Inspection on 10/05/06 for Elizabeth House

This inspection was carried out on 10th May 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 16 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Elizabeth House 13/12/07

Elizabeth House 12/12/05

Elizabeth House 04/05/05

Elizabeth House 17/01/05

Elizabeth House 17/06/04

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Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

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

CARE HOME ADULTS 18-65 Elizabeth House 59/61 St Ronans Road Southsea Hampshire PO4 0PP Lead Inspector Annie Kentfield Unannounced Inspection 10th May 2006 10:00 Elizabeth House DS0000012234.V288636.R01.S.doc Version 5.2 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 DS0000012234.V288636.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 Adults 18-65. 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 DS0000012234.V288636.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elizabeth House Address 59/61 St Ronans Road Southsea Hampshire PO4 0PP 02392 733 044 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) Mr M Khoyratty Mrs M Khoyratty Mr M Khoyratty Care Home 20 Category(ies) of Learning disability (20), Mental disorder, registration, with number excluding learning disability or dementia (20) of places Elizabeth House DS0000012234.V288636.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Current service users over 65 years of age may remain at the home. One named service user whose date of birth is 06/04/1936. Service users in the MD/LD categories must be at least 35 years of age. Date of last inspection 12th December 2005 Brief Description of the Service: Elizabeth House is a care home converted from two large houses and is situated in a pleasant residential area of Southsea, close to shops and other amenities. The current registered providers have owned and managed the home for nearly 20 years and live close by. Because many of the residents have lived in the home for some years, the residents are in the forty to seventy year age groups and although the home is registered for younger adults aged 18 – 65 years, the home cannot admit any new service users under the age of 35 years or over the age of 65 years. The home is registered to provide care for service users with a learning disability or mental illness or service users with a dual diagnosis. The registered manager is very clear that new residents are only admitted if they meet the categories of registration, and the needs of the existing residents are always considered. The home offers a good choice of communal space, with two good sized sitting rooms, a large dining room, a separate smoking area, hairdressing room, small conservatory used to hold care review meetings, and a paved and sunny garden area that residents have access to. All of the staff, office, and storage areas are situated in the basement that only staff have access to. Elizabeth House DS0000012234.V288636.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is based on evidence gathered from a number of sources including an unannounced visit to the home. This visit took place on a Wednesday between 10.00 am and 6.00 pm with two inspectors. Inspection comment cards for residents and visitors were sent to the home and the Commission received 10 comment cards from residents and 4 from visitors. Community health and social care professionals from two different community teams who have contact with the home were invited to feedback their views of the service. Comments were received from 2 care managers. What the service does well: What has improved since the last inspection? What they could do better: Comments from people who use this service are positive. Improvements need to be made to the home’s record keeping systems and there is a need to develop a person centred approach to recording and reviewing care plans. The comments about the care staff were very positive but the manager must ensure that recruitment procedures are thorough and meet regulatory requirements to ensure the safety and welfare of the service users. Generally, the home environment is suitable and comfortable for the service users but some improvements need to be made to specific areas in the home and these are detailed in the body of the report. Elizabeth House DS0000012234.V288636.R01.S.doc Version 5.2 Page 6 • The manager must ensure that new service users have an assessment of their care needs before moving into the home; the assessment should be recorded in writing. Care Plans and risk assessment/management plans should be regularly reviewed. Development of a Key Worker system and person centred care planning should involve the service users in drawing up and reviewing care plans. Recruitment procedures must be more robust and thorough to ensure that service users are safeguarded at all times. The manager must ensure that environmental risk assessments are recorded and particularly the risk to individual service users from hot pipe work and radiators. Some toilet seats need immediate replacement where they have become worn and cracked and are a risk to health. The manager must review the bathing facilities and bathing assistance needed by the service users, with the advice of an occupational therapist. Some areas of the home are in need of repair and replacement where internal decoration has been damaged by leaks in the chimney or roof. Bedding and bed headboards should be replaced when they are stained and worn. Communal toilets and bathrooms should have hand-washing facilities that meet recommended good practice for the control of infection or cross infection. • • • • • • • • Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Elizabeth House DS0000012234.V288636.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Elizabeth House DS0000012234.V288636.