Inspection on 16/10/07 for Elizabeth Court Rest Home

This inspection was carried out on 16th October 2007.

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

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

Other inspections for this house

Elizabeth Court Rest Home 22/11/06

Elizabeth Court Rest Home 27/09/05

Elizabeth Court Rest Home 07/12/04

Elizabeth Court Rest Home 16/06/04

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 Rest Home 4 Hastings Road Bexhill on Sea East Sussex TN40 2HH Lead Inspector Judy Gossedge Key Unannounced Inspection 11:00 16th October 2007 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 Rest Home DS0000036172.V346915.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 Rest Home DS0000036172.V346915.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elizabeth Court Rest Home Address 4 Hastings Road Bexhill on Sea East Sussex TN40 2HH 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) 01424 219105 01424 219105 elizabethc@surfree.co.uk Mrs Mandy Dade Mrs Carol Beverley Robinson Carol Beverley Robinson Care Home 24 Category(ies) of Old age, not falling within any other category registration, with number (24) of places Elizabeth Court Rest Home DS0000036172.V346915.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Service users should be older people aged sixty-five (65) years or over on admission. The maximum number of service users to be accommodated is twenty-four (24) . That up to two service users over the age of sixty-five (65) years on admission, with a dementia-type illness, who have been assessed by the home as suitable for this provision, may be accommodated within the total registration of twenty-four (24). That one service user under the age of sixty-five (65) years on admission, who has been assessed by the home as suitable for this provision, may be accommodated within the total registration of twenty-four (24). 22nd November 2006 4. Date of last inspection Brief Description of the Service: Elizabeth Court is situated in the old town area of Bexhill; with local amenities situated close by. The main Bexhill town centre with its shops and access to bus and rail services is approximately half a mile away. Accommodation comprises of twenty-four single bedrooms on three floors. There is not a passenger lift in the home and a stair lift is fitted to assist service users access first floor accommodation; three bedrooms can only be accessed via a further flight of stairs. All but three of the service users bedrooms do not have en-suite facilities. Assisted communal bathing facilities are provided in the home. There is a separate lounge and a separate dining area for service users to use and an attractive garden at the rear of the home. A copy of the Statement of Purpose and Service Users Guide is available to view in the home. At the time of the Inspection fees were documented to be between £335.00 and £400.00 per week. Additional charges are made for hairdressing, chiropody, manicure, toiletries and magazines and newspapers. Elizabeth Court Rest Home DS0000036172.V346915.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over six and three quarter hours on 16 October 2007. Prior to the inspection an Annual Quality Assurance Assessment (AQAA) was sent to the home, which has been completed and returned and information detailed within is quoted in this report. A tour of the premises took place to look at communal areas and a selection of service user’s bedrooms and care records were inspected. Twenty-one service users were resident and five service users were spoken with individually in their bedroom or communal area and a number were spoken with as part of the Inspection process in the communal areas. The care that four of the service users received was reviewed. The opportunity was also taken to observe the interaction between staff and service users in the communal areas. Three care workers, who have worked during the day or at night; one care worker who also provides domestic support, two cooks, the new quality assurance worker, the owner/head of care and the owner/Registered Manager were all spoken with. One relative was spoken with during the Inspection and a further three relatives were subsequently spoken with over the telephone. Service users and relatives/visitors surveys were sent out, but were not received by the home so not completed on this occasion. A visiting healthcare professional was spoken with over the telephone after the Inspection. The AQAA detailed that it was intended to recruit a deputy manager to support the Manager. Since completing this it has been decided to recruit a quality assurance worker to work in the home for three days a week. The Manager stated the role is still evolving, but key responsibilities will be to ensure compliance with the National Minimum Standards and development of the supervision and training provided to staff, a review of paperwork and systems in the home, development of activities facilitated in the home and to ensure quality assurance and monitoring of the service. What the service does well: The home provides service users with a homely, relaxed and caring environment. Service users are enabled where possible to exercise choice and control over their lives whilst resident in the home. Staff was observed to deliver care with dignity and respect. The service users spoken with felt the care provided respected their privacy and dignity. Elizabeth Court Rest Home DS0000036172.V346915.R01.S.doc Version 5.2 Page 6 The feedback from all the service users and relatives was that they were happy with the overall care provided in the home. Comments included, ‘very nice and homely,’ ‘very cheerful place,’ ‘staff are incredibly welcoming,’ ‘very, very caring,’ ‘it’s a family place,’ ‘I love being here,’ and ‘I am over the moon about the home.’ What has improved since the last inspection? 