Inspection on 22/11/06 for Elizabeth Court Rest Home

This inspection was carried out on 22nd November 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 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 16/10/07

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 4 Hastings Road Bexhill on Sea East Sussex TN40 2HH Lead Inspector Judy Gossedge Key Unannounced Inspection 11:45 22 November 2006 nd 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 DS0000036172.V318191.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 DS0000036172.V318191.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elizabeth Court 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 nightnurse83@yahoo.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 DS0000036172.V318191.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). 27th September 2005 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. Accomodation comproses 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 donot 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 £322.00 and £500.00 per week. Additional charges are made for hairdressing, chiropody, manicure, toiletries and magazines and newspapers. Elizabeth Court DS0000036172.V318191.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 seven and a half hours on 22 November 2006. Prior to the inspection a pre-inspection questionnaire was sent to the home to be completed with information required as part of the inspection process. This was 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, rotas and care records were inspected. Twenty-two service users were resident and six service users were spoken with in their bedrooms or the lounge. The care that three of these service users received was reviewed as part of the inspection process. The opportunity was also taken to observe the interaction between staff and service users in the communal areas. Ten service user surveys were sent out and nine came back completed. The head of care, three care workers, the cook, a member of the domestic team and the Manager were all spoken with. Five staff surveys were sent out prior to the inspection and three completed surveys were returned. Two relatives were contacted and spoken with on the telephone after the inspection. Two General Practitioners, two District Nurses comment cards and one comment card to a visiting Community Psychiatric Nurse were sent out and no completed comment cards were returned. What the service does well: The staff team were observed to deliver care in a way that ensured service users dignity and privacy was maintained. The feedback from all the service users and visitors was that they were happy with the overall care provided in the home. Comments included ‘they are very good’, ‘I am very happy at Elizabeth Court’, ‘I would like to say that it is as happy as I have ever been’, ‘I am happy with everything here’ and ‘its like a big family’. 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. Service users benefit from having their assessed care needs incorporated into detailed plans of care, with supporting risk assessments, that are regularly reviewed. Service users are enabled to exercise choice and control over their lives whilst resident in the home. Elizabeth Court DS0000036172.V318191.R01.S.doc Version 5.2 Page 6 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 DS0000036172.V318191.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 DS0000036172.V318191.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is detailed information available for prospective service users, which is fully accessible. Service users are protected by the completion of a contract/terms and conditions. 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. Intermediate care is not provided in the home. 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. The majority of service users surveys stated they had received enough information about the home before moving in. There is a detailed contract/terms and conditions in place to be used between the home and the service user. All but one of the of service users surveys Elizabeth Court DS0000036172.V318191.R01.S.doc Version 5.2 Page 9 confirmed that a contract was in place. The three service users whose care was reviewed two had a completed contract in place and the third 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. There were two new service users resident, they had been visited prior to admission and their preadmission information was detailed. Intermediate care is not provided in the home. Elizabeth Court DS0000036172.V318191.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 Quality in this outcome area is good. 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. Supporting risk assessments are completed and all these documents are regularly reviewed. Medication policies and procedures are in place, but care workers who administer medication would be further supported by the provision of medication training. EVIDENCE: Four 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 and these had been reviewed. It should be ensured that there is a photograph in the home of the service users resident as part of the admissions procedure. The majority of service users surveys stated they always received the medical support that they needed. Elizabeth Court DS0000036172.V318191.R01.S.doc Version 5.2 Page 11 Four of the service users spoken were asked and confirmed access to their own General Practitioner, dentist, optician or chiropodist as required. One commented, ‘nurses call regularly’. 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 surveys stated they always or usually received the care and support they needed. All stated that staff listened and acted upon what they said. The four service user files viewed and the three service users 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 ’ they are very good’, ‘I am very happy at Elizabeth Court’, ‘I would like to say that it is as happy as I have ever been’, ‘I am happy with everything here,’ and ‘its like a big family’. 