Inspection on 15/12/05 for Elizabeth House

This inspection was carried out on 15th December 2005.

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

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

Other inspections for this house

Elizabeth House 01/11/07

Elizabeth House 20/06/06

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 Bennett Unannounced Inspection 15th December 2005 10:00 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.V270984.R01.S.doc Version 5.0 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.V270984.R01.S.doc Version 5.0 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 Mr Philip Leicester 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.V270984.R01.S.doc Version 5.0 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. 27th April 2005 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 ensuite rooms and four shared ensuite 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. Elizabeth House DS0000062775.V270984.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unscheduled inspection took place on the 15/12/05. Time was spent talking to eight service users individually and with groups of service users. All were positive on the care they received and the sensitivity of staff. Their views are reflected throughout the report. A selection of records were examined and a tour of the premises undertaken. Interviews took place with staff and one visiting professional who said they were pleased with care delivery and the fact that the home always kept them informed of any developments. Eight service user questionnaires, three relatives and two professional questionnaires were left for completion. Only one professional’s questionnaire had been returned at the time of writing this report. This stated that they visited the home on numerous occasions and felt the home had a good working knowledge of the care needs of service users with dementia and the impact this had on other individuals in the home. What the service does well: What has improved since the last inspection? Out of fourteen requirements made at the last inspection nine had been completed with the remaining still being addressed by the proprietor and reflected in this report. Elizabeth House DS0000062775.V270984.R01.S.doc Version 5.0 Page 6 The home’s service user guide has been made into document which is easily understood by service users. The refurbishment of the home is still ongoing but has been completed sufficiently to reduce the disruption to service users. One service user said, “The home is really lovely and homely now since all the work has been completed especially the new carpets and chairs.” Staffing levels have been reviewed and improved since the last inspection. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Elizabeth House DS0000062775.V270984.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Elizabeth House DS0000062775.V270984.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,5. Service users are invited to visit prior to admission however there was a lack of information available for them to make an informed choice about what the home offers. Service users needs are assessed prior to admission and they receive a copy of their terms and conditions, which enables them to make an informed choice. EVIDENCE: The home’s service users guide and statement of purpose contained detailed information on the facilities and service available in the home. Unfortunately only the master copy was available therefore none were available for giving to prospective service users or service users in the home. Service users confirmed they were encouraged to visit the home prior to their admission. Each service users had a copy of their contract on file. Elizabeth House DS0000062775.V270984.R01.S.doc Version 5.0 Page 9 Four service user files were examined and found to have a professional assessment of their needs in order to draw up an effective care plan. Elizabeth House DS0000062775.V270984.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9,10. Outcomes for service users were positive however the health care needs of service users were not consistently recorded which might pose a risk to service users. Procedures for the storage, recording and handling of medication need to be reviewed for the protection of service users. The lack of privacy curtains in shared rooms may compromise the privacy of service users. EVIDENCE: Four care plans of service users were examined and reflected their assessed needs. Care plans gave detailed instructions to staff on care delivery. Food diaries had been completed for those service users who required nutritional screening and a record of professional visits was maintained. Aids and adaptations e.g. hoist, turntables were in place to promote service users independence. Elizabeth House DS0000062775.V270984.R01.S.doc Version 5.0 Page 11 Care delivery was not reflected in daily reports i.e. one service user needed to be seated on a pressure cushion, nothing had been written to evidence this was being provided. However at the time of this inspection a cushion was in place with the service user reporting, “Staff always ensure I have a cushion”. Errors were found in the recording of medication. Changes had been made to medication sheets, which had not been signed and dated. Medication fridge temperatures had not been recorded with medication being stored in the fridge, which was against