the staff have received training in Safeguarding adults and update courses are planned for January 2008. There have been no referrals made under the Safeguarding adults’ procedures. The Safeguarding adult’s policy for the home has been reviewed. The whistle blowing policy still needs review and should inform staff that they can contact CSCI if they need to. Staff spoken with understood the reporting procedures for any allegations of abuse. The restraint policy still requires review to ensure it links with the Safeguarding adults policy and reporting procedures. The Manager stated that there is no restraint used in the home anymore. Elizabeth Court DS0000013634.V353928.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 21, 22, 23 and 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People in the home benefit from a safe, clean and comfortable environment. They have access to appropriate communal, private and bathroom facilities that meet their needs. People in the home have the specialist equipment they need to maximise their independence. EVIDENCE: The home is clean and well maintained. Each person has a single bedroom with ensuite facilities that include a shower, sink and toilet. The home can cater for couples and have, in the past, provided a bedroom and lounge for couples use. There are additional bathrooms with assisted baths on each wing of the home. The bathrooms have been decorated to provide a comfortable and relaxing Elizabeth Court DS0000013634.V353928.R01.S.doc Version 5.2 Page 19 environment for people. The feedback from the people that live in the home showed they are happy with their bedrooms and bathroom facilities and feel that they meet their needs. All the bedrooms have telephones for the resident’s personal use. The home is divided into 5 wings and on each there is a large lounge, dining room and kitchenette. All the communal areas are furnished to meet the needs of the people that live there. Handrails are fitted in the hallways and the layout of the home is suitable for wheelchair users. There is a lift to all floors. Since the last inspection it has been made easier for people to find their way around the home, particularly for those with dementia. Photos and pictures have been placed near people’s rooms as memory triggers and the handrails have been painted a brighter colour so that they are easier to see. New signs have been fitted around the home to show people the direction to bedrooms, communal areas, bathrooms and kitchens. A seating area with a water cooler has been fitted in the reception area. Air conditioning has been fitted to two of the floors of the home recently and it is planed this will be extended to the rest of the home next year. The Manager is developing a redecoration plan for the home that will begin in March with repainting some of the hallways. The home has a computer room with internet access for use by the people that live in the home. The Manager and staff have recently decorated areas of the home with photographs of people enjoying various activities in and around the home. New pathways have been added around building and trees cut back from the pathways to make it safer for people to walk around the grounds. The garden has seating areas and a BBQ for use in the summer. It is planned that a sensory garden will be developed next year. Improvements have been made to the laundry service in the home. There is now a housekeeper in post who carries out all the laundry and supports the people in the home to do any items of laundry that they wish to do themselves. Laundry is now washed separately for each person in the home and they have their own laundry basket in their room. The Manager said the changes that have been made have stopped incidents of damaged or missing items. Feedback from people inn the home confirmed improvements in this service. Elizabeth Court DS0000013634.V353928.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards27, 28, 29 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The people that live in the home are supported by sufficient numbers of qualified, competent and trained staff to meet their needs. They are protected by the homes practices for recruiting new staff. EVIDENCE: Feedback from the people that live in the home confirmed they are happy with the numbers of staff available and that they feel there are enough staff on duty to meet their needs. However, there were some comments with regard to a high turnover of staff in the home. The Manager confirmed that there had been changes to staff in the home as, when changes to the way the service are run were made, some staff left. He said that the staffing of the home was much more stable than it had been earlier in the year. There are always at least two staff on duty on each wing, this was the case on the day of the inspection, and a team leader is on each shift in addition to these numbers. During the inspection people were seen to have their needs met in a timely fashion and call bells were responded to within a reasonable time. 74 of the staff team have their NVQ award, which assures people that they are supported by qualified staff that can meet their needs. All the team leaders have, or are working toward, the NVQ3 award. Elizabeth Court DS0000013634.V353928.R01.S.doc Version 5.2 Page 21 Since the last inspection staff have completed a number of training courses to help them to support people in the home. The training files for 4 staff members were inspected. They have completed all the core training in Health and Safety that they need to do to safely support people. All the staff have completed training in POVA and updates are planned for January 2008. In addition the staff had completed training in Depression and Anxiety, continence care, deaf awareness, food hygiene, challenging behaviour, medication, infection control and dementia. Some staff had also completed a course in ‘Dining with Dignity’. Training in Equality and Diversity is planned for all staff for January and February 2008. The recruitment files for three staff were checked. These showed that robust checks are being made of all new employees before they are allowed to start work in the home. The Manager has received training from the Home Office with regard to checking documents and the eligibility of people to work in the home. The application form now asks applicants to complete their full employment history. Elizabeth Court DS0000013634.V353928.