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. Medication policies and procedures are in place. Care workers have received ongoing medication training/guidance from the Manager of the home. But to fully meet the requirements of Standard 9 staff administering medication should attend further training as detailed in 9.7 of the Standard to complement the existing training in place. The Manager confirmed that a pharmacist regularly visits the home, but the records of these visits were not available to read during the inspection. No service users were self-administering at the time of the inspection although one spoken with confirmed they had been, but had requested not to self-administer any more. The storage and a sample of the recording of the administration of medication were viewed. Where new/repeat medication is ordered it is recommended a record of the order should be kept in the home to reference and when the medication is received in the home. It is recommended that a controlled drugs record book be kept in the home to ensure appropriate recording of controlled medication if prescribed. The medication cupboard was also being used for general storage of items in the home and should be kept for the sole use of medication storage. The key to the medication cupboard was accessible and kept in a public place. Where medication is held in a refrigerator this should be securely stored. This was discussed with the Manager who agreed to immediately ensure more secure storage arrangements for the key and for medication held in the refrigerator. The majority of service users surveys stated they always received the medical support that they needed. The three service users whose care was reviewed confirmed that they were happy with the arrangements for Elizabeth Court DS0000036172.V318191.R01.S.doc Version 5.2 Page 12 the administration of their medication and always received this at the agreed time. Elizabeth Court DS0000036172.V318191.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 Quality in this outcome area is good. 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: Elizabeth Court DS0000036172.V318191.R01.S.doc Version 5.2 Page 14 A programme of activities has been developed in the home. External entertainment/activities groups are also arranged to provide entertainment in the home. The pre-inspection questionnaire detailed exercise classes; musical afternoons and craft activities are facilitated. The majority of service user surveys stated activities are always, organised in the home. One comment received was ‘not keen on group activities’. The Manager stated that further training for staff was being organised in the facilitating of activities and developing the range of activities offered, which would include activities to meet individual service users needs. Activities were organised on either of the days of the inspection. The Manager stated this was due to the external person organising the activities not being able to attend the home. 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 or by attending a nearby church. Feedback from service users and the visitors 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. 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 stated she held a basic food hygiene certificate. There is a four-week rotating menu is in place. A cooked breakfast can be provided if requested. Alternatives to the dinner and tea menu are not detailed on the menu, but staff stated that alternatives are provided. One visitor commented that they had observed their relative being provided with their favourite meal as an alternative. Special diets are catered for and one service user who is a diabetic confirmed that their dietary needs were catered for. Lunch on the day was savoury mince and vegetables, followed by rice pudding. There was homemade birthday cake served during the afternoon. Assorted sandwiches were provided for tea. The majority of service user surveys completed stated they always enjoyed the meals provided. All the service users whose care was reviewed were happy with the meals provided. The Manager stated that fresh fruit is ordered to meet individual service users requests. Comments received were ‘lovely food’, ‘the food is very good and plentiful’, ‘the meals are always very good’, ‘the food is excellent and plenty of it’ and ‘there always appears to plenty of food, more than I could eat and is well presented’ and ‘very good, always enjoy my meals’. Elizabeth Court DS0000036172.V318191.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems 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. There are policies and procedures in place to protect vulnerable adults, but it should be ensured these are followed and that all staff have received training/guidance on these policies and procedures. EVIDENCE: There is complaints policy and procedure in place. One complaint has been received at the home during the last twelve months, which had been dealt with satisfactorily. The service users surveys stated they always know who to speak to and how to make a complaint if they are unhappy. The service users spoken with and the visitors felt it was an environment where they would feel comfortable to raise any issues and that they would be listened to. Comments received were, ‘I would speak to the owners’, ‘the owners are very approachable’ and ‘I am always happy here’. There are policies and procedures in place in relation to the protection of vulnerable adults. It should be ensured that these are followed, see Standard 29 for shortfalls in recruitment procedures. The CSCI received one complaint which was investigated under adult protection procedures. This was unsubstantiated and the owners of the home fully co-operated with the investigation. The majority of staff surveys stated and all the care staff spoken Elizabeth Court DS0000036172.V318191.R01.S.doc Version 5.2 Page 16 with all confirmed they had an awareness of adult protection procedures. The pre-inspection questionnaire detailed staff attendance at this training, but it should be ensured that all staff have received training/guidance on these policies and procedures. Elizabeth Court DS0000036172.V318191.R01.S.doc Version 5.2 Page 17 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 Quality in this outcome area is adequate. 