Inspection on 13/12/07 for Elizabeth House

This inspection was carried out on 13th December 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Elizabeth House 10/05/06

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,

Pinta

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 Marilyn Lewis Unannounced Inspection 13 December 2007 09:30 th Elizabeth House DS0000012234.V353996.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.V353996.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.V353996.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.V353996.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 10th May 2006 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. The registered manager stated at the time of the visit to the home on the 13th December 2007 that fees were at the Social Services rates of £294 to £335, depending on the level of needs. Elizabeth House DS0000012234.V353996.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Information from previous inspection reports and that provided by the registered manager together with information obtained during an unannounced visit to the home was taken into account when completing this report. The unannounced visit took place on the 7th December 2007, when the inspector met with residents, a support worker, the registered manager and the co provider. Records including care plans and those for staff training and recruitment and medication were seen. The registered manager is also the registered provider and his wife is also a registered provider. In this report Mr Khoyratty is referred to as the registered manager and Mrs Khoyratty as the co-provider. What the service does well: Prospective residents are able to visit the home on a number of occasions to view their room and meet with residents before making a decision about taking a place there. Residents said that they liked living at the home and they enjoyed the choice of meals provided. Residents also said that they felt able to talk easily with the registered manager and the co provider and staff were good. Comments regarding staff included ‘ they are very kind and friendly’, ‘ they help me to do the things I want to do’ and ‘I can tell them anything’. The home had a relaxed, friendly atmosphere and there was good interaction between staff and residents. Residents said that they were supported to participate in a wide range of social activities both in the home and the community. Residents go out into the local community either independently or with the support of a care worker. Some residents join with other social groups for outings and activities such as sport. Residents said that they had enjoyed a special Christmas meal at a local hotel on the day prior to the inspectors visit. Elizabeth House DS0000012234.V353996.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Staff have not received training in the protection of vulnerable adults to ensure they are aware of the procedures to follow should abuse be suspected. Staff have not received training in issues relating to the service group such as mental health and learning disabilities awareness. Some staff have also not received refresher training in moving and handling. At the time of the last inspection a requirement was issued for risk assessments to be completed with regard to hot radiators and pipe work. The assessments have been undertaken but the risks for some residents such as those with epilepsy, who could fall against the radiator during a seizure, need to be reassessed and any necessary actions to minimise the risk taken. Elizabeth House DS0000012234.V353996.R01.S.doc Version 5.2 Page 7 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 DS0000012234.V353996.R01.S.doc Version 5.2 Page 8 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.V353996.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. No one is admitted to the home without a care needs assessment to ensure the home can meet their care needs. Prospective residents are able to visit the home to view accommodation and meet with other residents before making a decision about taking a place there. EVIDENCE: Since the last inspection the registered manager has updated the information provided for prospective residents including the complaints procedures. One new resident has been admitted to the home in the last year. The registered manager said that information had been obtained from the care manager and the prospective resident had been visited at their home for an assessment of their needs to be undertaken with them. The assessment records seen indicated that all aspects of care provision had been assessed including the prospective residents preferences for how they wished to be addressed and their daily routine such as what time they liked to go to bed. The records documented visits to the home prior to the resident moving in when they were shown two rooms that were vacant and were able to choose which one they would prefer. Elizabeth House DS0000012234.V353996.R01.S.doc Version 5.2 Page 10 Records indicated that during the first week of their moving into the home staff shadowed the new resident to make sure they were able to find their way around the home and on visits to the local shops to confirm they were able to manage handling their money. The resident was provided with a written contract giving the terms and conditions for living at the home. The resident had signed the contract. Elizabeth House DS0000012234.V353996.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are involved in their care planning and are supported to make their own decisions and to take risks as part of an independent lifestyle. EVIDENCE: A requirement was made at the last inspection for care plans to be reviewed regularly and for residents to be involved in their care planning. Three residents asked, said that they knew what was written in their care plans as a carer had sat down with them to discuss them. The residents said that they agreed with their plans and had signed them. Care plans were seen for two residents including the resident who had been admitted this year. The care plans provided good information on the needs of the residents and actions required by staff to meet support them. The information in one of the plans was a little out of order and this made it difficult to find the current information. The registered manager said that he would deal with this. Elizabeth House DS0000012234.V353996.R01.S.doc Version 5.2 Page 12 The care plans had been reviewed and covered personal hygiene, medication, emotional needs and communication and also specific needs such as a recent bereavement when additional support was required. Since the last inspection the home has developed a key worker system where carers are responsible for the main care for a number of residents. Residents said that they knew who their key worker was and that they talked with them about the care they wanted. The wishes of the residents were documented in their care plans and residents spoken with said that staff allowed them to make their own decisions. A resident said that they were able to get up and go to bed when they wished and it was evident during the visit that staff encouraged residents to make their own decisions such as choosing their meals and whether they wished to go out or not. Risk assessments were contained in the care plans including those for going out including road safety and awareness for handling money, accessing the kitchen to make a cup of tea or snack and verbal aggression. There were also risk assessments in place for specific activities such as swimming, visits to social clubs and pub lunches. Elizabeth House DS0000012234.V353996.