Inspection on 14/12/05 for Elizabeth Court

This inspection was carried out on 14th December 2005.

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

The inspector 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 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 Deavanand Ramdas Unannounced Inspection 14th December 2005 10:00 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.V267981.R01.S.doc Version 5.0 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.V267981.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Elizabeth Court Address Elizabeth Court Grenadier Place Caterham Surrey CR3 5YJ 01883 331590 01883 347423 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) Anchor Trust Mrs Helen Hawthorn Care Home 58 Category(ies) of Dementia - over 65 years of age (27), 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.V267981.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th July 2005. Brief Description of the Service: Elizabeth Court is a care home that is 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 had private parking available to the front of the property. The home is managed by Anchor Homes and the registered manager is Helen Hawthorn. Elizabeth Court DS0000013634.V267981.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out by one inspector over a period of six hours. A partial tour of the premises took place, staff, service users, and a relative were spoken to and documents and records were examined. The inspector would like to thank the manager, deputy manager, staff, service users and a relative for their contributions to the inspection. A CSCI business card was left at the home for information. What the service does well: What has improved since the last inspection? What they could do better: The home must ensure records and documents kept at the home are up to date and accurate and a business and financial plan is in place to safeguard the interest and welfare of service users. The home must ensure complaints are Elizabeth Court DS0000013634.V267981.R01.S.doc Version 5.0 Page 6 recorded and kept up to date with details of any management taken for information. Supervision and induction for staff must be improved to ensure staff are adequately supported and regularly receive formal supervision to safeguard care practice in the home. 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 DS0000013634.V267981.R01.S.doc Version 5.0 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.V267981.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 4,5&6. The arrangements at the home for meeting service users’ needs are satisfactory ensuring service users’ needs are identified and met. The arrangements for trial visits are adequate ensuring service users and their relatives have the opportunity to visit and assess the suitability of the home. EVIDENCE: The home had a policy on enquiries allocation and admissions dated November 2004. The manager stated service users are admitted to the home based on an assessment of their needs and remarked specialist support is provided by the primary care trust. During an interview a relative stated she read the CSCI inspection report to obtain information about the home and remarked the home adequately meet the needs of her mother who has dementia. The inspector noted staff had training in person centred dementia care and the homes policy had been revised to include a named staff to do assessments on prospective service users. A service user stated “I am very happy here, very much so”. The manager stated the home offered trial visits, that which were reflected in the homes policies and licensing agreements. The inspector noted new admissions were on a trial basis and the manager remarked service users Elizabeth Court DS0000013634.V267981.R01.S.doc Version 5.0 Page 9 and their relatives were supported to visit and assess the suitability of the home. One service user who visited the home prior to admission stated “it is a good home for what it is and I am happy here”. The manager stated the home did not offer intermediate care and this standard was not assessed. Elizabeth Court DS0000013634.V267981.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9,10&11 The management of medications at the home is adequate promoting good health. The arrangement for privacy and dignity are adequate ensuring service users are treated with respect at all times. The arrangements for handling dying and death of a service user are satisfactory ensuring service users and their families are treated with sensitivity and respect. EVIDENCE: The home had a policy on medications dated November 2004 and a service level agreement with Boots Chemists dated July 2005. The deputy manager has put in place medication guidelines dated June 2005 for senior care officers and care staff. The inspector noted the home had a copy of administration and control of medicines document dated 2003 for information. The home had a metal cupboard secured to the wall in a room that was alarmed for the storage of stock medications and a fridge for the storage of eye drops. The inspector noted the fridge temperature was recorded twice daily and satisfactory. The senior care officer stated the home had controlled drugs that were appropriately stored, checked and recorded. The inspector sampled the controlled drugs register, which was satisfactorily maintained and the balance Elizabeth Court DS0000013634.V267981.R01.S.doc Version 5.0 Page 11 of medication correct. The inspector sampled medication record sheets dated and signed by staff, with a recent photograph of the service user attached. The inspector checked staff records and noted they had training in the administration of medications and the deputy manager stated they were awaiting a training pack from Boots Chemists. The home had a policy on privacy and dignity and the inspector noted staff addressed service users by their preferred names. Observations confirmed staff knocked on doors before entering service users bedrooms and the inspector noted personal care was given in the privacy of the bathroom. A service user commented “staff are very helpful and pleasant all the time” The home had a policy on dying, death and resuscitation and care plans reflected the religion and funeral arrangements of service users. The inspector noted the local policy took account of Hindu and Muslim faiths and senior care staff had attended a course in end of life care. The manager stated the home had in house training using a video on bereavement and offered relatives a guest suite to enable them to be with their relatives who are dying. Elizabeth Court DS0000013634.V267981.R01.S.doc Version 5.0 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 the following standard(s): 13&14 The arrangements for maintaining community contact are