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 should be 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. 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 Elizabeth Court DS0000036172.V318191.R01.S.doc Version 5.2 Page 18 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 will be completed by the end of December 2007. An additional heater was being provided in the lounge area where the heating system is not fully functioning and which was extremely hot to touch. This was discussed with the Manager during the visit and this was moved to another part of the room to ensure any risk to service users was eliminated. Three of the bedrooms have en-suite facilities, two with a wash-hand-basin, toilet and bath and one with a wash-hand-basin, toilet and shower. There are assisted communal bathing facilities in the home. At previous inspections it has been required that to reduce the risk of scalding individual thermostatic mixer valves should be fitted to hot water outlets; the Inspector was informed at the last inspection that a plumber was calling the day after the inspection to complete this work. A requirement was made that thermostatic mixer valves are fitted to hot water outlets on the baths in the home. There were no records to view of regular checks of the hot water temperature delivered in the home to ensure that hot water is delivered to outlets accessed by service users close to the recommended safe temperature of 43° C. Five hot water outlets used by service users were sampled and for three the temperature was excessive. This was discussed with the Manager during the inspection, who stated that thermostatic values had been fitted to all baths, but subsequently found not all had been fitted as the Manager had first thought. An Immediate Requirement Form was left to immediately consult with the Environmental Health Department and act upon any advice received. The Manager did this and the CSCI has subsequently received a satisfactory response detailing actions put in place to safe guard service users. There is a garden at the rear of the home, where a new patio area has been built furnished with wooden tables and chairs and with a raised fishpond. One comment received was, ‘there is a very pleasant garden’. There is also a new outside shed and greenhouse as the Manager stated that a number of service users 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. All twenty-four bedrooms are single of which two do not meet the minimum space requirements 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. There is a large lounge and a separate dining room for service users to use. Elizabeth Court DS0000036172.V318191.R01.S.doc Version 5.2 Page 19 The home was clean and odour free and feedback from the majority of service users and visitors was that the home is always ‘fresh and clean’. One commented ‘very good’. Two domestic staff and a laundry assistant were working in the home during the morning. One was spoken with who had not received training/guidance in infection control, control of substances hazardous to health regulations (COSHH) and the use of protective clothing. Recording of routine fire checks carried out in the home were viewed and were satisfactory. Elizabeth Court DS0000036172.V318191.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is adequate. 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: Elizabeth Court DS0000036172.V318191.R01.S.doc Version 5.2 Page 21 Staffing levels on the day of the inspection were satisfactory; records examined and staff spoken with confirmed that satisfactory levels of staff are maintained. The majority of service users surveys stated staff were always available when needed. The majority stated that staff listened and acted upon what was said to them. The three service users whose care was reviewed also confirmed that the call bells were answered promptly. One of the owners is the head of care and works alongside the care workers in the home. At night the home now deploys one ‘waking night’ member of care staff who is supported by another ‘sleep in’ member of care staff. The night staffing provided should be kept under review to ensure that the care needs of the service users resident continue to be met. Staff feedback from the completed surveys received were, ‘good teamwork’, ‘the home has a good team and the Managers are wonderful people to speak to if you have a problem’, ‘I would not change anything. The owners are always there if I need them. I am very happy working at Elizabeth Court’ and ‘the owners give the service users everything they need, they care very much and all the service users are very happy. It is a very happy home to work in’. Standard 28 has not been met as fifty percent of the staff have not achieved NVQ level 2 or equivalent in care. The Manager stated that three care workers are working towards NVQ level 2 in care and further two care workers hope to be able start working towards this qualification shortly. Records were examined for the four new members of staff who were working in the home, which confirmed the recruitment procedures followed, when new members of staff are employed. For three members of staff a protection of vulnerable adults check, (POVA) First check had not been received prior to a Criminal