Inspection on 20/02/06 for Elizabeth House

This inspection was carried out on 20th February 2006.

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

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

Other inspections for this house

Elizabeth House 31/07/07

Elizabeth House 26/09/06

Elizabeth House 30/08/05

Elizabeth House 14/02/05

Elizabeth House 09/08/04

Elizabeth House 10/02/04

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

CARE HOMES FOR OLDER PEOPLE Elizabeth House Elizabeth Grove Union Road Shirley Solihull B90 3BX Lead Inspector Kulwant Ghuman Unannounced Inspection 20th February 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Elizabeth House DS0000004507.V284206.R01.S.doc Version 5.1 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 DS0000004507.V284206.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Elizabeth House Address Elizabeth Grove Union Road Shirley Solihull B90 3BX 0121 744 2753 0121 744 2753 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) Shirley Old People`s Welfare Committee Mrs Ann Baker Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Elizabeth House DS0000004507.V284206.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th August 2005 Brief Description of the Service: Elizabeth House is a registered care home catering for 19 older men and women aged 65 and over. A committee of a voluntary organisation is responsible for the home. The main criterion for admission is that the prospective resident should be able to walk with or without a walking aid but without the need for physical assistance from another person. The home has three lounges, a dining room and gardens at the front and rear of the building. Bedrooms are located on the ground and first floors. The kitchen, laundry and office are located on the ground floor. It is located in a pleasant cul-de-sac in Shirley, Solihull, which is conveniently close to the main Shirley shopping centre, with amenities such as places of worship, places for socialising and public transport. Elizabeth House DS0000004507.V284206.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out on an unannounced basis by one inspector on 20th February 2006. This was the second of the statutory visits for the home for 2005/6. To gain an overview of the standards assessed this report should be read in conjunction with the report of the inspection of 30th August 2005. During the inspection a partial tour of the building was undertaken, some care and health and safety documents were sampled. The manager was spoken with along with two visitors and 8 residents. What the service does well: What has improved since the last inspection? What they could do better: The manager needed to ensure that care plans were comprehensive and there were strategies for managing any identified risks. The risk assessments Elizabeth House DS0000004507.V284206.R01.S.doc Version 5.1 Page 6 needed to be cross referenced to the care plans. Audits of staff administering medicines needed to be carried out and there needed to be receipts for all purchases of goods and services on behalf of residents. There needed to be records for any monies raised through fund raising for the residents. 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 DS0000004507.V284206.R01.S.doc Version 5.1 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 DS0000004507.V284206.R01.S.doc Version 5.1 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 There was suitable information available for prospective residents about the facilities and services in the home enabling an informed decision about admissions to be made. Copies of terms and conditions were given to residents on admission. EVIDENCE: There was a statement of purpose available in the home, which had been amended since the last inspection providing information for residents to enable them to make informed choices about whether to move into the home. There were copies of the terms and conditions of residence on the files sampled. The inspector was informed that there had been no new admissions to the home since the last inspection although it was difficult for the manager to remember exactly. Elizabeth House DS0000004507.V284206.R01.S.doc Version 5.1 Page 9 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 There were care plans and risk assessments in place but improvements were needed in them to enable the staff to adequately meet the residents’ needs in a consistent manner and so that risks could be minimised and managed through identified strategies. The management of medicines was generally good. EVIDENCE: The files of two residents’ were sampled. The care plans on both of the files needed further development. The care plans identified that both residents needed assistance form the care staff but did not clarify what assistance was required. The care plans needed to ensure that all areas of need were identified and included details of how these were to be met. The inspector was informed that the home was developing new formats for the care plans but these were with the assistant manager. Care plans needed to be reviewed on a monthly basis and any changes incorporated into the care plans. There were risk assessments in place that identified the risks but did not indicate how these risks were to be managed. Elizabeth House DS0000004507.V284206.R01.S.doc Version 5.1 Page 10 For example, one resident was prone to falls and to exhibit aggression