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 32, 33, 35, 36 and 38 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The people that use the service benefit from a competent and approachable Manager. They can be assured that the service is run in their best interests and that their financial interests are safeguarded. The health and welfare of staff and the people that live in the home are protected. EVIDENCE: At the last inspection a new Manager had taken up post and this Manager is now permanently employed for the home. He has applied for registration with CSCI, has the Registered Managers Award and is working toward the NVQ4 in Elizabeth Court DS0000013634.V353928.R01.S.doc Version 5.2 Page 23 care. There is a new Deputy Manager in post who has undertaken a management induction and is also working toward the Registered Managers Award. The team leaders have weekly meetings with the Manager and Deputy Manager to discuss practice issues within the home. They also have 1-1 supervisions every two weeks. The care staff receive monthly supervisions and have the opportunity to attend regular team meetings. All the team leaders are booked to do leadership and supervision training for March 2008. The Manager walks around the home to visits everyone that lives there on a daily basis. It was evident that despite the new Manager only being in post for a few months the people in the home were comfortable with him and able to raise any concerns that they have. The Manager and Deputy Manager work closely together to ensure they are delivering a high quality service and consistent support for staff. There are questionnaires in the entrance hall that visitors can complete to give their views of the service and a newsletter is sent to all relatives quarterly. The last inspection report is in the hallway for everyone to read if they wish. The organisation sends surveys to the people that use the service on an annual basis and produces a report. In addition the chef Manager speaks with people daily about their views of the food and the housekeeper asks for feedback from the residents and relatives meetings. Some people have asked the home to manage their personal money on their behalf. The Manager has undertaken training in this area and a recent audit of all the records and storage of money had taken place. There were no issues of concern following this audit. Everyone had secure lockable space in their own rooms to store their belongings safely. There is a handyman employed in the home who carries out some decoration and minor repair works. A weekly check of the environment of the home is completed and any health and safety concerns are reported. All equipment in the home has been safety checked. The Environmental Health Report for the home had listed some requirements. These have been met. Risk assessments have been completed for individual risks and also risks within the general environment. The temperature of the hot water in the bathrooms is regulated and radiators are covered to avoid risks of scalding. The home is kept clean and hygienic. Elizabeth Court DS0000013634.V353928.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 3 3 3 3 x X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 3 Elizabeth Court DS0000013634.V353928.R01.S.doc Version 5.2 Page 25 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 OP18 Regulation 13(6) Requirement The whistle blowing policy and restraint policy must be revised to ensure that the link with adult protection is made. This requirement was made at the last inspection and is not yet met. 2. OP7 15 The care plans must include how a persons social needs will be met. The records in the care plan must evidence that the care plan has been followed with regard to social needs. 3. OP10 OP15 12(4)(a) The registered person must ensure that people have their dignity and choices respected at all times. 31/01/08 31/01/08 Timescale for action 31/01/08 Elizabeth Court DS0000013634.V353928.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations It is recommended that the way the records for personal care are completed by staff be reviewed to ensure they provide the information needed for monitoring purposes. It is recommended that guidance be produced for staff as to when PRN medications should be given to each person. It is recommended that the way the menu is displayed be reviewed to meet the communication needs of people in the home. 2 3 OP9 OP15 Elizabeth Court DS0000013634.V353928.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone, Kent ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Elizabeth Court DS0000013634.V353928.R01.S.doc Version 5.2 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. 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