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 4 and 5 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. The registered manager assesses all new service users - also using the care management assessment where appropriate. However, the manager must ensure that all assessments are recorded in writing otherwise there is no evidence that the home is suitable to meet the care needs of individual service users and no evidence that consultation has taken place with the service user and others involved in their care. Records show that service users have a signed contract that sets out the terms and conditions of living in the home. This needs to be updated to make sure that the complaints procedure includes information about contacting the Commission for Social Care Inspection and not the National Care Standards Commission, and refers to the current relevant legislation (Care Standards Act 2000). EVIDENCE: The manager is aware that the initial care assessment should be recorded in writing and records show that usually this is the case as the manager has his own assessment pro-forma. However, there was nothing recorded for one service user who has been admitted to the home although the manager confirmed that he had met with the service user prior to admission to ensure Elizabeth House DS0000012234.V288636.R01.S.doc Version 5.2 Page 9 that the home was able to meet the care needs identified by the community care manager. New service users are invited to visit the home before deciding to move in and encouraged to stay for a meal or stay for a night or weekend if appropriate. This should be recorded as part of the assessment to demonstrate that service users are actively involved in choosing to move into the care home. Service users are asked to sign a contract that sets out the home’s terms and conditions and some of these were seen in individual files. The information in the terms and conditions sets out what the home does or does not provide. The information about the complaints procedures is out of date and needs to be reviewed and re-printed with the correct information. Of the comment cards received from 10 service users, all but two said that they had received enough information about the home before they moved in. Elizabeth House DS0000012234.V288636.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. Comments from residents and from care managers demonstrate that the home is meeting the care needs of the residents well. Care plans are in place but could be more detailed and there needs to be greater consultation about the plan of care with the residents and regular reviews. EVIDENCE: Records show that the home is meeting individual care needs but the care plans themselves do not provide sufficient evidence of this. The manager explained that paperwork is not his strongpoint but does understand the need to have all care needs identified, recorded, and reviewed, to ensure that care needs are being met at all times. Staff keep a daily record of care and it is recommended that this is dated with the day, month and year to ensure that current records are clearly identified. The manager and staff work closely with the community health and social services, and care plans are regularly reviewed as part of the community care Elizabeth House DS0000012234.V288636.R01.S.doc Version 5.2 Page 11 programme approach (CPA). Feedback from care managers confirms that the manager and staff have a positive and flexible approach to meeting the care needs of the residents and have a “good engagement with the service users”. The care plans could contain clearer information for staff on how care needs can be met. Residents spoken to had not seen their care plan. The manager has taken action on the recommendation from the previous inspection and two of the staff have recently had some training in how to develop a key worker system. When this is in place, it should provide greater opportunity for service users to be involved in their care plan and regular reviews should identify changing care needs as well as individual aspirations and choices. A key worker system should provide the opportunity for developing a person centred approach to care planning and delegate some of the responsibility of reviewing care plans to the key workers, in consultation with the service users and/or their representatives, wherever practicable. There is evidence from speaking to service users and to community care managers that service users are encouraged to participate in the daily living activities in the home and some service users like to help with household tasks such as laying the tables, making a hot drink etc. There are no formal resident meetings but it appears that service users are consulted on an informal 1:1 basis and individual choices accommodated. Elizabeth House DS0000012234.V288636.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. One of the residents spoken to say they thought the opportunities for residents to take part in activities they like was “OK”. Most residents thought that they could do what they want to do at all times, but one resident felt this was “sometimes”. Residents said they can come and go in the home and usually tell a member of staff if they are going out and when they are coming back. Many of the residents manage their own finances and some with support from the manager where agreed. Another resident said that visitors are always welcome in the home. All residents spoken to and in written comments said the food is “good”. Elizabeth House DS0000012234.V288636.R01.S.doc Version 5.2 Page 13 EVIDENCE: Some of the residents have recently started to go on Sunday coach outings with a member of staff and some of the residents have the opportunity to go on holidays, either with family or with other people in the home. Some of the residents are able to go out independently to local shops and amenities. Some of the residents go to local day centre activities. The residents and staff celebrate special events and last Christmas a party was held in a local hotel. During the inspection staff were observed engaging with residents, chatting, and doing a manicure with one resident. A care manager commented that the home is good at providing opportunities for residents to take part in different activities