storage recommendations. A large amount of structural and refurbishment had taken place in the home with some outstanding items affecting the privacy of service users in some areas i.e shared rooms and one communal toilet and bathroom without locks. Interviews with service users demonstrated that staff were considerate to service users needs ensuring that personal care was undertaken in private. In four instances call bells were inaccessible to service users, however pull cords were available. Interviews with service users in these rooms found they were confident that they would be able to summon help if required. The home should ensure the accessibility of the call system to ensure help can be summoned in an emergency. Four service users were interviewed regarding care delivery all were very happy with the time and consideration shown by staff. Elizabeth House DS0000062775.V270984.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,14,15. The lack of social activities for service users may result in them becoming bored and unfulfilled. Meal times were well managed which increases the interaction between service users. Service users had control over their daily lives, which increased their feeling of autonomy. EVIDENCE: The extensive refurbishment of the home has had both positive and negative impact on the home. Service users spoke about their interest in the home’s development and they had enjoyed watching the building and decoration work. The day before the inspection new carpets had been fitted throughout which they really liked. The atmosphere in the home was lively and interactive with both staff and service users. The down side had been the restriction on structured activities which now needs to be addressed with records maintained. Elizabeth House DS0000062775.V270984.R01.S.doc Version 5.0 Page 13 Several service users go out unaccompanied and others discussed a recent trip to Blackpool. One service user said, “I am going out with staff this afternoon shopping”. Different service users made this comment on a number of occasions. Service users appearance was well groomed with ladies wearing tights, jewellery and nail polish if they wished. One service user was asked what they liked about living in the home and said” I like the ease of the place, they don’t rush you and let you do things in your own time and go to bed and get up when you want.” Another service user said, “Laundry always comes back the day after and we just put it away.” Meals are served in a congenial setting with a choice of seating areas. Food served was ample in portion and nutritional with choices offered. Menus were being reviewed at the time of inspection through consultation with service users. Service users said that food was always good and a cooked breakfast was available to them if they wished. One service user said, “We can do and have what we want, we also have wine some times.” Elizabeth House DS0000062775.V270984.R01.S.doc Version 5.0 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 There was a lack of evidence that complaints made directly to the home are recorded which may indicate that complaints of service users are not taken seriously. EVIDENCE: The home has a detailed complaints procedure which service users were aware of. No record was kept by the home of any complaints made or action taken. Service users said they felt able to complain to the manager or staff and were confident that their complaints would be listened to. Elizabeth House DS0000062775.V270984.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26. The home has continued to make improvements in the environment which has enhanced the comfort for service users. The lack of privacy curtains in shared rooms may compromise the privacy of service users. Service users rooms are personalised providing a sense of belonging. EVIDENCE: Since the last inspection the home has continued with their refurbishment programme, which is still ongoing. A number of areas still require to be addressed e.g. Radiator covers had been provided in high-risk areas with risk assessments being undertaken on the remaining radiators, the replacement of which forms part of the refurbishment programme. Gardens had been landscaped, however there remains some rubble and rubbish from the building and refurbishment, which needs removal. Elizabeth House DS0000062775.V270984.R01.S.doc Version 5.0 Page 16 At the time of this inspection new carpets had been fitted throughout the downstairs areas. Service users said, “ it was very interesting watching them lay the carpet and we like it very much, makes the home warm and homely”. New chairs had also been provided in the lounges. Service users have access to four lounges one of which is a smoking lounge and a dining room. Many of the service user rooms had been personalised. There are four shared rooms with ensuite all other rooms are single ensuite. Privacy curtains need to be provided in shared rooms and a privacy lock to the upstairs bathroom. The home employs a maintenance person 35hr a week that was addressing these issues. The home was clean, tidy and odour free. Elizabeth House DS0000062775.V270984.