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 Rest Home DS0000036172.V346915.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 Rest Home DS0000036172.V346915.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): 1, 2, 3 and 6. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There is detailed information available for prospective service users. The admissions process is good with staff being provided with adequate information in advance of admission to ensure each service users care needs can be met in the home, but it should be ensured that the assessment documentation is fully completed. EVIDENCE: There is a detailed Statement of Purpose, Service Users Guide and a copy of the last Inspection report available to read at the entrance of the home, which are in need of some minor updating. Three of the four relatives confirmed they had received this information and all stated that they had had the opportunity to look around and ask any questions. Where possible the service user had also visited the home prior to moving in. Elizabeth Court Rest Home DS0000036172.V346915.R01.S.doc Version 5.2 Page 9 There is a detailed contract/terms and conditions in place to be used between the home and the service user. The documentation for five service users was viewed and all but one had a completed contract in place, which the Manager stated was in the process of being completed. New service users are visited prior to any admission. This is to ensure individual service users care needs can be met in the home and to provide staff with information on the care to be provided. The documentation for three of the new service users resident since the last Inspection was viewed and confirmed they had been visited prior to admission and their pre-admission information was recorded. One relative also confirmed a home visit had been made. The detail recorded varied and not all had been dated and signed by the person completing the assessment. This was discussed with the Manager who stated this would be rectified. New care workers receive an induction and attend mandatory training. There are policies and procedures in place for staff to reference. There is a programme for National Vocational Training (NVQ). Intermediate care is not provided in the home. Elizabeth Court Rest Home DS0000036172.V346915.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): 7, 8, 9 and 10. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are protected by an individual detailed plan of care being in place, where all their personal, social and health care needs are identified at the start of their stay and which informs staff of the care which needs to be provided. The regular reviews should be maintained to ensure all the information detailed is kept up-to-date. Medication policies and procedures are in place, and care workers who administer medication have been provided with medication training. The recording of the administration of medication must be maintained to protect service users. EVIDENCE: Seven of the service users individual care plans were viewed. These were detailed and gave clear guidance to staff of the care to be provided, service users health care requirements, dietary needs, social and leisure interests, how any identified risks are to be managed. These had been reviewed, but a Elizabeth Court Rest Home DS0000036172.V346915.R01.S.doc Version 5.2 Page 11 number had not all been reviewed recently and one care plan was found to be slightly out-of-date. This was discussed with the Manager who stated that it would be ensured that the all the reviews were up-to-date. It was noted, in care plans that were examined, that appointments with or visits by health care professionals are recorded. Service users spoken were asked about access to a GP, chiropodist optician or a dentist. Not all had required these services, some they stated they had accessed these services either in the home or at a local surgery. The staff team were observed during the Inspection to ensure that the privacy and dignity of service users is respected at all times. The care and support provided was observed to enable service users where possible to exercise choice whilst at Elizabeth Court. The service users and relatives feedback was that service users received the care and support they needed. The four service with whose care was reviewed confirmed this. The feedback from all the service users and visitors was that they were happy with the overall care provided in the home. Comments included, very nice and homely,’ ‘very cheerful place,’ ‘staff are incredibly welcoming,’ ‘very, very caring,’ ‘it’s a family place,’ ‘I love being here,’ and ‘I am over the moon about the home.’ From observations and discussions with service users it was evident that they were treated with respect and dignity by staff. The home has a cordless telephone so that service users can make and receive telephone calls in private. Service users said that they have choices in all areas of their daily living including how to spend their time and what time to get up and go to bed. Relatives also confirmed that service users were supported to live the life they choose. The AQAA details that medication policies and procedures are in place, that care workers have received medication training and a lot of work has been undertaken to address the issues raised at the last Inspection. Day staff spoken with confirmed they had completed medication training and the Manager stated further training is now going to be provided to the night staff, who has also become involved with medication administration. No service users were self-administering at the time of the Inspection. The storage and a sample of the recording of the administration of medication were viewed. Where new/repeat medication is ordered this is directly though service users GP’s, but a record is kept of when the medication is received in the home. There were a number of errors