they may not usually have the opportunity to do. They also commented that the home is good at offering “culturally appropriate” activities and food for the residents. Some of the residents said they look after their own finances. The manager confirmed that small amounts of personal monies are looked after where agreed and the manager acts as appointee for some residents. Comments from a care manager said that the financial arrangements in the home are “open and transparent” and the manager liaises with the community care managers if they are any concerns about service users’ finances or if an expensive purchase needs to be made. Meals are freshly prepared every day and a cook is employed for 5 days per week. The food store was well stocked with plenty of good quality supplies and the cook said that she uses fresh meat and vegetables wherever possible. Special dietary needs are catered for. The menu is decided daily and some residents said they didn’t mind this. There is always an alternative offered if there is something on the menu residents don’t like. Meals are taken in the dining room and there is plenty of space for all of the residents to sit down at small tables for 3 or 4 people. Elizabeth House DS0000012234.V288636.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. Comments from residents spoken to during the inspection were “I like it here”, “the staff are very good” and generally residents were happy with the care provided. This was also confirmed by comments from a care manager who said that the staff in the home are good at meeting health and emotional care needs and have a flexible approach to meeting individual care needs. Residents are able to self-medicate if agreed in their care plan and risk assessment, otherwise medication is administrated and dispensed by the manager and care staff. EVIDENCE: It was evident that service users are supported to see GPs and all health services as required, and on the day of the inspection a member of staff was accompanying a service user to a health appointment. Service users expressed their satisfaction with the care they receive and were complimentary about the staff being kind and caring. Elizabeth House DS0000012234.V288636.R01.S.doc Version 5.2 Page 15 Some service users said that if they need help there is a call alarm system and staff always respond promptly. Comments from service users confirmed that residents are able to get up and go to bed when they choose. One care manager said that the manager and staff are good at identifying relapse triggers or indications that a service user may be unwell and respond quickly and communicate well with the community mental health services. It is the policy of the home that all senior staff dispense medication but the manager has overall responsibility. One resident who self-medicates confirmed that they have a lockable storage space for medicine. The medication cupboard is in the dining room and kept locked. Procedures were not inspected as service users were in the dining room for a meal at the time. However, a care manager said that as far as they were aware, service users always receive the medication they are prescribed. It is recommended as good practice that staff receive accredited training in the safe administration of medicines to ensure that they are aware of correct procedures for recording and handling medication and have an understanding of the effects and side effects of medication used in the home. Elizabeth House DS0000012234.V288636.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. Generally, residents’ comments indicated that there was always a member of staff they could talk to if they had any concerns and one resident said, “cannot think of anything in the home that could be better”. The written complaints procedure for service users’ information needs to be updated. The manager said that he has not received any complaints about the home and none were recorded in the complaints book. One member of staff spoken to confirmed an awareness and understanding of what to do if they had any concerns that a resident was being abused or neglected. EVIDENCE: Although the residents do not meet together in a residents’ meeting, there is sufficient evidence that residents feel their views are listened to individually, and staff are always available if they have something they want to discuss. The home has a policy for staff to read about adult protection and the procedures to follow when concerns are identified. In discussion with the manager, it was recommended that staff should have specific training in adult protection awareness to ensure that all staff are aware of their duties and responsibilities to protect vulnerable service users at all times. There have not been any recorded incidents or allegations since the last inspection. The requirement from the previous inspection – to identify any Elizabeth House DS0000012234.V288636.R01.S.doc Version 5.2 Page 17 protection issues in individual care plans and risk assessments, has been addressed by the manager. The complaints procedure needs to be updated – as previously discussed. Elizabeth House DS0000012234.V288636.