Inspection on 17/04/07 for Elizabeth House

This inspection was carried out on 17th April 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Elizabeth House 27/02/06

Elizabeth House 16/08/05

Elizabeth House 01/02/05

Elizabeth House 26/11/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Elizabeth House Sandy Hill Werrington Stoke On Trent Staffordshire ST9 0ET Lead Inspector Sue Jordan Unannounced Inspection 17 April 2007 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 DS0000004936.V336368.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Elizabeth House DS0000004936.V336368.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elizabeth House Address Sandy Hill Werrington Stoke On Trent Staffordshire ST9 0ET 01782 304088 F/P 01782 304088 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 Philip Harold Fradley Mrs Susan Elizabeth Fradley Mr Philip Harold Fradley Care Home 28 Category(ies) of Dementia - over 65 years of age (14), Old age, registration, with number not falling within any other category (28), of places Physical disability over 65 years of age (10) Elizabeth House DS0000004936.V336368.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27/02/06 Brief Description of the Service: Elizabeth House is a Registered Care Home for 28 older people, 14 of whom may have dementia care needs and 10 of which may have a physical disability. The Home is owned by Mr and Mrs Philip Fradley, both of whom are actively involved in the running of the business. Mr Fradley is also the registered manager. The Home stands in private grounds, which provides ample car parking for visitors. The Home is situated in Werrington, in a residential area on the outskirts of Stoke-on-Trent, bordering the Staffordshire Moorlands. Internally the accommodation is of a high standard with a good standard of housekeeping throughout. It is warm, well furnished and comfortable. There is a choice of three lounges/sitting rooms of varying sizes and a separate dining room. There are twenty-eight single bedrooms, twenty-six of which have en-suite facilities. There is a safe courtyard area in the centre of the Home. The fees charged are from £344 to £388 per week. At the time of this inspection the Home was full and the manager reported having to turn people away. Elizabeth House DS0000004936.V336368.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over seven and quarter hours. This was a ‘key inspection’ and the core standards were assessed. The methodologies used were: A day of pre-inspection preparation, including scrutiny of the pre-inspection questionnaire completed and returned by the manager, and of the ten questionnaires completed by residents, nine by relatives and two by health professionals. During the visit, three residents and two care staff were interviewed. The assistant manager on duty assisted the inspection process and feedback was given to the proprietors/manager. Observations were made of staff and service user interaction and non-personal care tasks, including part of an activity session. Lunch was taken with the residents. The medication systems were examined and a tour of the environment undertaken. Four residents’ care records were checked and the records of three new staff employed since the last inspection, including recruitment and training documents. The service users financial records were also checked. This is the first inspection since February 2006. In September 2006, the Home changed their registration with the Commission for Social Care Inspection to provide accommodation and support to an additional five people. What the service does well: Any person considering moving into Elizabeth House is given assurance that the Home can meet their needs; they are assessed prior to moving in and are encouraged to visit the Home before making any decision. If the Local Authority refers a prospective resident, the manager obtains an assessment from the social worker and in all cases a member of the Home’s management assesses the person themselves. Relatives have paid tribute to the staff and management for helping new residents to settle in so well. All residents have a contract with the Home, which clearly says what they can expect to receive. Elizabeth House DS0000004936.V336368.R01.S.doc Version 5.2 Page 6 A plan of care is drawn up for each resident, which is regularly reviewed. The Home is commended by relatives, residents and the community matron for its high standard of care. The residents’ health is monitored and appropriate services accessed. This was confirmed during interviews with residents and from comments made by relatives in pre-inspection questionnaires. The residents are treated with respect and privacy is maintained. Medication systems are generally robust and the staff trained in safe administration. The food provided by the Home is varied and of a high standard. Its quality is praised by all residents spoken to and in numerous relatives’ comments cards. The Home is able to support those residents needing assistance to eat. There have been no complaints received about the service provided at Elizabeth House, either by the Commission for Social Care Inspection or the Home. There is an open culture in the Home and residents and relatives say that they would feel comfortable expressing any concerns to the staff or management. The Home’s environment is well maintained, clean and warm. All of the residents have their own bedroom and many have en-suite facilities. The residents are supported by