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to take part in social activities both in the community and in house and to maintain contact with family and friends. The residents enjoy the choice and variety of meals provided. EVIDENCE: At the time of the last inspection one relative had commented on her mother’s wish to attend church services. The co provider said that efforts had been made with regard to the resident attending services but so far the resident had declined to go. The minister from the church had visited the resident and on numerous occasions the resident had said she would like to attend but just before leaving the home she would change her mind. Two other residents have said that they would like to go to church on Christmas day and arrangements have been made for this to take place. Some residents visit church social events such as coffee mornings on a regular basis. Elizabeth House DS0000012234.V353996.R01.S.doc Version 5.2 Page 14 Residents said that they went out to the local shops or places of interest either on their own or with a staff member. Trips out and social activities were documented in the records seen including for one resident helping on an allotment, visiting a sports centre and trips to the theatre. Some of the residents are involved in social groups in the community where they have the opportunity to attend activities arranged by the group. One of the groups holds tea dances throughout the year and some of the residents attend. Two of the residents spoke of their enjoyment of a special Christmas meal they had attended the previous day, arranged by the tea dance group in a local hotel. Residents said that they knew the DJ playing the music as he played for the dances. The co provider said that some of the residents had requested that relatives go with them to the lunch and this had been arranged. A staff member stayed at the home to support those residents who did not wish to go to the meal. Records seen for one resident documented a holiday to Wales earlier in the year. Staff who had supported the two residents who went on the holiday recorded how the residents had been involved in the decisions regarding what they were going to do and documented the enjoyment of the residents. The co provider said that in house activities included dominoes and board games, exercises with music and singing, drawing and listening to music. One resident said that they had been busy making Christmas cards with staff recently. The co provider also said that residents were encouraged to help keep their rooms clean and tidy by doing some tasks such as the dusting, but this was up to the resident. One resident said that she enjoyed putting her room tidy after breakfast and another said that they helped lay the tables for lunch. Residents said that they were able to do ‘what they wanted to do’ with regard to social activities and were able to join in or not as they wished. The co provider said that visitors were welcome at anytime but it was preferred they came between 10am and 10pm so that residents lives were not disturbed during the early morning and late night. Records seen indicated that some residents had frequent visits from relatives and friends. The home employs a cook and a kitchen assistant/relief cook. The co provider also assists in the preparation of meals as needed. Residents said that they had a good choice of food and they enjoyed the meals provided. During the morning the relief cook asked residents for their choice of meal for lunch and the meals provided were faggots, lamb chop or pasty with creamed potatoes, mixed vegetables or peas followed by ice cream. One resident had cheese on toast, her choice, as she was going out and would be eating a main meal later. Residents said that at supper they could chose from items such as jacket potatoes, fish fingers or burgers and there was homemade pudding or cake plus yoghurts or fruit. Elizabeth House DS0000012234.V353996.R01.S.doc Version 5.2 Page 15 Residents took their lunch in the dining room where there was plenty of room for them to sit at tables of two, three and four. The atmosphere in the dining room was relaxed and staff chatted with residents in a friendly and caring manner. Elizabeth House DS0000012234.V353996.R01.S.doc Version 5.2 Page 16 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. 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 available evidence including a visit to this service. Residents receive personal support in their preferred manner and their health care needs are being met. Residents are protected by the home’s policies and procedures for dealing with medication. EVIDENCE: Three residents said that they were able to manage their own personal care and one said that staff sometimes ‘reminded him’ when to put on clean clothes. The wishes of the residents for how they would like support with personal care was written in the care plans seen. One care plan advised staff that the resident might prefer a shower to a bath at times and both were to be offered with the resident able to chose which one they would prefer. All the residents spoken with said that the staff were caring and kind with comments of ‘the carers are friendly’, ‘the staff always have time for you’ and ‘the carers are really nice’. Records seen indicated that the residents’ health care needs were being met. One resident said that she had not felt well and staff had arranged for her to Elizabeth House DS0000012234.V353996.R01.S.doc Version 5.2 Page 17 see her GP that day. Visits to dentists, GPs and outpatient appointments were documented in the residents’ records. One resident said that the registered manager had arranged for her to be provided with an orthopaedic bed as she had backache and also for a portable fan as she felt hot at times. The registered manager who is a trained nurse said that he was responsible for the administration of medication with carers sometimes administering them under his supervision. Systems are in place for the recording of medication brought into the home and for the disposal of