in the recording of administration of medication particularly for two days, where there was very limited recording. This was discussed with the Manager who was unaware of this omission. But stated this would be discussed with the head of care, that she had recently undertaken further advanced medication training and had already started to discuss with staff further improvements to the handling of medications in the home, which included recording of administration. So a Requirement was not made on this Elizabeth Court Rest Home DS0000036172.V346915.R01.S.doc Version 5.2 Page 12 occasion. A controlled drugs record book is now kept in the home and there was appropriate recording of controlled medication prescribed. The medication cupboard is now kept for the sole use of medication storage and the key secure. A separate refrigerator is now available to store medications. The service users spoken with stated they always received the medical support that they needed and were happy with the arrangements for the administration of their medication and always received this at the agreed time. Elizabeth Court Rest Home DS0000036172.V346915.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Where possible service users are enabled to exercise choice in their lives whist resident in the home, there are opportunities to participate in social and recreational activities provided, service users maintain contact with family and friends as they wish and a varied diet is provided. EVIDENCE: The AQAA details that training for staff had been organised in the facilitating of activities and the new quality assurance worker will be working with staff in developing the range of activities offered, which would include activities to meet individual service users needs. A range of activities were organised during the Inspection with an external organiser running an exercise class, a small group of service users meeting as a follow up to a recent service users meeting to discuss meal suggestions, which could be included on the menu and a further small group met to undertake a group activity. We observed two of these groups, when there was a pleasant atmosphere and good interaction Elizabeth Court Rest Home DS0000036172.V346915.R01.S.doc Version 5.2 Page 14 between staff and service users. One service user was busy with a puzzle and another went out into the town for the afternoon. Service users’ religious denomination is recorded in their care plan. It was noted that service users are supported to participate in their beliefs either at the home. Two relatives particularly remarked on the efforts made in the home to mark service users’ birthdays, which are always celebrated with a gift and a homemade birthday cake. Feedback from service users and the relatives identified that there is flexible visiting, that staff are always very welcoming and it is possible to go to a service user’s bedroom if a private meeting is required. The care and support provided was observed to enable service users where possible to exercise choice whilst at Elizabeth Court. The seven service user files viewed and the service users and relatives spoken with confirmed this. There is a separate dining room where meals are served and staff were observed to be available to offer service users assistance with their meals if required. The cook working on the day and the supper cook both stated they held a basic food hygiene certificate. The AQAA detailed that the food provided is all fresh and home cooked. There is a four-week rotating menu is in place for dinner and a two week menu for suppers. A cooked breakfast can be provided if requested. Alternatives to the dinner and tea menu are not detailed on the menu, but staff and service users stated that alternatives are provided. It was not clear on the day that service users are always aware of the menu on the day, and this was discussed with the Manager to ensure that service users are aware in time to request an alternative if they wish. Special diets are catered for. Lunch on the day was faggots, potatoes, cabbage and carrots. There was homemade cake ready to be served during tea. Service users were asked during the afternoon what they wished to select for tea. The Manager stated that fresh fruit is ordered to meet individual service users requests. A sample of records was viewed of individual service users food consumption, which had been maintained to help ensure that they had received a varied and adequate diet. Comments received were, ‘the food is very good, I have no complaints,’ ‘there is always a hot tea and looks very nice,’ food is very, very good,’ ‘the food always smells good,’ ‘the food is getting better and we are meeting to discuss the menu.’ Elizabeth Court Rest Home DS0000036172.V346915.R01.S.doc Version 5.2 Page 15 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): 16 and 18. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Procedures are in place to enable service users or their representatives to raise any concerns about the care being provided and to ensure that service users are protected from abuse. EVIDENCE: The home has a complaints policy and procedure in place and this was available to view in the home. The AQAA detailed that no complaints had been received since the last Inspection and the CSCI has not received any concerns in relation to Elizabeth Court. All of the service users and relatives knew who to speak to if they had any concerns and the service users spoken with during the Inspection confirmed that they would feel comfortable raising any concerns with staff. The AQAA detailed that there is a policy and procedure in place in relation to vulnerable adults and a whistle-blowing policy. Staff spoken with had an awareness of the policies and procedures some had recently received training and others confirmed they were due to attend training later in the month. Elizabeth Court Rest Home DS0000036172.V346915.