a well-recruited, trained and supervised work force. Those staff spoken to demonstrated an enthusiasm and commitment to their work. The management team monitor the practices in the Home and gather the residents and relatives’ views regularly, making changes and improvements as required. What has improved since the last inspection? What they could do better: Elizabeth House DS0000004936.V336368.R01.S.doc Version 5.2 Page 7 Although care plans and risk assessments are developed for each resident, there are situations in which more information should be included to ensure that the staff know exactly what support is required and how to manage any risks. The manager was asked to change one area of the medication practices. Two of the residents spoken to did not seem to be aware of all the choices and options available to them. It was recommended that the manager discuss the area of choice with the staff to ensure that all of the residents are being offered the options available. The manager needs to seek advice from the fire safety officer to check that a lounge door can be kept open and to meet the latest legislation regarding individual evacuation procedures. The use of bed guards needs to be reviewed, to ensure that they are the only option available and to make certain that all risks incurred with their use are assessed. Where possible, health professional advice should be sought. The care staff should be discouraged from going in and out of the kitchen and attention given to whether it is necessary. The manager was advised to review this within the Home’s infection control policy. Robust recruitment of staff is often dependent on the actions of others, for example the speed in which people return references. The manager was advised to record all action taken. 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 DS0000004936.V336368.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Elizabeth House DS0000004936.V336368.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their families have the information needed to help them use the Home and be assured that it will be able to meet their individual needs. EVIDENCE: The Statement of Purpose and Service Users Guide are available in the lobby area of the Home. They are regularly reviewed. Four service users records were checked during this inspection. They had all moved into Elizabeth House recently. A member of the Home’s management team undertakes an assessment of the prospective resident’s needs in all cases. In the case of a referral by the Local Authority an assessment is Elizabeth House DS0000004936.V336368.R01.S.doc Version 5.2 Page 10 received from the relevant social worker. This gives the resident and/or their family confidence that the Home can meet their needs and care for them appropriately. A recommendation is made that the person undertaking the assessment signs the document. A generic risk assessment is undertaken for each resident and a manual handling assessment is also undertaken. In some cases more information is required as to how people are to be assisted with their mobility. The generic risk assessment needs to be dated, so that it is open to review. More attention is required to the overall area of risk management, to ensure that individual risks are carefully assessed and that the staff have the information required to manage those risks in a manner, which keeps the people who use the service safe. This should be kept under review. Where possible prospective residents and/or their families are encouraged to visit the Home before moving in. One of the residents spoken to during this visit said that she knew the Home because an Aunt had lived there and therefore she had made a specific choice. Another resident said that Elizabeth House had been recommended to her. Both were happy with their decision. When the resident moves into the Home, they spend time with a member of the management team, who helps to settle them in. A ‘welcome’ sheet is given to each person, which gives him or her some vital information. For example, meal times, where they can find the telephone and housekeeping arrangements. This sheet is posted in the resident’s bedroom for easy access. Comments from relatives within pre-inspection surveys included: “The people of this care home have taken good care of my step mother, helping her to settle after the difficult time of leaving her home”. “Our relative settled in far quicker than we could ever have anticipated, entirely due to the friendship and kindness offered to her by all the staff. We are very satisfied with the level of care and support she receives and have no concerns whatsoever about Elizabeth House”. Those residents paying for their own care receive and sign a contract with the Home, which stipulates the terms and conditions and clearly explains what is, and what is not, included in their fees. The Home does not provide intermediate care. Elizabeth House DS0000004936.V336368.