satisfactory ensuring service users maintain contact with their families and friends. The systems at the home supports service users to exercise choice over their lives. EVIDENCE: The home had a policy on activities and interests dated May 2005 and employed an activities organiser who worked 30 hours a week. The activities organiser remarked the home had contact with local churches, schools and service users were invited to Christmas lunch at a local day centre. During a discussion service users stated they had trips to the seaside and visited a hop farm in Kent. The deputy manager stated the home had contact with age concern and a local volunteer visited the home weekly to play scrabble with a service user and help in activities in the home. The inspector noted a service user with a relative in the privacy of the lounge area and the senior care officer stated the home supported relatives to visit the home. During a discussion a relative stated she “visited regularly, always unannounced and staff were friendly and welcoming”. The deputy manager stated service users are supported to exercise choice and remarked one service had her own furniture in her bedroom to make her feel at home. The inspector noted service user choice was reflected in care plans and covered religion, food, interests and social activities. The deputy manager commented one service user had an Elizabeth Court DS0000013634.V267981.R01.S.doc Version 5.0 Page 13 advocate that looked after his welfare and interests. During a discussion one service user stated “I have the choice to sit here and read the newspaper”. Elizabeth Court DS0000013634.V267981.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16&17 The complaint process is satisfactory with complaint information available to staff, relatives and services users. However, complaint records must be kept up to date to ensure prospective service users and relatives have adequate information on which to make decisions about admission to the home. The arrangements for protecting the rights of service users are satisfactory. EVIDENCE: The home had a complaints policy dated August 2004 and complaints information was available in the foyer. The manager stated the home had a complaints folder that was sampled and the inspector noted three complaints were recorded in 2005 and management action was taken. During discussions a relative stated she had been made aware of the complaints policy and spoke to a senior care officer if she had any problems. Staff stated they were aware of the complaints policy and one staff remarked “I am very happy, I have no complaints”. The inspector noted two complaints that were made about the home were not logged in the complaint folder: this was discussed with the manager and action has been required in respect of this matter. The deputy manager stated service users had their names on the electoral register and some service users who were unable to visit a polling station had requested postal votes. The manager stated the home would encourage service users to use advocacy services and commented one service user had an advocate to safeguard his rights. Elizabeth Court DS0000013634.V267981.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20&24 The arrangements for managing the premises are satisfactory ensuring the home is well maintained and safe for service users. The shared facilities at the home are adequate ensuring service users have access to comfortable communal spaces. The toilets, bathing and washing facilities are adequate. The bedrooms are well furnished and equipped ensuring service users have comfortable bedrooms with their own possessions. EVIDENCE: On the day of the inspection the home was clean, ventilated and free from mal odour. The home is accessible, safe and well maintained and operates a security system that is restricted to the entrance areas. The manager stated the home had a maintenance programme and the inspector noted new carpets on the middle floor. The garden was well maintained, safe, secure and easily accessible. The manager stated the home had adequate communal facilities and the inspector noted units had communal areas and dining areas that were well furnished and had adequate lighting. The inspector noted service users were sitting in the dining area in wing 1 and were engaged in activities making Elizabeth Court DS0000013634.V267981.R01.S.doc Version 5.0 Page 16 Christmas decorations that were displayed on the window. One service user stated “everything is wonderful about this place, it truly is and I recommend it to anyone”. The inspector noted the home had adequate toilets, washing and bathing facilities that were clean and hygienic. Observations confirmed toilets were available close to the dining room and lounge areas and were clearly marked and easily accessible. Bedrooms were well presented, nicely decorated and personalised with pictures, family photographs, plants, ornaments and television. The deputy manager stated one service user had brought her own furniture to put in her bedroom and another service user stated “I am comfortable in my bedroom” The inspector noted heating and lighting was adequate and bedrooms and communal areas had individual thermostatic control to regulate the temperature of the home and make it comfortable for service users. Emergency lighting was available in the home and regularly serviced and maintained. The inspector noted water temperatures were regularly monitored and recorded to provide water close to 43 degrees centigrade. Elizabeth Court DS0000013634.V267981.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29&30 The arrangements for staffing are adequate ensuring sufficient numbers of staff are on duty to support service users. The recruitment and vetting of staff is adequate ensuring service users are protected from harm or abuse. The arrangements for induction of staff are satisfactory however the outcomes of induction training must be evaluated to ensure the training is appropriate to the needs of service users. EVIDENCE: On the day of the inspection the home was adequately staffed and the inspector noted the manager, deputy manager, senior care officer, six carers, the homes administrator and her assistant, a chef, activities co-ordinator and housekeeping staff were on duty as was reflected on the duty roster. One staff stated “having two carers in each unit is a big improvement”. The manager stated she used the residential forum formula to calculate staffing levels, which is department of health guidance. The home has recruitment and selection policy dated September 2005. The inspector sampled recruitment files and noted they contained a recent photograph of the employee, completed application forms, references, curriculum vitae, health questionnaires, statement of terms and conditions and CRB disclosure information. The deputy manager stated the home had a checklist that is used for the induction of new staff. The inspector sampled staff induction records that covered the organisation, role of the staff, safe working practices and service users’ needs that was completed, dated and signed by the employee and the supervisor. The inspector noted the home did not have a formal system for checking Elizabeth Court DS0000013634.V267981.R01.S.doc Version 5.0 Page 18 induction training was appropriate to the work employees were expected to perform. This was discussed with the manager and action has been required in respect of this matter. Elizabeth Court DS0000013634.V267981.