Inspection on 28/04/06 for Elizabeth Court

This inspection was carried out on 28th April 2006.

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

The inspector 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 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 Deavanand Ramdas Unannounced Inspection 28th April 2006 10:00a 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.V290974.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Elizabeth Court DS0000013634.V290974.R01.S.doc Version 5.1 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) sharon.blackwell@anchor.org 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.V290974.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th December 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.V290974.R01.S.doc Version 5.1 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. On the day of the inspection the home manager was off duty and the deputy manager was on leave and senior care officers on duty facilitated the inspection process. A tour of the premises took place, staff and service users were spoken to and documents and records were examined. The inspector would like to thank the care staff, service users and the visiting district nurse for their contribution to the inspection. What the service does well: What has improved since the last inspection? The home has met the previous requirements which have resulted in improvements in the home. The home has an updated complaints register and appropriate management action taken. Staff induction training is evaluated by the manager to ensure outcomes are satisfactory and staff are happy with training opportunities offered by the company. Records have improved and service users financial transactions are recorded, dated and signed by staff to safeguard the interest of service users. Policies and procedures at the home have been updated and well maintained to ensure staff have accessible and up to date information. Elizabeth Court DS0000013634.V290974.R01.S.doc Version 5.1 Page 6 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. Elizabeth Court DS0000013634.V290974.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Elizabeth Court DS0000013634.V290974.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&3 The homes statement of purpose and service user guide are good providing service users with the details of services the home offers enabling an informed choice to be made about admission to the home. The arrangements for assessing needs are adequate ensuring service users needs are assessed and identified before admission to the home. EVIDENCE: The home has a statement of purpose and service user guide which was nicely presented and clearly written in plain English to make the information accessible to staff, service users and relatives. The statement of purpose was reviewed and updated to include the requirements made following a complaint investigation by the CSCI (Commission for Social Care Inspection) and available in the foyer of the home. A recommendation has been made for a copy of the updated statement of purpose to be sent to the CSCI for information. The home has a policy on assessment of needs and the senior care officer stated service users are admitted to the home after a full assessment which covers health, personal and social care needs. The inspector sampled care plans and noted service users had a needs assessment and a written care plan which included personal safety and risks. The manager Elizabeth Court DS0000013634.V290974.R01.S.doc Version 5.1 Page 9 has recently reviewed and updated the homes assessment of needs procedure to include a named staff responsible for assessments with detailed written records and information available prior to admission to the home. The home does not offer intermediate care and this standard was not assessed. Elizabeth Court DS0000013634.V290974.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 The arrangements for care planning needs strengthening to ensure they are regularly reviewed to meet the needs of service users. The systems at the home for health care are adequate ensuring service users health is promoted and maintained. The management of medications at the home is satisfactory promoting good health. The arrangements for privacy and dignity are adequate ensuring service users are treated with respect. EVIDENCE: The home has care plans which are drawn up with the involvement of the service users and the plan sets out in details the action which needs to be taken to ensure service users needs are met. Care plans sampled indicated one service user with a medical condition had his special dietary needs assessed and a gluten free diet was provided to meet his needs. The manager had introduced a system for the monthly review of care plans and the inspector noted some care plans were in need of updating and action has been required in respect of this matter. Service users are registered with a GP and have access to hearing and sight tests, chiropody and dental services are provided by the local primary care Elizabeth Court DS0000013634.V290974.R01.S.doc Version 5.1 Page 11 trust. The inspector spoke to the district nurse who stated ‘‘the home is very good’’ and staff ‘‘follow carefully any recommendations made about care’’. The home uses a nutritional screening criteria and a nutritional profile to monitor the needs of service user and a weight gain or weight loss record is kept for information. The home has a policy on medications and a service level agreement with a local chemist. Medications were appropriately stored and medication record sheets were dated and signed by staff. Staff have training in the administration of medications and certificates were in staff training files. The home had a policy on privacy and dignity and the inspector noted staff addressed service users by their preferred names and knocked on doors before entering service users bedrooms. The district nurse upheld the privacy of a service user by treating her in the privacy of her bedroom and staff closed the door to the bathroom whilst supporting a service user with personal care. Elizabeth Court DS0000013634.V290974.R01.S.doc Version 5.1 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): 12,13,14&15 The arrangements for social contact and activities are good which meet the needs of service users living at the home. The home