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use these services have access to healthcare and personal care is delivered with privacy, respecting individual wishes. EVIDENCE: The care records of four residents were checked during this inspection. In all cases, a plan of care has been developed, which is reviewed on a monthly basis. A summary of this information is kept in each resident’s bedroom so that the staff have immediate access to it. It is recommended that in some cases the information be expanded to ensure that staff know exactly what support is required. For example, one of the residents only requires verbal prompting to undertake personal care, but the care plan states that this person requires the assistance of one care worker. Elizabeth House DS0000004936.V336368.R01.S.doc Version 5.2 Page 12 Two of the residents have sensory difficulties and the night staff have recently asked for guidance when giving them a drink. These details could be included in the care plan. One of the relatives commented in a survey, “I feel that the standard of care at this Home is very good and that the owners and staff really do care for the residents”. Another said: “I feel that Elizabeth House does help to meet the physical, social and spiritual needs of the residents”. The care plans show ample evidence that the residents’ health is monitored and the appropriate professionals contacted on their behalf. All of the residents have general practitioner and community matron support from a local practice. Both are complimentary about the care provided to the residents. The district nurses and National Health Service Chiropodist are also based at the same practice. The community matron commented in a pre-inspection survey, “This Home appears to be well organised due to the competency and confidence of the assistant care managers. They are both professional in their attitude to clients and health professionals, which is immediately apparent when visiting the Home. The accommodation and care is generally of a high standard”. A relative commented in a pre-inspection survey, “If my relative has been ill, they soon get the doctor, and they see to all the prescriptions and medicines, which has been a very big help to me. I feel that my relative’s health and walking has improved since moving into the Home”. One of the residents spoken to said, “If I’m poorly, I couldn’t be better looked after”. She also said that she could have a shower whenever she wanted and that she only had to pull the cord, if she required assistance when in her bedroom. Another resident said, “ If you move a limb the staff are there, at your attention”. The community matron also commented that the residents receive medical assessment in the privacy of their own bedrooms. A privacy curtain has recently been fitted into one of the toilets because the doorway opens out onto a communal area. Nearly all of the bedrooms have been fitted with locks, to which the residents can have a key if they wish. Elizabeth House DS0000004936.V336368.R01.S.doc Version 5.2 Page 13 The lunchtime administration of medication was observed. The medication systems in the Home are generally robust and the staff well trained and competent. It was noticed that some medication is being removed from the original boxes and placed, in strips, into the individual plastic containers in the main storage cupboard. The manager was advised that this practice must cease because the staff must administer medication from the original container, which has on it the pharmacist label and consequently the general practitioner’s instructions for that particular individual resident. Elizabeth House DS0000004936.V336368.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Daily lives and routines have been improved by the introduction of a more structured activities programme. Visitors are made welcome in the Home and the food provided is of a high standard, varied and nutritional. EVIDENCE: Two relatives commented within the pre-inspection surveys that more activities could be arranged. Action has been taken by the Home to address this area. Two members of staff have now been delegated to organise and provide daily activities. A different activity is planned for every afternoon and these include quizzes, bingo, mobility exercises and crafts. Elizabeth House DS0000004936.V336368.R01.S.doc Version 5.2 Page 15 One of the residents said that she loved the quizzes, whilst another said that they had painted some ceramic tiles the day before. A notice is placed in the lounge, which tells the residents what is planned for that week. Outside entertainers and a party tea are arranged to help celebrate residents’ birthdays. The senior care worker responsible for organising activities completes an individual activity sheet for each resident. Those residents not able, or choosing not to join in with the communal activities are given the opportunity of quieter one to one activities. The care worker involved in the activities during this visit was enthusiastic and managed to involve most of the residents in the room. The Community matron commented in a pre-inspection survey, “There is a pleasant, informal atmosphere in the Home. Staff seem to know the service users as individuals and treat them accordingly. There are lots of activities and visiting musicians”. A relative commented, “They have exercises and games suitable for elderly people”. All of the residents spoken to confirmed that their relatives were made welcome. Some of the residents are taken into the local community by their families. Three residents were interviewed during this inspection and all said that they could get up and go to bed when they choose. One resident said, “You can please yourself, it is home”. She was sitting in her own bedroom from choice and said that meals could also be served there if wished. Another resident said that she had had a lie-in that day. She said that the staff come round with a cup of tea at 07:00 but that sometimes she went back to sleep. One of the relatives