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is decorated and furnished in a homely style. A maintenance plan is in place to ensure that the standard of the environment continues to be maintained and improved. Regular health and safety checks in the home are maintained to ensure that service users are provided with a safe environment in which to live. EVIDENCE: A tour of the building was made. The home is decorated and furnished in a homely style. There is evidence of wear and tear and the Manager confirmed an awareness of this and there is an ongoing maintenance programme-taking place in the home to ensure the continual improvement of the environment. The AQAA detailed that in the last twelve months more automatic door releases have been fitted to bedroom doors to stop the use of doorstops, Elizabeth Court Rest Home DS0000036172.V346915.R01.S.doc Version 5.2 Page 17 thermostatic valves have been fitted to all the baths. Two walk-in showers have been fitted and the owners have replaced all the baths, sinks and toilets in the communal bathrooms. New carpet has been laid in all the hallways, staircase and landing and six bedrooms have been redecorated, re-carpeted and refurnished. A new hot water boiler has been fitted and furniture in the lounge replaced. It is planned to upgrade the kitchen during the next twelve months. Heating is provided by a central heating system with most radiators guarded in the home. The Manager stated that there is a rolling programme in place to cover the remaining radiators, with the priority of covers to be fitted being determined by the risk assessments, which have been undertaken, recorded and are regularly reviewed. This work is on target to be completed by the end of December 2007. There were records to view of regular checks of the hot water temperature delivered in the home, which recorded that hot water is delivered to the baths accessed by service users close to the recommended safe temperature of 43° C. The temperature recorded at the wash-handbasins was well in excess of this. The Manager has taken advice from Environmental Health and stated that risk assessments are in place, which are regularly reviewed. Four service users spoken with confirmed that there was adequate hot water and heating in the home. All twenty-four bedrooms are single and the bedrooms are situated on all the floors in the home. All bedrooms have an emergency call system fitted. A number of bedrooms viewed displayed service users’ individual styles and interests. Three of the bedrooms have en-suite facilities, two with a washhand-basin, toilet and bath and one with a wash-hand-basin, toilet and shower. There is a garden at the rear of the home, where a patio area has been built and furnished with wooden tables and chairs and with a raised fishpond. There is also an outside shed and greenhouse for service users who like to help in the garden by growing flowers for the garden and vegetables for the kitchen. There is also a small side garden with a decked area with chairs and planters. There is not a passenger lift and a stair lift enables service users to move between the ground and first floor. Three bedrooms on the second floor are only accessible by a further flight of stairs. There is a large lounge and a separate dining room for service users to use. The home was clean and odour free and feedback from service users and relatives was that the home is always ‘fresh and clean’. One domestic staff, a domestic/care worker and a laundry assistant were working in the home during the morning. One was spoken with who had received training/guidance in infection control, control of substances hazardous to health regulations (COSHH) and the use of protective clothing. Elizabeth Court Rest Home DS0000036172.V346915.R01.S.doc Version 5.2 Page 18 Recording of routine fire checks carried out in the home were viewed and were satisfactory. Elizabeth Court Rest Home DS0000036172.V346915.R01.S.doc Version 5.2 Page 19 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): 27, 28, 29 and 30 People who use this service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staffing levels are satisfactory. A robust recruitment procedure needs to be in place to ensure service users are in safe hands at all times. Care workers are being provided with training to ensure they can meet the care needs of the service users. EVIDENCE: Staff spoken with and rotas viewed confirmed that two members of care staff were deployed to work in the home, one of who was one of the owners of the home during the day. A further care worker who also covers some domestic duties was also working in the home during the morning. The Manager and quality assurance worker was also working in the home at the time of the Inspection. During the afternoon between five and eight o’clock there are only two care workers with the supper cook on duty, prior to the night staff arriving. This level of staffing at this time should continue to be kept under review to ensure that all the service users care needs continues to be met. At night the home deploys one ‘waking night,’ and one ‘sleeping in’ members of care staff. Ancillary staff is also employed in the home, with full time cook and supper cook, who between them cover seven days a week and a laundry assistant and a domestic were are on duty. Elizabeth Court Rest Home DS0000036172.V346915.R01.S.doc Version 5.2 Page 20 The AQAA details that of the nine care workers in the home, four care workers hold NVQ level 2 in care and further two care workers are working towards this qualification. On completion the home will then have over fifty percent of the care staff qualified. The Manager stated that it is planned that further care workers will start to work towards this qualification shortly. Again a thorough recruitment process was not demonstrated to be in place. The documentation was viewed for the two new