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. Generally, the home is very clean and tidy and provides a comfortable and homely environment for the residents. There is a stair lift in the building but no passenger lift. The manager must re-assess the service users’ needs with regard to bathing facilities and ensure that specialist bathing equipment is provided to meet those identified needs. Some areas of the building are in need of minor replacement or repair and these are detailed in the evidence. Generally, hygiene in the home is very good but the manager must ensure that suitable hand-washing facilities are provided in shared toilets and bathrooms that meet good practice in hygiene and the control of infection. EVIDENCE: During the inspection visit the home was seen to be very clean and tidy and residents confirmed that this was usually the case. The home employs a parttime cleaner and other tasks are done by the care staff. The front of the Elizabeth House DS0000012234.V288636.R01.S.doc Version 5.2 Page 19 building is neat and attractive and the manager plans for the outside of the building to be painted in 2006. Service users have a good choice of communal rooms that they can use and there is a small and sunny secluded garden area that residents can use. Furniture and fittings in all of the communal areas are domestic in scale and comfortable and ‘homely’. Service users were happy for the inspectors to view most of the bedrooms and mostly these are single occupancy, where rooms are shared – there is screening available for privacy. Bedrooms are all individually furnished and personalised as service users choose. It was noted that everyone accesses the hairdressing room via one residents’ bedroom. Staff said that the resident did not mind but the inspectors were not able to confirm this as the resident was out at the time. There is alternative access to the hairdressing room. The manager explained that the building has not been re-decorated for some years but his aim had been to ensure that the original work on the building was done to a high standard to ensure that it lasted. One person described the home as “old but homely and comfortable” and it is evident that residents feel comfortable and ‘at home’. The manager keeps a record of all maintenance work done and it is recommended that a plan for ongoing work be produced to ensure that urgent work is prioritised. A tour of the premises identified some areas that require replacement as part of the ongoing maintenance of the building: 1. Toilet seats that are cracked or have surface damage must be replaced to ensure good hygiene. (this should be done urgently) 2. Several bedrooms need decorative repair where old leaks from the roof or chimney have damaged decoration. 3. The headboard in one bedroom was worn and stained and must be replaced. 4. Bedding should be regularly checked and replaced when duvets and pillows become worn and thin. 5. Shared toilets and bathrooms must have adequate hand-washing facilities that meet current good practice for infection control. 6. Radiators and hot pipe work must be assessed for every resident and covered where any risk is identified. Risk assessments must be kept in writing for every resident. 7. Some of the assisted bathing equipment is out of date or unused, or in need of repair. Bathing needs must be re-assessed and suitable equipment provided to meet those needs. It is recommended that any assessment be done in consultation with an occupational therapist. In discussion with the manager, the inspectors recommended that bedrooms and all areas of the home are checked on a regular basis and any maintenance Elizabeth House DS0000012234.V288636.R01.S.doc Version 5.2 Page 20 work or replacement required could be recorded in writing to ensure that nothing is missed. The manager has recently refurbished the basement area to provide large amounts of storage, staff rooms, and the office. This is the only area of the home that residents do not have access to. Elizabeth House DS0000012234.V288636.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. Generally, service users were very complimentary about the staff team and there is evidence from care managers that staff are considered to communicate well with the service users and have a good understanding of individual care needs. The manager needs to develop a staff training programme that is linked to the service users’ needs and individual plans (National Minimum Standard 35.7) and reflects the home’s aims to provide a specialist service to service users with either a mental disorder or learning disability. The manager must ensure that recruitment procedures are thorough and meet current regulatory requirements to ensure the safety and welfare of the service users. EVIDENCE: The registered owners work in the home on a daily basis with the staff team of 7 people. The staff rota shows that there is usually 2 care staff on duty during the day, with the manager in addition, and 1 wakeful staff member at night with the owners on call if needed. Elizabeth House DS0000012234.V288636.R01.S.doc Version 5.2 Page 22 Previous inspections have raised concerns about there being only one member of staff on duty at night, and this was discussed with the manager and some of the residents. It was felt that this was sufficient to meet the needs of the service users at present and the manager keeps the situation under regular review and explained that he is rarely called out during the night. There have also been concerns expressed about the number of hours worked by the registered owners, however, in discussion, the manager explained that as he and his wife live close by, they are able to maintain close supervision of the running of the home and would take action to increase staffing levels as necessary. 5 of the 7 staff have already achieved NVQ level 2 in care and 2 people are currently doing NVQ level 3 in care. There are plans to develop a key worker system and this will be looked at during the next inspection. There was evidence that staff follow an initial induction training programme and some of the staff have done training in infection control and first aid and there are plans for staff to have training is safe moving and handling. It is recommended that the manager produce a training matrix to ensure that all staff have done mandatory training in all aspects of safe working practice and that this is regularly updated as required. It is also recommended that the manager develop staff training to include Learning Disability Framework accredited training to underpin staff knowledge in this specialist area with their NVQ training. In addition, training in the area of mental health is seen as good practice for a home that offers a specialist service to service users with either a mental illness or learning disability. Staff recruitment records were inspected and some shortfalls were noted. This was a requirement from the previous inspection. New staff can only start working in the home if there is a satisfactory check against the POVA list (Protection of Vulnerable Adults) and there is sufficient employment history and two satisfactory written references. New staff with these checks must be supervised until a satisfactory Criminal Record Bureau check is received. Failure to do this is a breach of the Care Homes Regulations 2001 and has the potential to put vulnerable service users at risk. The inspectors spoke to one member of staff who confirmed that there are regular staff meetings and that staff receive formal supervision. Elizabeth House DS0000012234.V288636.