commented in a pre-inspection survey, “Elizabeth House provides a very homely, comfortable and relaxed atmosphere, welcomes visitors and has a very caring, dedicated and committed staff”. Discussions with two residents indicated that they did not know of all the choices available. It was suggested that the proprietors discuss the area of choice with the staff and ensure that the residents are being offered the options. All three of the residents spoken to praised the quality of the food. One said, “Just like being at home”. Elizabeth House DS0000004936.V336368.R01.S.doc Version 5.2 Page 16 Ten residents completed a survey prior to the inspection and all ticked to say that they liked the food. A new cook has been employed and she confirmed a plentiful supply of fresh fruit and vegetables. Fresh fruit juice is also available. The care staff have received basic food and hygiene training and the cook has more advanced qualifications. A four weekly menu is in place, a hot meal is provided at lunchtime and the tea varies from day to day and is not always sandwiches. A water cooler has been provided for the service users. Some of the residents require assistance to eat their meals and this is provided with sensitivity. Elizabeth House DS0000004936.V336368.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is an open culture in the Home and the people using the service feel able to express their concerns. EVIDENCE: There have been no complaints to the Home or the Commission for Social Care Inspection. The complaints procedure is available and accessible to each resident. The surveys received from residents, relatives, the general practitioner and the community matron all indicated that people feel comfortable approaching the management of the Home with any concerns and confident that they would be addressed. This was also confirmed in discussions with residents during the inspection. There has been no Protection of Vulnerable Adults referrals or investigations. One of the assistant managers undertook the ‘Train the Trainer’ in Adult Abuse on 02/02/07 and is able to train staff ‘in-house’. Discussions with a staff member indicated awareness of what to do in the event of an abusive situation being suspected or identified. Elizabeth House DS0000004936.V336368.R01.S.doc Version 5.2 Page 18 The procedures protecting the residents’ finances and personal property are robust and regularly audited. Elizabeth House DS0000004936.V336368.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables the residents to live in a safe, well-maintained and comfortable environment. EVIDENCE: Elizabeth House has twenty-eight single bedrooms, twenty-six of which have en-suite facilities, three communal areas and adequate toilet, bathing and showering facilities. There is also an outside courtyard area, where the residents can sit safely. Some of the bedrooms have their own small patio area. Elizabeth House DS0000004936.V336368.R01.S.doc Version 5.2 Page 20 Since the last inspection, a smoking room has been provided, the laundry systems have been improved, the medication drug cabinet has been moved from the dining room, additional equipment has been provided in the kitchen and five new bedrooms with en-suite shower rooms have been built onto the property. They offer a high standard of accommodation. The management team monitor the cleanliness, appearance and maintenance requirements in the Home and re-decoration and refurbishment is undertaken continuously. There are plans to refurbish the kitchen. The maintenance records provide evidence that the building and the equipment within are maintained on a regular basis. A tour of the Home was undertaken and generally the environment is kept clean and warm. The manager was advised to review some of the infection control practices in the Home to assist in the prevention of cross contamination. The Home has employed designated laundry workers and claims major improvements in the quality of washing and ironing. One of the lounge doors has to be wedged open to allow the resident free access. This is a fire door and the manager was advised to seek the advice of the fire officer. A few of the residents use bed guards. The decision to use them is usually made as a result of accident analysis, when it has been established that the resident is at risk of falling out of bed. A discussion was had at this inspection regarding the use of bed guards as a last resort and the proprietors were advised to look at alternative methods of keeping people safe. In the event that bed guards are to be used, where possible, health professional advice should be sought and in all cases, comprehensive risk assessments must be completed, which include regular safety checks during the night. Elizabeth House DS0000004936.V336368.