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,34,35,36&37 The systems for quality assurance are satisfactory ensuring the home is run in the best interests of service users. The financial procedures at the home are unsatisfactory and must be improved to safeguard the welfare of service users. The procedures for handling service users’ money are satisfactory however some aspects of record keeping must be improved to ensure service users financial interests are safeguarded. The arrangements for staff supervision are unsatisfactory and must be improved to ensure staff are appropriately supervised and supported. Records at the home must be improved to ensure the rights and interests of service users are safeguarded. The arrangements for health and safety are adequate ensuring the health, safety and welfare of service users and staffs are protected. EVIDENCE: The manager stated the home had operated a quality assurance system based on seeking the views of service users, relatives and families. The inspector noted the home had quarterly meetings with service users and their relatives Elizabeth Court DS0000013634.V267981.R01.S.doc Version 5.0 Page 20 and minutes were taken of meetings. The inspector sampled minutes of meetings and noted activities, catering and transport were discussed at the meeting held on the 23/6/05. The home used questionnaires to survey service users, relatives and professionals to obtain feedback about the home. It was recorded on a questionaire dated 7/7/05 “no transport for clients available at Elizabeth Court” and this was discussed with the manager who stated this matter would be raised at the next business plan meeting with the area manager. The inspector noted the manager is doing a training course on leadership skills in person centred dementia that will improve the quality of care and management of service users. The home had a business plan dated April 2004 and the information it contained was in need of updating and action has been required in respect of this matter. The manager stated a business plan meeting had been arranged with the area manager to address this issue. The inspector noted the home had a certificate of employers liability insurance that will expire on 31/3/06. The home employed a full time homes administrator with responsibility for the management of service users’ money. The homes administrator stated the home had a policy on service users personal money and the home provided a safe that was in the office for storing money and valuables. The inspector sampled records and noted the home had an information bulletin dated July 2005, a service user agreement form, money transaction records, personal account book and a record of incidental spending that covered aromatherapy, hairdressing and chiropody. The inspector noted some transactions were not signed by staff in line with the homes policy and a requirement has been made as a result. The deputy manager stated the home had a supervision policy and a supervision structure based on a key worker allocation system. The manager supervised the deputy, administrative staff, chef manager and night seniors and the deputy supervised day seniors, head housekeeper and handyman. The inspector sampled supervision records and noted a supervision contract and supervision agenda that was dated and signed. While supervision had improved there is an inconsistency in the frequency of supervision and the lack of a clear plan outlining the supervision arrangements within the home and action has been required in respect of this matter. Records were observed to be confidentially and securely stored however some were in need of updating. The manager stated the home had a policy on health and safety dated November 2004. The inspector noted the home had monthly health and safety checks dated 27/11/05, fire alarm tests dated 13/12/05, water temperature checks dated 30/11/05, legionella risk assessment dated 14/9/04 and staff fire training dated 27/11/05. The home had a service level agreement with an approved company for the disposal of clinical waste and a certificate of inspection for fire safety dated 26/7/05. Elizabeth Court DS0000013634.V267981.R01.S.doc Version 5.0 Page 21 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 X 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 X 3 3 3 X X 3 3 X STAFFING Standard No Score 27 3 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 2 2 2 2 3 Elizabeth Court DS0000013634.V267981.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? No. 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 NMS-OP-16 Regulation 22(8) Sch 4(11) Requirement The registered person must ensure that any complaint made under the complaints procedure is recorded with the action taken in response and the outcomes. The registered person must ensure the outcomes of staff induction training are evaluated and documented for information. The registered person must ensure the home has a business and financial plan that is up to date and a copy sent to the Commission for information. The registered person must ensure written record of transactions involving service users’ money are signed by staff in line with the homes policy. The registered person must ensure staffs are regularly supervised at least six times a year and a list with the names of staff and their named supervisor is available for information. The registered person must ensure records required for the running of the home are maintained up to date. DS0000013634.V267981.R01.S.doc Timescale for action 10/01/06 2 NMS-OP-30 18(1)(c) (i) 25(2)(c) 10/02/06 3 NMS-OP-34 01/03/06 4 NMS-OP-35 17(2) Sch 4(9) 10/01/06 5 NMS-OP-36 18(2)(a) 01/02/06 6 NMS-OP-37 25(2c)17 (2)Sch4 (3) 01/03/06 Elizabeth Court Version 5.0 Page 23 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 Elizabeth Court DS0000013634.V267981.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Surrey Area Office 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 DS0000013634.V267981.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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