supports service users to maintain family contact ensuring service users see their family and friends as they would wish. The arrangements at the home supports service users to exercise choice over their lives. Meals at the home are good and offer variety, choice and cater for the special dietary needs of service users. EVIDENCE: The home has a policy on activities and interests an employed an activities coordinator who offers service users the opportunity to exercise choice in leisure and social activities and cultural interests. The home has a weekly activities programme and information about activities is widely available in the home. The inspector noted social activities were age appropriate and information about activities were in a format accessible to service users. Service users are supported to maintain community contact and are able to receive visitors in private. The activities co-ordinator stated ‘‘service users are offered choice in daily activities’’ and the inspector noted service users choices were reflected in care plans and covered food, social activities and religion. The home supported service users to practice their religious beliefs and a priest visited the home regularly for Sunday service. The home had weekly Elizabeth Court DS0000013634.V290974.R01.S.doc Version 5.1 Page 13 menu plans, employed a chef and had a hospitality assured award. On the day of the inspection service users had a lunch of fish, chips and peas with fruit cocktail for dessert. Apple juice and orange juice was available at lunch and service users stated they enjoyed the meal. Mealtimes was relaxed, unhurried and staff supported service users appropriately. One service user stated ‘‘the food is excellent and we have a choice’’ and during discussions staff remarked ‘‘the quality of the meals are good’’. Elizabeth Court DS0000013634.V290974.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17&18 The complaints process at the home is satisfactory with complaints information available to staff, service users and relatives however complaint leaflets are in need of updating. The arrangements for the protection of service users needs strengthening to ensure staff have training in safeguarding adults to ensure the welfare of service users. EVIDENCE: The home has a complaints policy and complaint information is widely available in the home. The home has a record of complaints which was sampled and appropriate management action taken. During discussions staff stated they ‘‘were aware of the complaints procedure’’ and one staff remarked she ‘‘was happy with things and had had no complaints’’. A recent complaint made about the home was investigated by the CSCI (Commission for Social Care Inspection) and appropriate management action has been taken to safeguard the welfare of service users. The inspector noted compliments, concerns and complaints leaflet did not have the address or contact number of the local CSCI office and action has been required in respect of this matter. The home has a safeguarding vulnerable adults procedure and the inspector noted staff needed refresher training in safeguarding vulnerable adults. A recent complaint about the home was investigated under the local authority (Surrey County Council) procedures for safeguarding vulnerable adults and appropriate management action has been taken to safeguard the interests and welfare of service users. Elizabeth Court DS0000013634.V290974.R01.S.doc Version 5.1 Page 15 The inspector noted the home did not have an up to date copy of the local authority (Surrey County Council) procedures on safeguarding vulnerable adults and a recommendation has been made in respect of this matter. Elizabeth Court DS0000013634.V290974.R01.S.doc Version 5.1 Page 16 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): 19,20,24,25,26 The management of the premises is satisfactory ensuring service users live in a well maintained and comfortable environment. Communal facilities are adequate ensuring service users have access to comfortable communal facilities. Bedrooms are well furnished and equipped ensuring service users have comfortable bedrooms. Heating and lighting is satisfactory ensuring service users live in comfortable surroundings. The arrangements for control of infection need to improve and staff need to have up to date training in infection control. EVIDENCE: On the day of the inspection the home was clean, nicely presented and well maintained with a good standard of décor. The grounds were private, secure, attractive and accessible to service users. The senior care officer stated the home has an ongoing routine maintenance programme and the inspector noted parts of the home was fitted with new carpets and had new furniture. Communal lounges were large, spacious, airy and well furnished. Bedrooms were nicely decorated and personalised with adequate heating, ventilation and Elizabeth Court DS0000013634.V290974.R01.S.doc Version 5.1 Page 17 emergency lighting is provided throughout the home. The inspector noted the home was fitted with adaptations and aids to promote the independence of service users with disabilities. The home had policies and procedures on infection control and the inspector noted staff needed refresher training in infection control and action has been required in respect of this matter. The home has a service level agreement with an approved contractor for managing clinical waste and laundry facilities were adequate. Observations confirmed staff practiced infection control measures and used gloves, aprons and washed their hands regularly. One service user stated ‘‘the home is very clean’’. Elizabeth Court DS0000013634.V290974.R01.S.doc Version 5.1 Page 18 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): 27,28,29&30 The arrangement for staffing is satisfactory with adequate numbers of staff on duty to meet the needs of service users. The arrangement for staff training needs to improve to ensure staff have the appropriate qualifications to support service users. The recruitment and vetting practices at the home is satisfactory ensuring service users are protected from harm or abuse. Staff induction at the home is adequate ensuring staff are trained to do their jobs. EVIDENCE: On the day of the inspection the home was adequately staffed with senior care officers, care assistants, cleaners, cook and a handyman. The duty roster was sampled