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use services and their relatives have confidence in the staff that care for them. EVIDENCE: The staff recruitment records were checked for the last three people employed in the Home. Protection of Vulnerable Adults and Criminal Records Bureau checks had been undertaken for all three and two references requested. In two cases only one reference had actually been received and one of the proprietors said that she had some difficulties in obtaining them. She was advised to record all action taken in attempting to get the references, including verbal, telephone references, if applicable, in the interim period. All staff are given a contract of employment. The management have assessed the care staff levels required and additional staff have been rostered due to the additional five service users. One relative commented, “ We have total confidence in all of the staff”. Elizabeth House DS0000004936.V336368.R01.S.doc Version 5.2 Page 22 The residents spoken to praised the staff and comments included, “The care staff are fabulous, no fault with them at all, they spoil us”, “Everybody’s very kind and helpful here” and, “The care staff are lovely, every one of them”. Two staff were interviewed and both confirmed their commitment to the Home and the residents. Nine of the twenty-one care staff have already achieved National Vocational Qualification 2 in care or above and there is a commitment to on-going training. Mandatory Health and Safety courses are organised on a rolling programme and supplementary training is provided dependent on the needs of the residents and roles of the staff. New staff receive induction training. A training package is being developed to teach the staff more about dementia and how to support people with these particular needs. Elizabeth House DS0000004936.V336368.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The management closely monitor the quality of the service and make changes and improvements where identified and required. EVIDENCE: Elizabeth House is owned by Mr and Mrs Philip Fradley, both of whom play an active role in the Home, the latter being the registered manager. There is a robust management structure within the Home, one of the two assistant managers work every day and there is always a senior care worker on duty. Elizabeth House DS0000004936.V336368.R01.S.doc Version 5.2 Page 24 The management team closely monitors the practices in the Home and there is a robust Quality Assurance system. The assistant managers monitor the well being of the residents and the practices in the Home and this information is reported to the manager. Action plans are developed, which are reviewed monthly. Questionnaires were sent out to residents, relatives and other stake holders in October 2006 and a summary of the answers are posted in the lobby area of the Home. The management also actively encourage people to participate to the Commission for Social Care Inspection process. The Home maintains robust systems and records of all residents’ finances and property. These are audited on a six monthly basis. Staff are regularly supervised and records made. Staff confirm this and their attendance at staff meetings. The community matron commented, “The senior care managers provide appropriate supervision of less experienced colleagues”. One relative commented, “According to my knowledge, the care home is efficiently organised”. The Home is well maintained and records kept. The manager has completed a generic fire risk assessment and is aware of the need to complete individual evacuation plans for each resident. Fire safety is checked and regular fire drills and training provided for all staff. The staff complete the basic Health and Safety training as well as additional advanced training, where appropriate. Elizabeth House DS0000004936.V336368.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 2 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 3 X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 4 3 X 3 Elizabeth House DS0000004936.V336368.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 13 (4) Requirement More attention is required to the area of risk management, to ensure that individual risks are carefully assessed and that the staff have the information required to manage those risks in a manner, which keeps the people who use the service safe. This should be kept under review. 2 OP9 13 (2) Staff must only administer 30/04/07 medication from the original container, which has on it the pharmacist label and consequently the general practitioner’s instructions for that particular individual resident. Timescale for action 01/06/07 Elizabeth House DS0000004936.V336368.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP3 OP7 Good Practice Recommendations It is recommended that the person undertaking the preadmission assessment sign the document. It is recommended that the care plan information be expanded to ensure that staff know exactly what support is required to meet the needs of the residents. It is recommended that the manager discuss the area of choice with the staff to ensure that all of the residents are being offered the options available. The manager is advised to seek the advice of the fire officer regarding the fire door in the lounge being open and the individual fire evacuation procedures for the residents. The registered person is recommended to pursue the varying options available for keeping safe those people at risk of falling out of bed. In the event that bed guards are to be used, where possible, health professional advice should be sought and in all cases, robust risk assessments completed, which include regular safety checks during the night. The manager is advised to review some of the infection control practices in the Home to assist in the prevention of cross contamination. The registered person is recommended to record all action taken with regard to recruitment of staff. 3 OP14 4 OP19 5 OP22 6 OP26 7 OP29 Elizabeth House DS0000004936.V336368.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 DS0000004936.V336368.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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