Inspection on 08/08/07 for Elizabeth Court

This inspection was carried out on 8th August 2007.

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 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 13/12/07

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 Susan McBriarty Unannounced Inspection 09:30 8 August 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.V342290.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.V342290.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 keri.sherwood@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) Post vacant 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.V342290.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th April 2006 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. Fee levels in 2007 ranged from a minimum of £583 to a maximum of £675 Elizabeth Court DS0000013634.V342290.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 9:35am and was in the service for eight and a half hours. It was a thorough look at how well the service is doing and took into account detailed information provided by the service’s manager, including a completed annual quality assurance audit (AQAA) required by the Commission and any information that CSCI has received about the service since the last inspection. A new manager and deputy manager were in post and were working through an action plan designed by the manager to meet the shortfalls found in the home. The report identifies the actions taken to date and where further work is required. What the service does well: What has improved since the last inspection? The revised care plans enable the home to detail the needs of the people living at the home and how they are to be met. The dining rooms had been fitted with air conditioning units to assist in making the area more comfortable for the people who live there. A recent quality assurance audit had taken place and the home was in the process of acting on the issues raised by residents and relatives. Elizabeth Court DS0000013634.V342290.R01.S.doc Version 5.2 Page 6 A relatives’ meeting had taken place and the management team of the home was taking action to make sure that their views had been listened to and were being acted on. Training plans had been devised which set out all the training needs of the members of staff and a plan was in place to make sure that all future training had the necessary documents to confirm that training had been completed. 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.V342290.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.V342290.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): Standards 1 and 3 were assessed. Standard 6 does not apply. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A plan was in place to make sure that the statement of purpose and service user guide were up to date and showing the recent changes in the home. This will make sure that prospective residents and their relatives can be clear about what the service will and will not provide. Pre-admission assessments were carried out before anyone moved into the home, making sure that anyone offered a place at the home could be confident that their needs would be met. EVIDENCE: A number of changes were taking place within the home including a new manager and deputy manager being in post. The statement of purpose and service user guide will require further revision to ensure it is up to date. The manager was aware of this and stated that it was part of the planned work expected to take place. Once completed a copy will be sent to the Commission. Elizabeth Court DS0000013634.V342290.R01.S.doc Version 5.2 Page 9 Eight surveys were received from people who use the service, five said they had received enough information about the home before making a decision to move in, two did not respond and one said they did not have enough information before their move. The manager said that the home had introduced a new system for assessment. A number of resident files were sampled and all had a copy of the pre-admission assessment information. The assessment format covered all areas of daily living including communication and religious needs and would enable the home to make a decision about whether they could meet the prospective resident’s needs. Elizabeth Court DS0000013634.V342290.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 and10 were assessed. People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvement is needed to make sure that the personal and health care needs of the residents are met and that their privacy and dignity is maintained. EVIDENCE: As noted in the summary of this report the home was going through a period of change and the manager, who was confirmed in post on the day of the inspection, said he was making a number of changes to improve the service provided. A number of care plans were sampled; the manager said the care plans in use had recently been revised. The AQAA received stated that workshops were being held with members of staff to minimise the use of a two-tier system in the interim, night time check agreements had also been put in place following Elizabeth Court DS0000013634.V342290.R01.S.doc Version 5.2 Page 11 a review of incident and accident records. The Commission viewed the night time check agreements and all those seen had been signed by the named resident. The care plans sampled contained detailed information about the individual, their needs, how they must be met and risk assessments had been completed as part of the process. Improvement was needed to make sure that care plans were followed by members of staff or to ensure accurate recording of information. One care plan said a record of food and fluid intake was to be kept for one week, but this did not occur. Some records had been made, for example one day’s food intake was noted, and information about fluids when recorded did not say how much fluid was