Records Bureau (CRB) check before staff commenced work in the home. This was highlighted and discussed with the Manager during the inspection, to ensure that for future recruitment of staff to the home the required checks are in place prior to staff commencing work in the home. The pre-inspection questionnaire detailed that four care workers from overseas had left employment in the home following further employment status checks. The Manager has taken further advice and is now satisfied that staff employed from overseas to work in the home have the required checks carried out prior to commencing employment. This could not be evidenced and should be. Records viewed and two care workers spoken with who had been recently recruited to work in the home stated that they had received an induction. The Manager stated that information of the new induction-training course to meet the requirements of General Skills for Care induction standards has been received and will be implemented. Elizabeth Court DS0000036172.V318191.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 and 38 Quality in this outcome area is adequate. 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. Staff should be provided with regular supervision. Systems need to be in place and maintained to ensure a safe environment for staff and service users. Quality assurance systems have been developed to enable ongoing feedback about the care provided in the home. 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 has become the Registered Manager of the home since the last inspection, is a Registered Nurse and has almost Elizabeth Court DS0000036172.V318191.R01.S.doc Version 5.2 Page 23 completed the Registered Managers 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. But that although service users forums have been introduced annually into the home, the last meeting was cancelled due to service users on the day not wishing to attend. A monthly newsletter is circulated to service users in the home. The service users care plans are regularly reviewed. The quality assurance process also enables relatives/representatives and other professionals who attend the home to give their views on the care provided. The outcome from the quality assurance process should be collated, published annually, and available to the CSCI, service users and their representatives, and other stakeholders. This was discussed with the Manager who stated this would be addressed. The preinspection questionnaire detailed that policies and procedures are in place in the home and these have recently 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. But in two instances the records and the balance of money held did not tally, each by a small amount of money. The Manager stated that she would relook at the records/receipts and balences and would be this would be addressed. None of the service users spoken with had used this facility. The Manager stated that staff supervision and team meetings do not occur to meet the requirements of Standard 36. Staff spoken with confirmed good access to training and of attendance on moving and handling, health and safety training, basic food hygiene and fire precautions. The pre-inspection questionnaire detailed staff have received basic first aid training/guidance and care workers spoken with on the day had attended this training. There is not a fully qualified first aider working in the home. The Health and Safety Executive should be consulted with and their advice acted upon as to the number of fully qualified first aiders required to be working in the home. A fire risk assessment is in place and had been reviewed. A regular fire check of the building had not been undertaken and recorded. Whilst walking around the home it was observed that there was extensive use of door wedges in the home. An Immediate Requirement Form was left to consult with the East Sussex Fire and Rescue Service and act upon advice given in relation to this practice. The Manager stated that she had done this and the CSCI has Elizabeth Court DS0000036172.V318191.R01.S.doc Version 5.2 Page 24 subsequently received a satisfactory response detailing actions put in place to safe guard service users. The pre-inspection questionnaire detailed that the maintenance of equipment and services has been carried out. The Manager stated that restrictors are now fitted to the windows in the home. Recording was viewed of incidents and accidents, which had occurred in the home. The collation of this information has improved to facilitate easy access and to identify any patterns in incidents and accidents, which have occurred in the home. Elizabeth Court DS0000036172.V318191.R01.S.doc Version 5.2 Page 25 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 2 3 X X X X X 1 2 STAFFING Standard No Score 27 3 28 1 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 2 Elizabeth Court DS0000036172.V318191.R01.S.doc Version 5.2 Page 26 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. 2. Standard OP9 OP26 Regulation 13 (2) 13 (3) Requirement That care workers receive medication training. That domestic staff receive training/guidance on infection control, the use of protective clothing and COSHH. That a POVA First check has been received prior to staff working in the home. That staff are appropriately supervised. 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. That a regular fire check is undertaken in the home and recorded. Timescale for action 28/02/07 31/01/07 3. 4. 5. OP29 OP36 OP38 19 (1) (b) 18 (2) 13 (4) 31/12/06 31/01/07 31/01/07 6. OP38OP38 Reg 23 (4) (a) 31/01/07 Elizabeth Court DS0000036172.V318191.R01.S.doc Version 5.2 Page 27 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 DS0000036172.V318191.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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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