and reflected adequate staffing levels and during discussions care staff stated ‘‘things have improved and staffing is much better’’. One service user remarked ‘‘the girls (care staff) are very good and very kind’’ The home is committed to staff development and the manager is undertaking a training needs analysis to assess and identify training needs for the whole staff team. The inspector noted a shortfall in NVQ (National Vocational Qualification) training and a requirement has been made for the manager to do a training plan outlining how targets in the NMS (National Minimum Standards) would be met to ensure service users are in safe hands at all times. The home has a policy on staff recruitment and a recruitment procedure. The inspector sampled staff recruitment files and noted they were in good order and had completed application forms, two written references, a recent photograph, terms and conditions, and a CRB (criminal records bureau) check. Elizabeth Court DS0000013634.V290974.R01.S.doc Version 5.1 Page 19 The home has a staff induction programme and all staff have completed induction training. During discussions, staff recently recruited to the home stated they ‘‘had induction training and a named supervisor’’. Staff induction training records were sampled dated and signed by the employee and supervisor and there is evidence the manager evaluated staff induction training. Elizabeth Court DS0000013634.V290974.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38 The arrangements for the day to day management of the home are adequate ensuring service users live in a home which is run and managed by a person who is fit to be in charge. The systems for quality assurance are adequate ensuring the home is run in the best interest of service users. The policies and procedures at the home are adequate and safeguard the financial interests of service users. The arrangements for staff supervision need to improve to ensure staff are appropriately supervised and feel supported. The arrangements for safe working practices need to improve to promote the safety of service users and staff. EVIDENCE: The home has an experienced registered manager who provides management stability, leadership and direction to the staff team. There is a management structure within the home with clear lines of accountability and the manager is Elizabeth Court DS0000013634.V290974.R01.S.doc Version 5.1 Page 21 currently doing a course in dementia care to meet the needs of service users. During discussions staff stated ‘‘the management is open and is always ready to help’’ and a service user stated the ‘‘the manager is approachable’’. The home has a quality assurance system in place and regular meetings with relatives and service users to obtain feedback about the home. There is regular Regulation 26 (monitoring visits) to the home and appropriate management action taken on issues raised. The home uses satisfaction questionnaires to seek the views of stakeholders and results of surveys are available at the home for information. The home has a policy on service users money, provides facilities for the safekeeping of money and valuables and employs an administrator with responsibilities for managing service users finances. The home has a policy on staff supervision and a supervision structure. The inspector noted from records that staff supervision was inconsistent and action has been required in respect of this matter. The home has a policy on service users’ money and the inspector noted records and receipts are kept of all transactions to safeguard the interests of service users. The home has a health and safety policy and some staff have training in health and safety, fire safety, first aid, food hygiene, moving and handling, and infection control. The manager is undertaking a review of staff training and a requirement has been made for all staff to receive appropriate training for the tasks they are expected to perform. The inspector noted a food safety survey was carried out on the 8th March 2006 by environmental health and no action was required. Elizabeth Court DS0000013634.V290974.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 3 3 X X 3 3 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 2 Elizabeth Court DS0000013634.V290974.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? No Elizabeth Court DS0000013634.V290974.R01.S.doc Version 5.1 Page 24 Elizabeth Court DS0000013634.V290974.R01.S.doc Version 5.1 Page 25 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 OP1 Regulation 4(2) Requirement Timescale for action 01/06/06 2 OP2 15(2)(b) 3 OP16 22(7)(a) 4 OP18 13(6) 5 OP28 12(1)(a) 6 OP28 18(1)(a) 7 OP36 18(2)(a) 8 OP38 12(1)(a) Elizabeth Court The registered person must ensure a copy of the homes statement of purpose is sent to the CSCI (Commission of Social Care Inspection) without delay. The registered person must 01/06/06 ensure care plans are reviewed monthly to meet the needs of service users. The registered person must 01/06/06 ensure complaints leaflets at the home have the address and contact number of the local CSCI office for information The registered person must 01/08/06 ensure all staff working at the home have training in safeguarding vulnerable adults to protect service users from harm and abuse. The registered person must 01/06/06 ensure staff have training in infection control to prevent the spread of infection. The registered person must do a 01/08/06 plan with timescales outlining how the home would achieve the targets set in the NMS for NVQ training. The registered person must 01/06/06 ensure staff working at the home have regular supervision at least six times a year to ensure staff have the skills to support service users. 01/06/06 The registered person must ensure staff working at the home have adequate training for the DS0000013634.V290974.R01.S.doc Page 26 tasks they are expected to Version 5.1 perform including fire safety, food hygiene and first aid. 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 OP18 Good Practice Recommendations The registered person shall obtain an up to date copy of the local authority (Surrey County Council) procedures on the safeguarding adults for information. Elizabeth Court DS0000013634.V290974.R01.S.doc Version 5.1 Page 27 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.V290974.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!