given, only that a cup of tea or glass of water was provided. Another care plan documented that one person had only had five baths or showers over a period of two months. Some of the care plans sampled set out the nutritional needs of residents although these had not been assessed. The home required two members of staff to sign the night time check sheet and in some instances only one had signed. Some of the care plans sampled showed that a review had taken place. The record made said the care plan had been reviewed and was signed and dated but did not identify if the resident or relative had taken part in the review. The requirement from the 28th April 2006 had been met but further development is needed to make sure that residents and relatives are involved. Feedback was received from eight service users; three said they always receive the care they need, four said usually and one said sometimes. Seven relatives provided feedback about the service provided; three said the care needed was always given, three said the care needed was usually given, one did not respond. One said there were insufficient baths given and members of staff did not always check that clean clothing was being worn. A letter of commendation received by the Commission thanked the home for the care and attention provided to their relative. A requirement is made to ensure that members of staff follow and complete the care plan documents as required by the home, confirming that care has been given including information and support about nutritional needs and who else has been involved in the monthly reviews. This will make sure that the people who use the service receive the care they need when they need it. Elizabeth Court DS0000013634.V342290.R01.S.doc Version 5.2 Page 12 The care plans sampled, although recently revised, did not evidence access to, for example, dental care, chiropody or optician. The manager told the Commission that the people who use the service were supported to access such appointments. However, there was no evidence to confirm this. The AQAA received stated that all health care professionals are encouraged to see residents in their bedrooms and in the ‘could do better’ group said they needed to improve their knowledge of local and social care resources to meet people’s needs, for example specialist equipment. A number of records were seen that evidenced that residents had seen the doctor and received appropriate treatment. One record noted an individual was unwell and was seen by the doctor three days later. It was not clear who called the doctor or if there was a good reason for the delay as no record had been made to confirm the action taken. A requirement is made for the home to review the care plans and make sure that where health appointments had been attended these are recorded and to take action where necessary if appointments were required with any health care professional. A pharmacist inspector carried out a specialist inspection at the home on the 12th December 2006, three requirements and one recommendation were made. The requirements were: • • • Complete and accurate records must be kept of all medicines in the home including: All those received into the home, all doses given to service users, any doses not given together with a reason why. All medication must be labelled with a dispensing label indicating to whom the medication is to be administered and at what dosage and frequency. Medicines must not be given to service users when they are beyond their expiry date The recommendation was: • It is strongly recommended as good practice that when it is necessary to handwrite on a medication administration record chart in the home that the member of staff writing the chart signs and dates the chart and that a second carer checks the entry for accuracy and then initials the chart. Elizabeth Court DS0000013634.V342290.R01.S.doc Version 5.2 Page 13 In addition the entry should include a reference to where this information was sourced, such as the prescriber’s name During the visit of the 8th August medication was sampled in one area of the home. A significant number of entries showed that skin creams had been refused by residents over the previous three days. A reason for the refusal had not been given for each occasion; two entries said it was because the person was eating. The manager confirmed that it was not appropriate to offer to provide intimate skin care during meals. One record showed that for a period of time a skin cream was not available. This was followed by records stating that the person refused the cream - it was not clear when the cream had arrived in the home or why it was refused. One person had been prescribed antibiotics and refusals were recorded and ‘other’ on another day it could not be confirmed that the person had received the medication they required. Where medication had ceased this had been documented on the medication record sheet. However, those sampled had not been signed nor did the record state clearly who said the medication must cease. Sampling of labels on medication did not take place during this visit due to the number of concerns raised in a small sample. Given the number of issues raised one requirement made by the pharmacist inspector is brought forward to ensure that the home carries out a full review and that medication practice within the home is improved. Further sampling did not take place and an immediate requirement was made to ensure that all medication in the home was reviewed within twenty four hours to make sure that residents were receiving the medication they had been prescribed and at a suitable time, ensuring that residents’ privacy and dignity were protected. Other issues had been raised with the Commission and the home by a health care professional. The manager said they had met and discussed the issues raised and considered that the matters raised were being dealt with. The AQAA received stated that robust medication policies and procedures were in place, a training programme was in place for all staff and medication audits were in place. Please also see the staffing section of this report. Elizabeth Court DS0000013634.V342290.R01.S.doc Version 5.2 Page 14 A telephone discussion took place on the 13th August 2007 with the manager. The Commission was informed that immediate action was taken about the medication issues raised during the visit and members of staff had been informed clearly about what was expected by the home. Elizabeth Court DS0000013634.V342290.R01.S.doc Version 5.2 Page 15 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 were assessed. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Some work was needed to confirm opportunities for recreational and social activities were available to all the people who live at the home. The people who live at the home are able to access local amenities to suit their needs and preferences and maintain contact with family members. The home was taking action to make sure that the meals provided were appealing, wholesome and met the preferences of the majority of the residents. EVIDENCE: An activity co-ordinator was in post and spoke briefly with the Commission. A number of activities take place within the home and posters showing what was taking place and when had been placed on the walls near the dining room of each unit. Photographs of the people who use the service taking part in activities had been placed around the home, helping those with memory problems to remember some of the things they had taken part in. Elizabeth Court DS0000013634.V342290.R01.S.doc Version 5.2 Page 16 The activities co-ordinator confirmed to the Commission that they had not received any training and the manager, who said that training was planned, confirmed this. Care plan records identified where family members were involved and the manager told the Commission about a recent relatives’ meeting. The meeting highlighted some of the problems that the home has been having and informed relatives of the action being taken to improve the service. One relative spoken with during the visit said different family members had been spending time throughout the day at the home until they were happy that the needs of the person they cared for were being met in the way preferred. This was because the person had only just moved in and the family were concerned to make sure everything was alright. The AQAA received said that local churches provide services within the home or people who use the service can choose to attend church within the local community. Feedback from people who use the service and their relatives was received. Of the eight residents who responded three said that activities were always provided, two sometimes, two did not respond and one could not remember. The response from six relatives noted that four felt the home was usually able to respond to different needs (including age, peer and cultural needs), one said they were always able to respond and one said they were all treated the same. The manager and deputy manager said that a number of the people living at the home used the local day centre and it was observed during the visit that two people were going to the day centre for the first time that day to see if they wanted to go on a regular basis. Others used the local amenities including the pub. The feedback from relatives and residents indicated that not all are aware of the activities or events taking place or may not be able to take part. A recommendation is made for a review of the provision of activities to take place to make sure that all the people living at the home have the opportunity to take part in something they enjoy and prefer. Please also see the staffing section of this report regarding training. Elizabeth Court DS0000013634.V342290.R01.S.doc Version 5.2 Page 17 A comment book had been provided in the dining areas for members of staff and residents to comment on the food received. The manager said they planned to look more closely at the comments made and take action where needed to make improvements if necessary. Meals are taken in small dining areas in each unit where air conditioning had been placed, providing a pleasant space in which to eat. The meal of the day was on a board by the dining room in each area to assist those who were able to read and/or see. Of the eight residents who provided feedback four said they usually liked the meals, three always liked the meals and one sometimes liked the meals. Comments received from residents and relatives included: The meals are good and staff are very good at making sure I get the meal I need and the home provides for vegetarians. The AQAA received said that the home provided individual nutritional screening (see personal and healthcare) and that menu planning is carried out by the chef with the residents. Fresh fruit juice is available either on request or a self help basis in each of the units. Elizabeth Court DS0000013634.V342290.R01.S.doc Version 5.2 Page 18 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 were assessed. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Policies and procedures were in place to make sure that residents and their relatives’ views and concerns would be listened to and acted upon. Some work was needed to make sure that some policies and procedures relating to safeguarding adults were revised to confirm that residents would be protected from abuse. EVIDENCE: The home had a complaints procedure in place including timescales for action; the requirement from the inspection of the 28th April 2006 had been met. The manager said that previous records were such that the number of complaints received since the last inspection could not be confirmed as accurate. The manager told the Commission that a relatives’ meeting had recently taken place where it was highlighted that a number of relatives considered their views and concerns had not previously been addressed. A letter received from a relative and seen by the Commission confirmed this. Two complaints had been received by the new manager and written responses and outcomes were seen. Elizabeth Court DS0000013634.V342290.R01.S.doc Version 5.2 Page 19 The manager had also devised a new complaint format that offers the complainant the opportunity to make a record of and sign their view of the outcome. Separate files for complaints and compliments had been introduced and the Commission also looked at the compliments received where relatives had been pleased at the service provided. Feedback from the eight people who use the service confirmed that three usually knew who to speak to if they were unhappy, two always knew who to talk to ,one sometimes knew, one preferred someone else to speak for them and one did not respond. Four of the residents did not know how to make a complaint, two did not respond, one said not really and one did know. A recommendation is made for the home to seek ways to ensure residents and their relatives know how to make a complaint. The organisation’s policy and procedure for protecting adults was viewed and found to be a generic document about what to do if an allegation of abuse was made. The manager had recently drawn up a local policy and procedure that supported the local authority multi-agency procedures. The home and the local authority were dealing with a safeguarding matter at the time of this visit. The Commission was being kept informed of progress. The organisation’s whistle blowing and restraint policies and procedures required review. The whistle blowing policy talks about the registration team being informed (the Commission) and did make a direct link between whistle blowing and adult protection if an allegation of abuse were made. The restraint policy set out some types of restraint and then later said these restraints were inappropriate, so the message being given was unclear. The policy identified that in some instances restraint may be used, but members of staff had not received training in using restraint. A policy was also in place about dealing with aggression. Please see staffing section regarding training. A requirement was made on the 28th April 2006 that all members of staff receive training in safeguarding matters and this is carried forward as part of the overall training plan of the home, and a further requirement is made by the Commission under the staffing section of this report. Elizabeth Court DS0000013634.V342290.R01.S.doc Version 5.2 Page 20 A requirement is made for the policies and procedures relating to adult protection including whistle blowing and restraint to make sure that links to the home’s local adult protection procedure are clear and that if restraint may be used by staff they receive accredited training. Elizabeth Court DS0000013634.V342290.R01.S.doc Version 5.2 Page 21 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 and 26 were assessed. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a comfortable and safe environment that is kept clean and fresh for the people who use the service. EVIDENCE: A brief tour of the home took place and all the communal areas were seen and some bedrooms were seen from the corridor. Those bedrooms seen had been personalised by the residents. The manager said that air conditioning units in the dining areas had recently been fitted to reduce the heat and were functioning on the day of the visit. All the areas seen were clean and fresh with no obnoxious smells. Elizabeth Court DS0000013634.V342290.R01.S.doc Version 5.2 Page 22 Each bedroom was provided with an en-suite allowing privacy for the people who use the service, and communal bathrooms with suitable adaptations are available for use as necessary. All residents have access to the garden area and on the day of the visit the garden and access to the road was only through the front door. Externally the door and window frames were seen to be unclean and indicated that regular cleaning did not take place. The manager told the Commission that the matter would be dealt with. Trees overhung one side of the building reducing the light available within the home and increasing risks to anyone walking down the side of the building in poor weather. The manager said he was in discussion with the appropriate agencies to see if the trees could be cut back and resolve the light problem. It was recommended that a risk assessment be carried out on that section of the garden to consider those with mobility and/or a visual impairment. The AQAA received said that home maintenance was in place and supported by the organisation’s surveyor team. The maintenance person was on duty at the time of the visit but it was not possible for the Commission to speak with him due to the time taken on the inspection on this occasion. An infection control policy and procedure was in place and no issues of concern were raised during the visit. The AQAA made clear that improvement could be made regarding infection control training and auditing procedures (please see the staffing section of this report). The Commission spoke with the person responsible for the laundry; she and the manager confirmed that there had been significant problems with the laundry service within the home. For example, large amounts of laundry had been left unidentified and action was taken to make sure that the items were reunited with their owners. Individual laundry baskets had been provided and all washing is now carried out individually, washed, ironed and returned to the person. The member of staff spoken with said she always let the care staff know when the laundry is returned and asks them to check the contents to make sure there are no errors. This has assisted in improving the laundry service. Elizabeth Court DS0000013634.V342290.R01.S.doc Version 5.2 Page 23 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): Standards 27,28,29 and 30 were assessed. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Some work was needed to confirm recruitment practice was robust and further improvement was needed to make sure that all members of staff were appropriately trained. This will ensure that residents are all supported and protected by the home’s recruitment practice and by trained competent staff. EVIDENCE: The AQAA stated that 993 hours were provided in one week to provide the care and support necessary to the people living in the home. The home had 36 full time care staff and 32 part time care staff in post as at the 2nd July 2007. The staff group was diverse, for example 28 were white British, 3 were from another white background, 3 were other Asian background, 6 were Caribbean and 24 were African. Of the 50 people who use the service 47 were white British and 3 from another white background. The AQAA said that all of the residents were Christian but this was not supported by the feedback received from residents and relatives. Elizabeth Court DS0000013634.V342290.R01.S.doc Version 5.2 Page 24 A number of staff files were sampled and the necessary documents to assist recruitment were found. The application form had been changed on a number of occasions and the latest version in use had removed the request for a full employment history with a reason given for any gaps. A requirement is made for application forms to reinstate this request in line with The Care Homes Regulations 2001. The manager said the home had linked with immigration to make sure that all documents were checked to confirm they were correct. The home would benefit from a checklist to the front of the file setting out what documents were received, when they were received and be signed by the person stating that the information received was satisfactory. The manager informed the Commission that the records of the home regarding staff training had not been adequate enough to confirm that training had taken place. Evidence was seen of the action taken to date to make sure that all members of staff received the training they needed. This included where members of staff were said by the manager to have reported that a particular training course had been completed. The training necessary includes those matters noted earlier in this report, for example activities, qualifying training, appropriate recording, infection control, giving medication, restraint and other safeguarding matters. The home would benefit from ensuring that the training included equality and diversity, taking into account age, gender, religion and race. The requirements made during the inspection of the 28th April 2006 regarding training had not been met. Taking into account the plans made by the home, a further requirement is made. Please see the last paragraph of this section of the report. A meeting was taking place in the home with other members of staff who also work for the same organisation. The group informed the Commission that the organisation took training seriously and made sure all members of staff received training, including access to qualifying training. One member of staff spoken with said he had received an induction course on starting at the home. The AQAA confirmed that all new staff received formal induction training and said a range of training courses were provided. The AQAA did not identify the difficulties the home has experienced in confirming what training had occurred previously. Elizabeth Court DS0000013634.V342290.R01.S.doc Version 5.2 Page 25 Feedback from residents and relatives included: Staff are generally pleasant and helpful, kindness and understanding are shown to residents, contact with the home and relatives is good, very happy here and the care level is excellent at all times. One member of staff was observed by the Commission working with a resident. The member of staff was seen to make sure that they were at the same level as the resident, were softly spoken, calm and gave the person time to talk about what was happening. The task being carried out took some time but at no point did the member of staff change their approach. A requirement is made for the home to inform the Commission of the dates agreed for all the training required in order to ensure that the plans in place are carried through effectively and the people who use the service are supported and protected by members of staff who are competent and trained. Staff supervision was not inspected during this visit although a requirement was made on the 28th April 2006 for members of staff to receive appropriate levels of supervision. The new manager said supervision was now in place and would continue to be provided regularly. Elizabeth Court DS0000013634.V342290.R01.S.doc Version 5.2 Page 26 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 31,33,35 and 38 were assessed. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Further improvement was needed by the home to confirm the health, safety and welfare of people who use the service and members of staff were promoted and protected. The views of residents and their relatives had been listened to and acted upon. EVIDENCE: The new manager was formally confirmed in post by the organisation on the day of this visit and a copy of the letter received was passed to the Commission. Elizabeth Court DS0000013634.V342290.R01.S.doc Version 5.2 Page 27 The manager confirmed to the Commission that application for registration would be made as soon as possible. The AQAA and discussion with the manager confirmed that he had the Registered Managers Award, had completed the assessors’ award for National Vocational Qualifications (NVQ) and was working toward NVQ Level 4. The deputy manager had also completed the Registered Managers Award. The manager had been transferred from another where