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Staff recruitment, induction, training and supervision were not robust enough to provide adequate protection for service users. The number of staff who holds NVQ needs to be increased to ensure the care needs of service users are met. EVIDENCE: Duty rotas reflected appropriate staffing levels to meet the needs of service users at the time of inspection. Examination of staff files found that 2 staff hold NVQ3, 8 staff NVQ2 all other staff had been enrolled to undertake NVQ2. The deputy manager had completed NVQ4. The home must ensure that 50 of staff is trained in order to meet the standard fully. Additional training had been provided in dementia care, Parkinson’s disease and moving and handling. Through staff interviews and inspection of records it was identified that no staff supervision had been carried out and the induction process was not in line with Skills for Care training. Recruitment procedures in the home were not adequate in two instances Criminal Record Bureau Checks or POVA first had not been obtained prior to the commencement of employment. Elizabeth House DS0000062775.V270984.R01.S.doc Version 5.0 Page 18 Staff confirmed at interview they were encouraged to read care plans and were always given handovers at change of shift on the care needs of service users. The deputy manager works closely with them and provides on the job supervision, which now must be formalised. Service users were complimentary regarding the care staff provided. Elizabeth House DS0000062775.V270984.R01.S.doc Version 5.0 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,34,36,37, There is a lack of formal management in the home to ensure the care needs of service users are met. The lack of formal staff supervision, training and induction may pose a risk to service users. Service users finances are not safeguarded and improvements need to be made in the homes recording systems to ensure service users are adequately protected. EVIDENCE: The management of the home needs to improve; there is a lack of formal staff supervision to ensure consistency in care practices. Elizabeth House DS0000062775.V270984.R01.S.doc Version 5.0 Page 20 Examination of service users financial expenditure found that in one-instance monies had been spent on behalf of the service users without documented evidence of the consultation process. Good risk assessments had been carried out on all aspects of the home and building work while the refurbishment of the home is still ongoing. Record keeping in the home needs to be improved has mentioned previously in this report. (Standards 7,9,12,29,34,) Elizabeth House DS0000062775.V270984.R01.S.doc Version 5.0 Page 21 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 2 3 3 X 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 x X X X X X 2 2 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 X X 2 2 2 X Elizabeth House DS0000062775.V270984.R01.S.doc Version 5.0 Page 22 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 OP7OP37 Regulation 15(1) Requirement The registered person must ensure that care delivery is recorded in daily reports. Staff must also receive training on how to complete daily reports. The registered person must ensure that call bells are assessable to service users unless otherwise indicated by a risk assessment. The registered person must ensure that any changes made to medication records are signed and dated. Medication must be stored has directed by the pharmacist. Fridge temperatures must be recorded and maintained between 3-8 degrees. The registered person must ensure a planned programme of activities is developed for service users. (Timescale of 31/08/05 not met) The registered person must ensure a log of complaints is maintained together with any action taken. DS0000062775.V270984.R01.S.doc Timescale for action 31/01/06 2. OP8OP37 12(1) 31/01/06 3. OP9OP37 13(2) Sch 3 31/01/06 4. OP12 16 (2) m 31/05/06 5 OP12OP37 17(2) 31/01/06 Elizabeth House Version 5.0 Page 23 6. OP10OP24 12(4) 7. OP28OP30 OP31OP32 18(1) 8. OP37OP29 OP31OP32 19 Sch 2 9 OP31OP32 OP35OP37 17(2) Sch 4 10. OP31OP32 OP36 18(2) The registered person must ensure that privacy locks are provided on toilets and bathrooms. Privacy screens must be provided in shared rooms The registered person must ensure the number of staff who hold NVQ is increased to 50 . Staff inductions must be extended to include ongoing care practices in the home and be in line with Skills for Care guidance. (Timescale of 31/12/05 not met) The registered person must ensure that criminal records bureau checks are obtained for staff before their employment is confirmed. The registered person must ensure that the consultation process is fully recorded of any expenditure on behalf of service users. The registered person must ensure that staff supervision is carried out a minimum of six times a year. (Timescale of 31/12/05 not met) 31/01/06 31/05/06 31/01/06 31/01/06 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP1 OP25 Good Practice Recommendations The registered person should make copies of the service user guide available to service user The registered person should ensure that the refurbishment plan includes covers to remaining exposed pipe work and radiators and is completed within timescales. Any building materials left over should be removed from outside of the premises. Elizabeth House DS0000062775.V270984.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD 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 DS0000062775.V270984.R01.S.doc Version 5.0 Page 25 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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