unwanted medicines. Medication records seen had been completed appropriately. Medicines were stored in a locked cupboard in the dining room with insulin kept in the fridge in the kitchen. It is advisable for the insulin to be stored in a plastic container. The registered manager said that currently no medication was stored in the controlled drug cupboard and no residents were responsible for their own medicines. The registered manager said that he provides the training for staff in the handling of medicines. It was recommended at the last inspection that staff receive accredited training in the safe administration of medicines to ensure they have an understanding of the effects and side effects of the medicines used in the home. The registered manager said that he has not yet arranged this training. The book providing information on medicines (BNF) was dated 2003 and a new version should be obtained to ensure up to date information is available. Elizabeth House DS0000012234.V353996.R01.S.doc Version 5.2 Page 18 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. 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 available evidence including a visit to this service. Resident’s complaints are taken seriously and acted upon quickly. The home has procedures in place for the protection of vulnerable adults but staff would benefit from training in the prevention of abuse to ensure they are aware of the procedures to follow should abuse be suspected. EVIDENCE: Residents said that they would speak with the registered manager or co provider if they had any complaints and they felt their complaints would be dealt with quickly. One resident said that ‘you only have to mention you are not happy with something and it gets sorted’. The registered manager said that no complaints had been received since the last inspection. The complaints procedures had been updated since the last inspection but needed further amendment to clearly indicate that complaints could be taken to the commission at any time and not just if they had not been satisfactorily resolved by the home. The registered manager amended the procedures during the inspectors visit. A resident said that they do not meet together to discuss life at the home because they do not want to but they do talk on a one to one basis with the registered manager, co provider or their key worker. The registered manager was aware of the procedures to follow should abuse be suspected. The procedures are available for staff and the registered manager said that staff have been told to read them but this is not followed up during Elizabeth House DS0000012234.V353996.R01.S.doc Version 5.2 Page 19 training or supervision to ensure they have understood the procedures. Staff said that they had not received training in the protection of vulnerable adults and this needs to be addressed to ensure they are aware of issues relating to the prevention of abuse. The registered manager said that some of the residents manage their finances independently while the home supports others who keep their money in a bank account run by the home. The account is run solely for the residents and records are kept of all transactions. The registered manager said that the amount of money documented in his records matched the amount stated on the bank statements and there was evidence that he was auditing the records monthly. The registered manager said that the residents used to hold their money in Post Office accounts but this was no longer possible so an account had been opened at a bank. The registered manager said that it had not been possible to open accounts individually. The registered manager was advised to seek guidance from the commissions website for professionals under the heading In Safe Keeping regarding residents’ finances. Elizabeth House DS0000012234.V353996.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements made to the environment have provided residents with a clean and comfortable home. The registered manager must reassess the risks for some residents regarding hot radiators and pipes and take action to cover hot surfaces were a risk is identified. EVIDENCE: At the time of the last inspection five requirements were issued regarding the environment including the replacing of damaged toilet seats, decorating of bedrooms damaged through a leak in the roof, replacing worn bedding and a headboard and assessing equipment used for bathing. Radiators and hot pipe work also needed risk assessing. Residents said that they liked their rooms and those seen contained many personal items including audio equipment, televisions, pictures and ornaments. Elizabeth House DS0000012234.V353996.R01.S.doc Version 5.2 Page 21 One resident said that they ‘have everything they needed’ and another said that their room felt ‘like home’. The home looked clean and areas previously noted needing attention had been addressed. The rooms that had been damaged through a leak in the roof had been redecorated and new bedding had been purchased to replace worn items. The resident whose headboard had been identified as needing replacing said that he liked the headboard and had declined the offer of a new one. The registered manager said two headboards had been purchased and the resident was offered the choice of either but would not change the old one. Damaged toilet seats had been replaced with new ones and disposable towels had been provided for communal bathrooms and toilets to reduce the risk of cross infection. The registered manager said that he had requested advice from an occupational therapist with regard to the bathing equipment but this was not possible as the occupational therapist said they were unable to visit. The registered manager said that the one bath seat that has a hydraulic mechanism had been serviced recently and that the residents do not use the other bathing equipment. The registered manager said that he would record this in the residents’ records. The registered manager had assessed the risks from radiators and hot water pipes for each resident and these assessments were seen during the visit. However the registered manager needs to reassess this for some residents such as those with epilepsy who could fall against the radiators during a seizure. At the time of the visit some of the radiators felt very hot to the touch and could be a cause for concern in the incidents indicated above. Residents have access to the communal areas of the home that includes two lounges, a large dining room, smoking room, small conservatory and the garden. The accommodation is provided in sixteen single and two shared rooms over three floors. There is no lift but a chair lift is provided for residents who have difficulty with the stairs. The basement of the home is used for staff offices, rest room, storage and the laundry. Residents do not have access to this area. Elizabeth House DS0000012234.V353996.