previous experience of managing a home of this size had been gained. A recent quality assurance audit had been completed and the outcomes were made known to the Commission. The outcomes identified higher levels of negative feedback in catering and meals from relatives and visitors. As noted earlier in this report the manager was seeking to rectify these matters in response to the issues raised. It would benefit the home to make sure that the outcomes from the identified action plan are made known to residents and their relatives. The AQAA confirmed that administrators are responsible for making sure that accurate records are kept of any monies kept on behalf of the people who use the service. The records were not sampled during this visit. The manager told the Commission that, where possible, residents take care of their own money and where assistance is needed the family deal with money on their behalf. The money kept by the home was for payment of, for example, hairdressing and chiropody provision. Organisational policies and procedures were in place and the AQAA received confirmed that policies and procedures used by the home such as infection control, medication, confidentiality, concerns and complaints, health and safety, first aid and moving and handling were reviewed during 2006. The AQAA also confirmed dates of safety checks on electrical circuits, lifts, hoists, emergency call equipment and soiled waste disposal. Matters raised during this visit confirmed that the management team was aware of the most significant issues that required attention in the home and action had been or was being taken. The management informed the Commission of the shortfalls they were aware of during the visit. However, ongoing issues relating to medication in particular was a concern, as were the shortfalls in recording the health needs of the residents in the care plans. At the time of this visit it could not be confirmed that the home was promoting and protecting the health and welfare of all the people who use the home. Elizabeth Court DS0000013634.V342290.R01.S.doc Version 5.2 Page 28 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 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 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Elizabeth Court DS0000013634.V342290.R01.S.doc Version 5.2 Page 29 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 OP7 Regulation 15, 17, Schedule 3 and 4 Requirement Members of staff must complete the documents required by the home to record how the care and health needs of all residents are met, when and by whom, for example when a doctor is called out, baths and/or showers taken, food and fluid intake where required. This will ensure that members of the care staff are following the plan of care agreed with the resident and residents’ health and care needs are fully met. Timescale for action 14/08/07 2. OP9 13(2) All medications prescribed to 09/08/07 residents living in the home must be reviewed within 24 hours to make sure that the people who use the service receive the medication they have been prescribed, including skin creams, taking into account their right to privacy and dignity. Elizabeth Court DS0000013634.V342290.R01.S.doc Version 5.2 Page 30 3. OP9 13(2) Complete and accurate records must be kept of all medicines in the home including all those received into the home, all doses given to service users, any doses not given together with a reason why. This will make sure that the people who use the service are supported and protected by the policy and practice of the home when giving medication. Timescale from the pharmacist inspection of the 12th December 2006 not met. 14/08/07 4. OP18 13(6) The whistle blowing policy and restraint policy must be revised to ensure that the link with adult protection is made and to ensure a clear procedure for the use of restraint within the home. This will further confirm that residents are protected from abuse. The application form used by the home must be revised to include the request for a full employment history with a reason for any gaps in employment. This will further confirm that robust recruitment practices are in place to protect residents. The management of the home must keep the Commission informed of the progress of planned training to confirm that a competent and trained workforce provide the care and support required by the people who use the service. 31/10/07 5. OP29 19 31/10/07 6. OP30 18 28/09/07 Elizabeth Court DS0000013634.V342290.R01.S.doc Version 5.2 Page 31 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 OP12 Good Practice Recommendations It is recommended that a review take place of the activities provided by the home to make sure that all residents have the option to take part and are aware of the activities being provided. It is recommended that the home review how residents and relatives are informed about how to make a complaint to ensure that the information is readily available and accessible. It is recommended as good practice that when it is necessary to handwrite on a medication administration record chart in the home, the member of staff writing the chart signs and dates the chart and that a second carer checks the entry for accuracy and then initials the chart. In addition the entry should include a reference to where this information was sourced, such as the prescriber’s name. It is recommended that the area by the side of the home be risk assessed taking into account the mobility needs and any visual impairment of the people who use the service to ensure that safe access is available and reducing the risk of falls and or trips. 2. OP16 3. OP9 4. OP19 Elizabeth Court DS0000013634.V342290.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Oxford Office 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU 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. 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