Inspection on 01/11/07 for Elizabeth House

This inspection was carried out on 1st November 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Elizabeth House 20/06/06

Elizabeth House 15/12/05

Elizabeth House 27/04/05

Similar services:

Chirnside House

Keer Sands Residential Home

Sunny Bank (P.R.S.) Ltd

Ruskin Lodge

Bushell House

Ashwood Court Unit 1

Langrigg House

Parkside

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Elizabeth House 35 Queens Road Oldham Lancashire OL8 2BA Lead Inspector Sandra Buckley Unannounced Inspection 1st November 2007 09:30 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 House DS0000062775.V351884.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 House DS0000062775.V351884.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elizabeth House Address 35 Queens Road Oldham Lancashire OL8 2BA 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) 0161 626 6435 0161 287 8191 Elizabeth House (Oldham) Ltd Susan Leach Care Home 30 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (19), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (5), Old age, not falling within any other category (30) Elizabeth House DS0000062775.V351884.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 30 service users to include: *up to 5 service users in the category of MD(E) (Mental disorder excluding learning disability or dementia over 65 years of age). *up to 19 service users in the category of DE(E) (Dementia over 65 years of age); *up to 2 service users in the category of DE (Dementia under 65 years of age); *up to 30 service users in the category of OP (Old age not falling into any other category). The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. No more than two service users may be admitted into the home between 55 and 64 years of age. 26th October 2006 2. 3. Date of last inspection Brief Description of the Service: Elizabeth House is a large detached property situated close to Oldham town centre. Accommodation is presently 22 single en-suite rooms and four shared en-suite rooms. There are four lounges with dining areas and a large dining room. Adapted bathing facilities are provided with communal toilets being situated close to lounge areas. Outside of the property consists of a large garden and patio area to the front and enclosed patio to the rear, including a small parking area. Fees charged by the home range from £338 - £350. Elizabeth House DS0000062775.V351884.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced inspection was made to the home on 1st November 2007. This inspection looked at all the key standards and included a review of all available information received by the Commission for Social Care (CSCI) about the service provided at the home since the last inspection. During the site visit information was taken from various sources, which including observing care practices and talking to people in the home. The manager, relatives and some members of the staff team were also interviewed. A tour of the home was undertaken and a sample of care, employment and health and safety records were seen. Comments from questionnaires returned by residents and their relatives are also included in this report. All the requirements made at the last inspection had been addressed. However, there still remain a number of service developments to be addressed. The CSCI requires the home to complete an annual quality assurance assessment (AQAA) in order to demonstrate the level of care provided. Comparisons are made with this document at the time of inspection. There was a lack of information, especially in relation to safe recruitment procedures. What the service does well: The manager operates an open and inclusive environment, although on an informal basis, which results in a lively interactive atmosphere between people who live in the home, both with each other and staff. A detailed assessment of need is obtained from professionals which is then transferred into care planning. Staff training and induction is given a high profile, with over 50 of staff having achieved NVQ level 2 or above. Training had also been provided in line with people’s needs, for example, dementia. Elizabeth House DS0000062775.V351884.R01.S.doc Version 5.2 Page 6 One visiting professional said, “Staff deal with clients who present with challenging behaviour very well. They also deal with a crisis admission well”. One relative said, “We have only admiration for the staff and manager, my mother could not be cared for any better anywhere than Elizabeth House.” Comments from people in the home included: ‘I originally came for a four week period but the care was so good I applied for a permanent placement.’ Also ‘If I need a doctor they get me one and if I am not well they look after me. I have never been more comfortable.’ Another relative said, ‘Mother’s speech has improved since being in the home. She has come on leaps and bounds since being in Elizabeth House.’ All people in the home said the food was very good and that routines were flexible. One person said, ‘When I want to talk to staff they take the time to listen to me.’ What has improved since the last inspection? What they could do better: The outstanding requirement from the previous inspection related to the need for a structured activity programme. Although there was evidence that activities did take place, because some people said, ‘I like dancing with other ladies and playing music, I am playing dominoes this afternoon.’ Also ‘I like to go to my room for a rest in the afternoon unless staff say there are activities on.’ Another person said, ‘I would like to get out more’ and ‘I am bored, there is nothing to do.’ Therefore a structured programme needs to be introduced that looks at group and individual needs.’ Elizabeth House DS0000062775.V351884.R01.S.doc Version 5.2 Page 7 Although a lot of thought is given to providing a congenial environment for people, there was still a lack of thermostatic valves on some taps to provide safe water temperatures. The manager said this was to be included in the home’s refurbishment plan. Recruitment procedures were not robust to provide effective protection for people in the home. Other aspects of the recording systems need to be addressed; in particular, staff supervision and quality assurance systems. Although outcomes in the home remain very positive, the lack of good and appropriate recording and safe recruitment detracts from the otherwise good practices in the home. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Elizabeth House DS0000062775.V351884.R01.S.doc Version 5.2 Page 8 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 House DS0000062775.V351884.R01.S.doc Version 5.2 Page 9 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): Standard 3 Quality in this outcome area is good. Professionals assess people’s needs before entering the home to ensure their needs can be met by Elizabeth House. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Three case files were examined in depth and were found to contain a professional assessment of need. Information relating to what the home can offer people is provided in the entrance of the home, together with the last inspection report. Elizabeth House DS0000062775.V351884.R01.S.doc Version 5.2 Page 10 Several people in the home were on a short-term respite period. Comments received from these people included, “Originally I came in for a four week period but the care was so good I applied for a permanent place,” and “I came into the home for a few short stays and would not want to go anywhere else.” Another said “Its very nice here although I do not tell anyone else so they can’t take my place”. Elizabeth House DS0000062775.V351884.R01.S.doc Version 5.2 Page 11 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 & 10 Quality in this outcome area is good. People’s needs are met through effective care planning and staff training in line with their assessed needs. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Three files were examined in depth and were found to be comprehensive, with care plans reflecting the assessed needs of people in the home. Examples of the file contents are care plans, risk assessments, food diaries, pressure and fluid charts, weight nutritional screening and mobility assessments. Accident recording was accurate and included in daily notes, which are discussed at each shift change. Elizabeth House DS0000062775.V351884.R01.S.doc Version 5.2 Page 12 One relative questionnaire returned said “ In the main staff are usually caring and helpful but sometimes there is a lack of continuity of care”. Also “I think the home could improve by carers being more aware of people’s needs with more information being passed from shift to shift.” The AQAA completed by the manager identified how they had improved by working more closely with outside agencies. They also recognised the need to involve families and people receiving the care in more detail and planned for future weekly care meetings with staff to ensure the needs of people are being met. Comments from relative questionnaires and from people who live in the home included, “My mother’s speech has improved since being in the home, she has come on leaps and bounds since being in Elizabeth House,” and “My aunt is always kept clean and her basic needs are met; she is treated with respect and privacy.” Also “We have only admiration for the staff and manager my relative could not be looked after any were better than Elizabeth House.” People who live in the home said, “If I need a doctor they get me one and if I am not well they look after me I have never been more cared for,” and “I very rarely ask for anything but if I do the staff are there for me”. Another person said “I am a poor sleeper I just ring my call bell and the night staff will bring me a cup of tea.” Questionnaires and interviews with professionals visiting the home said “Elizabeth House deals very well with our clients who suffer from dementia” and “Staff deal with crises admissions very well.” Also “Staff are always aware of what is needed”. One relative interviewed said, “Staff keep me informed of care planning and send me copies of reviews” and “All the staff are hero’s.” One comment stated they felt there was a lack of support pillows and cushions for people with posture problems. This issue was discussed with the manager who said support pillows were available and they would keep this situation under review. At the time of this visit, the inspector noted that people had appropriate support. Equipment was available to promote independence and to aid staff with moving and handling. Examples of these would be: hoist, safe hips to be worn at all times and pressure mats to be used throughout the night. Where people had poor mobility, it was documented on care plans to ensure sensible footwear was worn. Elizabeth House DS0000062775.V351884.R01.S.doc Version 5.2 Page 13 People in the home were clean, tidy and looked well cared for. Any exception to this was documented in care planning, for example, if a person was resistant to care or appropriate dress, staff were advised to continue trying at various times throughout the day. Examination of medication procedures found that medication was stored, administered and recorded effectively. Photographs were on file for easy recognition of people and any allergies and adverse reactions were also recorded on the front of recording sheets. Two staff were interviewed both had qualified to NVQ level 2. Other training included moving and handling, falls prevention, dementia care, pressure sore care and first aid. The inspector asked staff to discuss specific care needs of the people whose files had been examined. Staff were aware of the contents of the care plan and how this was carried out within the routines of the home. All staff had undertaken training in oral hygiene, which had been provided by the National Health Service. Comments in the visitor’s book from the health professionals who had provided training were that they were impressed by the standard of oral health care provided and staff on the course had an excellent outcome. There was evidence on care plans that people had access to health professionals, for example, podiatrist and consultants. Elizabeth House DS0000062775.V351884.R01.S.doc Version 5.2 Page 14 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 & 15 Quality in this outcome area is good. People’s well-being is promoted through flexible routines with dietary needs being catered for through a balanced and varied selection of food and choices. The introduction of a structured routine of activities would enhance people’s fulfilment in the home. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Throughout the inspection day good interactions were noted between both staff and people in the home and to each other. The atmosphere is lively and interactive, with the main area of the home being the hub of activity. This area is open plan, which also leads to an open plan kitchen with many people taking an interest in what is being prepared and cooked. Elizabeth House DS0000062775.V351884.R01.S.doc Version 5.2 Page 15 There is a choice of a smoking lounge or quiet area if people do not wish to participate in activities provided by staff. For example, dancing and singing, which staff undertake in the afternoon. One person said “I like dancing and singing with the other ladies and a game of dominoes in the afternoon, it helps to keep me fit.” Another person said, “I like to talk to staff and they take time to listen to me.” The manager said that two people still went out to their preferred church, with the local church coming in once a month to give communion. Activities did rely on staff availability. One relative questionnaire returned said, “There does not appear to be any mental or physical stimulation for people.” One person in the home said, “I would like to go out more”; also “I get really bored here there is nothing to do.” A record of activities undertaken by staff and who had participated in them was maintained. The manager had stated on the AQAA that they recognised the positive thing about the home was the interactive atmosphere, however they also recognised that more structured activities were needed. They stated that their plans for the next 12 months were to employ an activity co-ordinator and to organise more outside trips in the community. At the start of the inspection day some people were observed to still be eating breakfast, with some choosing to have a full cooked breakfast, which is always on the menu. Each room of the home offers a choice of dining area or people can use the main dining room. The inspector dined with a group of people who were served a tasty, nutritional meal in a congenial setting. It was observed that those people who had communication difficulties were shown both choices of meals so they could pick their preference themselves. People said food was always prepared and served to a good standard. person said, “The cook is very good and always cooks nice meals.” One On the day of inspection the home had just qualified for the Safer Food Better Business award. People felt that routines in the home were flexible. One person said “I go to bed when I want usually about 9.30.” They also confirmed that the hairdresser visits on a regular basis. Elizabeth House DS0000062775.V351884.R01.S.doc Version 5.2 Page 16 Another person said “I like to go to my room in the afternoon for a rest but when they say they are doing activities I usually stop and join in.” One care plan examined stated that staff must ensure privacy for the person when their relatives were visiting. Elizabeth House DS0000062775.V351884.R01.S.doc Version 5.2 Page 17 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 & 18 Quality in this outcome area is good. People were comfortable in making known any concerns they may have. Staff training in the protection of vulnerable adults ensures people’s safety in the home. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: People were aware of the home’s complaints procedure, which was also included in the service user guide. One person said, “The complaints procedure is on my bedroom door”. Other people said they would speak to the manager if they were not happy about anything. One person said “I go to the boss if I have any concerns.” There is a comments and complaints book and a suggestion book is placed in the entrance of the home. However, no complaints or concerns had been recorded. Elizabeth House DS0000062775.V351884.R01.S.doc Version 5.2 Page 18 The manager had stated on the AQAA that they could be more vigilant in recording any concerns or complaints and that during the last 12 months discussions with staff had taken placed to provide clarity on what may be a complaint, which required recording and general concerns. The majority of staff had undertaken the protection of vulnerable adults training. Two staff were interviewed who were aware of how abuse may present and what their role in prevention and reporting any such event. The manager had purchased a training video on adult protection in order to provide refresher courses. Comments received from people in the home included “Staff always treat me well and if they did not I would tell them so” and other said, “I have no cause for complaint, they really look after me.” Elizabeth House DS0000062775.V351884.R01.S.doc Version 5.2 Page 19 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 & 26 Quality in this outcome area is good. People are provided with a safe and comfortable, well maintained environment. Additional odour control will ensure people’s comfort is maintained. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: A selection of rooms were inspected and were found to be personalised to a good standard, with many people bringing in items from home. All bedrooms have an en-suite facility with a separate soap dispenser and paper towels for staff to eliminate cross infection. Elizabeth House DS0000062775.V351884.R01.S.doc Version 5.2 Page 20 The home was well maintained with an ongoing decoration programme. Some radiators in the home were still without protective covers. The manager said these had been incorporated into the refurbishment plan. Risk assessments had been completed in the interim. There had been a failure when the new extension was built to provide all taps with thermostatic valves; these were also recorded on the home’s refurbishment plan for fitting with timescales for action. Two rooms had an odour but the inspector was satisfied that the home had contacted professional help for odour control and taken advice from the incontinence nurse advisor. Details of this were also recorded in care planning. Since the last inspection 24 new lounge chairs, six new beds and easy glide dining chairs had been purchased. New curtains and blinds had been purchased for the lounge areas, which provided a congenial atmosphere and pleasant environment for people in the home. One person said “One of the lounges they use for television, the other for music you can choose which you want,” and another said, “The place is very clean especially the bedrooms and bedding.” Outside the home provides a large safe patio area overlooking the local park. People said they had really enjoyed sitting out in the summer. Elizabeth House DS0000062775.V351884.R01.S.doc Version 5.2 Page 21 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 & 30 Quality in this outcome area is adequate. Staff training is given a high profile in the home. The lack of robust recruitment procedures poses a threat to the health and safety of people in the home. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: Examination of the staff duty rota showed that sufficient staff were on duty to care for the numbers and dependency needs of people in the home at the time of this inspection. Staff induction was linked to Skills for Care through Oldham Social Services Training department. Access to other relevant course in the care needs of older people is also accessible through Oldham Social Services. Staff at interview discussed their training which included dementia care, food hygiene, falls prevention and oral hygiene. Over 50 of staff had achieved NVQ level 2. Elizabeth House DS0000062775.V351884.R01.S.doc Version 5.2 Page 22 At interview staff demonstrated a good knowledge of people’s care needs. One person said, “I always appreciate staff, they are always helpful and supportive” and “The staff are lovely and they are my friends as well.” One relative questionnaire said, “We feel they are doing a wonderful service. They have great patience I have never heard any of the staff raise their voice with anyone.” Another relative said, “Staff are always friendly and caring but sometimes seem to be overworked.” Care staff are often faced with challenging behaviour, as witnessed by the inspector over the lunchtime period, when two confused people became agitated. Staff handled the situation well and offered alternative seating in a calm and efficient manner. Examination of recruitment procedures in the home found them to be lacking safety checks, for example, Criminal Record Bureau checks and protection of vulnerable adults checks. Gaps in employment history had not been explored and references had been accepted which had been transferred from other homes. These are unacceptable practices and pose a risk to people in the home. They also detract from the otherwise good work and positive outcomes that were evident at the time of inspection. The manager had also failed to demonstrate in the AQAA the full recruitment process and that appropriate safety checks would be undertaken before staff commence employment. Elizabeth House DS0000062775.V351884.R01.S.doc Version 5.2 Page 23 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, 36 & 38 Quality in this outcome area is adequate. The positive outcomes for people in the home are undermined by the lack of evidence based practices, which may lead to people’s needs not being met. This judgement has been made using available evidence, including a visit to this service. EVIDENCE: The manager has a number of years’ experience in care and management and has successfully completed the registered manager’s award. Since the last inspection the manager has become a moving and handling facilitator and undertaken training in staff supervision. Elizabeth House DS0000062775.V351884.R01.S.doc Version 5.2 Page 24 They operate using an open and inclusive approach to professionals, staff, relatives and people in the home. However, this is done on an informal basis and needs to be more evidence based. Regular meetings should be held with people in the home and staff with minutes maintained. Quality assurance systems need to be enhanced to include professionals and relatives’ views. Insufficient information had been obtained to provide a clear picture on people’s views of the running of the home. The manager and provider had failed to demonstrate their understanding of procedures which take place in the home, as was evident by the lack of content in the AQAA. However, outcomes for people in the home remained very positive which may not continue unless other issues are addressed. Financial records were examined and were well maintained, with receipts being retained for proof of purchase and expenditure. Staff supervision was not taking place on a regular basis and needed to be increased. The manager said a new staffing structure had been introduced and a deputy manager was now in post. This would provide additional supernumerary hours for the manger to address the above issues. Health and safety issues had been addressed with evidence of regular safety checks on equipment in the home. Weekly fire test took place and staff had undertaken fire drills. Staff had completed health and safety training and the home had successfully completed the Safe Food Better Hygiene award on the day of inspection. Elizabeth House DS0000062775.V351884.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 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 X 3 Elizabeth House DS0000062775.V351884.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP29 Regulation 19 Requirement Ensure Criminal Record Bureau checks or POVA checks are undertaken prior to staff commencing employment. Two references must be obtained with any gaps on work history being explored with the applicant and recorded, to ensure the continued protection of people in the home. Timescale for action 30/11/07 Elizabeth House DS0000062775.V351884.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. 1 2 3 Refer to Standard OP12 OP19 OP33 Good Practice Recommendations A planned programme of activities for group and individual needs should be developed to ensure the continued fulfilment of people in the home. All taps that remain without thermostatic valves should be included in the home’s refurbishment plan to ensure the continued health and safety of people in the home. Quality assurance systems should be extended to include the views of professionals, relatives and people who live in the home to ensure they have a say in the continued development of practices in the home. Staff supervision should be undertaken on a regular basis to ensure their professional development and maintain positive outcomes for people in the home. 4 OP36 Elizabeth House DS0000062775.V351884.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Manchester Local Office 11th Floor, West Point 501 Chester Road Old Trafford Manchester M16 9HU 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. Extracts may not be used or reproduced without the express permission of CSCI Elizabeth House DS0000062775.V351884.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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