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Robust procedures are used for the recruitment of new staff to minimise the risk to the safety of residents and staff receive regular supervision. Staff are encouraged to obtain NVQ level 2 or above but some staff have not received refresher sessions in mandatory training such as moving and handling or training in topics relevant to the residents including mental health issues and learning disabilities to provide them with the skills to fully support the residents. EVIDENCE: Residents said that they felt there were sufficient staff on duty and the registered manager said that staffing levels were flexible to allow residents to attend social activities. During the day two care staff are on duty plus the registered manager and coprovider and at night one staff member is on duty with the registered manager who lives close by on call. The home also employs the cook and relief cook. Elizabeth House DS0000012234.V353996.R01.S.doc Version 5.2 Page 23 Six of the seven carers employed hold NVQ level 2 or above, enhancing their skills in supporting the residents. One of the carers said that she had been encouraged to follow level 2 with level 3 and was considering level 4. The carer said that she received good support throughout the training course. The co provider is undertaking level 4 in care and management. At the last inspection a requirement was issued for staff not to be employed at the home until all the necessary checks had been undertaken. Records seen for two staff members who had been recruited since the last inspection contained all the information required including two written references and confirmation that a Protection of Vulnerable Adult (POVA) and Criminal Records Bureau (CRB) checks had been completed before the staff member commenced work at the home, minimising the risk to the safety of the residents. It was recommended at the last inspection that a training matrix be kept to ensure that all training in areas of safe working practice is regularly updated as required. The registered manager had a training matrix for 2006 but it had not been updated for 2007. The records indicated that staff had not received moving and handling training annually with one staff member last trained in 2004. The registered manager said that staff were booked in for refresher first aid training in January and February and three staff members were booked on person centred planning sessions early in the year. Five staff had attended training in depression during March 2007 but staff had not received training in adult protection or in topics specific to the residents including mental health issues and learning disabilities for which the home is registered. This was highlighted at the last inspection. Staff said that they received regular supervision and an annual appraisal and records seen confirmed this. Elizabeth House DS0000012234.V353996.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The views of the residents are taken into account in the running of the home. Systems are in place to ensure regular checks and maintenance of the home including fire safety equipment but the risk from hot radiators and pipe work for some residents must be reassessed and actions taken as necessary. EVIDENCE: The registered manager/provider is a trained nurse who has run the home together with his wife who is a co provider, for nearly twenty years. The registered manager holds NVQ level 4 in management. Staff said that they received very good support from the registered manager and his wife and residents also said that they were able to speak with them at Elizabeth House DS0000012234.V353996.R01.S.doc Version 5.2 Page 25 any time. During the visit it was evident that the registered manager and the co provider had a very good rapport with the residents and with staff. They were very aware of the needs of the residents and spoke with them in an easy, friendly manner. The residents said that they did not wish for monthly meetings but were able to talk on a one to one basis with the registered manager or co provider and felt able to give their opinions about life at the home. Records seen indicated that residents were asked to complete survey questionnaires regarding the quality of care provided at the home and completed surveys seen indicated that they were very satisfied with how the home was run. However the registered manager had not audited the information or documented how changes were to be made to improve the quality of care provided where needed. Staff meetings are held every two months and records of meetings seen indicated that all aspects of care at the home were discussed. A staff member said that the meetings provided a good opportunity to discuss the care provided at the home. Staff said that protective clothing such as disposable gloves and aprons were readily available to them. Records seen for maintenance of the electrical and gas systems and for the stair lift indicated that regular servicing took place. Fire records indicated that checks were made on fire safety equipment as needed and staff attended fire drills to ensure they were aware of the procedures to follow should an incident occur. As previously stated some staff require refresher training in mandatory topics such as moving and handling and risk assessments for hot surfaces need to be redone for some residents depending on their care needs. Elizabeth House DS0000012234.V353996.R01.S.doc Version 5.2 Page 26 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 3 3 x 4 3 5 3 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 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 3 3 x x 2 x Elizabeth House DS0000012234.V353996.R01.S.doc Version 5.2 Page 27 YES Are there any outstanding requirements from the last inspection? 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 YA35 Regulation 18 (1)(c) Requirement Timescale for action 30/04/08 2. YA42 13(4) The registered person must ensure staff receive the training they require to meet the needs of the residents, including the protection of vulnerable adults, mental health and learning disabilities awareness. This was a recommendation of the last report dated 10th May 2006. The registered person must 31/01/08 assess the risks for residents from hot radiators and pipe work and take actions to minimise the risks as necessary including the covering of hot surfaces. This is a partial repeat requirement of the last report dated 10th May 2006. 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 Good Practice Recommendations DS0000012234.V353996.R01.S.doc Version 5.2 Page 28 Elizabeth House Standard Elizabeth House DS0000012234.V353996.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 DS0000012234.V353996.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. 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