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. Generally, the home is well managed and comments from service users, visitors, and care managers, demonstrate that the home is safe, and run in the best interests of the service users in a friendly and informal way. Systems are in place for fire safety and regular safety checks as required. Risk assessments must be carried out on radiators. The Quality Assurance system needs to be developed to ensure that the views of the service users and others are regularly sought and used to contribute to the review of how the service is meeting its stated aims and objectives. EVIDENCE: The manager is qualified and experienced and it is evident from observation and comments from service users and others that the owners/managers are Elizabeth House DS0000012234.V288636.R01.S.doc Version 5.2 Page 24 very well liked and respected. The manager and staff were welcoming and helpful and co-operated fully with the unannounced inspection visit. The manager is particularly mindful of fire safety in the home and records show that all equipment and fire safety systems are regularly checked. Records also show that all required checks on gas and electrics are carried out as required. Evidence from the last food safety inspection of September 2005 showed there were no requirements. Daily menus are recorded and also fridge and freezer temperatures. The manager must ensure that staff training is regularly updated in all aspects of safe working practice as required. The manager must ensure that health and safety risk assessments are recorded including individual assessments of any risk from radiators and hot pipe work. The manager must also assess service users’ needs for supported bathing facilities in consultation with an occupational therapist. The manager has started to develop a quality assurance system but the results of a previous questionnaire have yet to be summarised and reviewed and this needs to be done at appropriate intervals. Elizabeth House DS0000012234.V288636.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 Adults 18-65 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 X 2 2 3 2 4 2 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 2 28 X 29 2 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 2 X Elizabeth House DS0000012234.V288636.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. Standard YA2 YA3 Regulation 14 Requirement Prospective service users must have their care needs and individual aspirations assessed and recorded before they move into the home. The home must demonstrate that they can meet the health and emotional care needs of prospective service users. The complaints procedure for the home must be reviewed and updated. The individual plan of care must be drawn up with the service user/and or representative and regularly reviewed. Develop a key worker system as part of a person centred careplanning approach. This was a recommendation from the inspection of 12/12/05 Replace damaged toilet seats. Provide suitable hand washing facilities in shared toilets and bathrooms. Ensure bedrooms are appropriately decorated where there has been damage caused DS0000012234.V288636.R01.S.doc Timescale for action 10/05/06 2. 3. YA5 YA6 5 15 30/06/06 30/06/06 4. YA6 15 30/06/06 5. YA30 YA24 YA27 YA24 16(j) 13(3) 16(c) 30/06/06 6. 30/12/06 Elizabeth House Version 5.2 Page 27 by leaks to the roof or chimney. 7. 8. YA24 YA29 YA27 16(c) 14 13(5) Replace worn bed headboards and duvets and pillows as appropriate. Assess the needs of the service users for assisted bathing equipment and provide appropriate equipment in consultation with an occupational therapist. Staff must not be employed in the home unless all satisfactory checks are in place including written references, satisfactory employment history, POVA check and CRB check. Staff may be supervised if awaiting a satisfactory Criminal Record Bureau check and all other checks are in place. This was a requirement from the inspection of 12/12/05. Failure to meet this requirement will result in enforcement action being taken. The manager must review the service provided as part of the quality assurance system for the home. The manager must record risk assessments for all safe working practice in the home. Radiators and hot pipe work must be individually assessed for each service user and covered where a risk is identified. 30/06/06 30/06/06 9. YA23 YA34 19 and Schedule 2 10/05/06 10. YA39 24 30/12/06 11. YA42 12 13(4) 30/06/06 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 DS0000012234.V288636.R01.S.doc Version 5.2 Page 28 Elizabeth House 1. 2. 3. YA23 YA32 YA34 YA32 YA34 The policy for protecting vulnerable adults should include specific training for staff in adult protection awareness. Staff training should include specialist knowledge in the areas of learning disability and mental health. It is recommended that a staff-training matrix be kept to ensure that all training in areas of safe working practice is regularly updated as required. Elizabeth House DS0000012234.V288636.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Southampton, Portsmouth and Isle of Wight Ground Floor Mill Court Furrlongs Newport, IOW PO30 2AA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Elizabeth House DS0000012234.V288636.R01.S.doc Version 5.2 Page 30 - 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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