members of care staff, both of whom had been recruited since the last Inspection. One of the members of staff had commenced working in the home prior to two satisfactory written references having been received. This was discussed with the Manager who has stated that a robust recruitment procedure will be followed. The Manager has previously confirmed that the remaining staff working in the home has had a Criminal Records Bureau (CRB) check and was able to evidence both these staff had had the required checks. The Manager stated that the induction meets the requirements of General Skills for Care induction standards. Elizabeth Court Rest Home DS0000036172.V346915.R01.S.doc Version 5.2 Page 21 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): 31, 33, 35, 36 and 38. People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home benefits from a Manager who ensures an open, supportive, homely and caring environment. Quality assurance systems have been developed to enable ongoing feedback about the care provided in the home and the outcome from the quality assurance process will need to be published annually, and available to the CSCI, service users and their representatives, and other stakeholders. EVIDENCE: One of the owners of Elizabeth Court is the Registered Manager of the home, is a Registered Nurse and stated she has completed the Registered Managers Elizabeth Court Rest Home DS0000036172.V346915.R01.S.doc Version 5.2 Page 22 Award. The management structure and senior responsibilities within the home are clearly defined and the management team work together in running of the home. A quality assurance system has been developed. The Manager stated and evidenced that feedback about the service provided is sought from service users using questionnaires, and that regular service users forums have been introduced into the home. The minutes of the last meeting were viewed. A regular newsletter is also circulated to service users in the home and one relative spoken with also confirmed receipt of the newsletter. The quality assurance process also enables relatives/representatives and other professionals who attend the home to give their views on the care provided. Again the outcome from the quality assurance process has not been collated, published annually, and available to the CSCI, service users and their representatives, and other stakeholders. This was discussed with the Manager who stated the new quality assurance worker would undertake this. The AQAA detailed that policies and procedures are in place in the home and these have been reviewed and updated. Where a small ‘float’ of money is held for some service users, this was securely stored and there were detailed financial records to support this activity and checks on the balances of money held. The balances were not up-to-date and this was discussed with the Manager who stated that this would be addressed with balences rectified more frequently. None of the service users spoken with had used this facility. Care workers and records viewed evidenced that staff supervision and team meetings have been introduced. Some staff had not received individual supervision with a regularity to meet the Standard. The Manager stated this was being rectified with the new quality monitoring worker taking the lead in supervising staff, who in turn was able to demonstrate work, which had already commenced to address this. So a further Requirement has not been made on this occasion. Staff spoken with confirmed good access to training and of attendance on moving and handling, health and safety training and basic food hygiene. The Manager stated that they were in the process of looking for training providers and booking updates for staff in basic food hygiene and infection control and was aware that some updates were overdue. Further moving and handling training was booked for staff to attend in November. First aid training is still outstanding and again a Requirement has been made that the Health and Safety Department are consulted with to ensure there are an adequate number of qualified first aiders are working in the home. The AQAA detailed that a fire risk assessment is in place and had been reviewed, and that regular health and safety/fire check of the building had been undertaken and recorded. There were records of regular fire drills Elizabeth Court Rest Home DS0000036172.V346915.R01.S.doc Version 5.2 Page 23 although not all staff could remember attending. Regular fire training has not been provided to meet requirements. The AQAA detailed that the maintenance of equipment and services has been carried out. The sluice room in the home wass found to be open during the Inspection. The Manager was asked to address this during the Inspection to ensure the safe storage of cleaning fluids and restrrict access to equipment in the home. Elizabeth Court Rest Home DS0000036172.V346915.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 2 Elizabeth Court Rest Home DS0000036172.V346915.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 5. Standard OP38 Regulation 13 (4) Requirement That the Health and Safety Department are consulted with to ensure there are an adequate number of qualified first aiders working in the home and this is acted upon. This is to protect service users and staff. That the outcome from the quality assurance process is collated, published annually, and available to the CSCI, service users and their representatives, and other stakeholders. That staff receive regular fire training to protect serviced users and staff. Timescale for action 31/12/07 2. OP33 24 (1) (2) (3) 31/12/07 3. OP38 Reg 23 (4) (a) 31/12/07 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 Rest Home DS0000036172.V346915.R01.S.doc Version 5.2 Page 26 Elizabeth Court Rest Home DS0000036172.V346915.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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