however, the management strategies were not identified. These needed to be put in place so that staff could manage them in a consistent manner. The risk assessments needed to be cross-referenced to the care plans. There needed to be a manual handling assessment in place for each resident detailing how they were to be assisted by staff to transfer from chair to bed and so on and how staff were to assist a resident from the floor following a fall if they were not injured. Staff should not be lifting residents off the floor manually as indicated in the daily recordings. There was evidence that the residents’ health care needs were being met via the involvement of health professionals including district nurses, chiropodists, dentists, opticians, GP’s and the local hospitals. The district nurses were involved in nursing tasks such as dressing pressure areas. The inspector noted that care staff was undertaking dressings to pressure areas on a regular basis. The home was registered to provide residential care and needed to be sure that they were not providing nursing care. Not all residents were being weighed on a regular basis making it difficult to monitor whether their nutritional needs were being met. Where it was difficult to weigh residents the home needed to seek advice about how to monitor weights until such time that appropriate scales were obtained. The home used a monitored dosage system for the majority of medicines. Medicines were booked in and copies of prescriptions were kept. There were photographs of the residents with the MAR charts. All staff administering medicines had undertaken accredited training. No gaps were seen in the MAR charts however on a random checking of boxed medicines some discrepancies were noted. It appeared from the records that on occasions residents were given too many tablets and that staff had not checked that residents were taking paracetemol before giving some from the homely remedies stock. It was advised that the manager undertake staff audits on a regular basis to identify where any problems may arise. The manager needed to ensure that there were instructions for staff detailing when medicines prescribed for use ‘as and when necessary’ (PRN) were to be given to residents. Residents were treated with respect and their right to privacy was being upheld. Elizabeth House DS0000004507.V284206.R01.S.doc Version 5.1 Page 11 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, 13, 14, 15 Residents led a comfortable and fulfilled life maintaining contact with their families. Residents and relatives commented on the good quality of food provided. EVIDENCE: The Friends of Elizabeth House were involved in organising several activities in the home. There was a programme of activities organised for each day and these included art classes, dominoes, quizzes and live entertainment in the home. The inspector was able to speak to some residents in the art class and saw some of their work on display. Visitors to the home confirmed that they were able to visit the home whenever they wanted and were made comfortable when they came. Visitors were seen to come and go during the day. There was a visit from the local priest on a regular basis. Residents and visitors confirmed that the food provided in the home was good and home cooked. Food records examined showed that the meals were varied and the inspector was informed that alternatives would be provided if a resident asked for Elizabeth House DS0000004507.V284206.R01.S.doc Version 5.1 Page 12 something different however, the residents liked what was being provided. The records seen indicated that all the residents ate the same food. There was one resident who required food to be pureed but this was not identified on the food records. Residents were able to have visitors when they wanted, could sit anywhere in the lounges or their bedrooms. They were able to make choices about the clothes they wore and when to get up and go to bed. Elizabeth House DS0000004507.V284206.R01.S.doc Version 5.1 Page 13 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 Complaints were being appropriately responded to by the home. EVIDENCE: The complaints procedure on display in the home did not include timescales within which a complainant would be responded to and did not make it clear that a complaint could be made to the CSCI at any time. Visitors stated that any issues raised with the home were dealt with. The home had recorded two complaints made by residents in the home. The complaints were appropriately responded to. No complaints had been received directly by the CSCI since the last inspection. Elizabeth House DS0000004507.V284206.R01.S.doc Version 5.1 Page 14 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): 19, 22, 25, 26 The premises were clean and well maintained providing very comfortable communal and private accommodation for the residents, which was suited to their needs. Bathing and toilet facilities with specialist equipment were provided suited to meet the needs of the residents. EVIDENCE: The premises were well maintained, warm and clean. The lounges and dining rooms were pleasantly furnished and comfortable for the residents. There were no odours in the home. The home was accessible to residents throughout with bathing facilities available on both floors. There were adaptations in place to assist residents with mobility difficulties, a call system was in place, and there were raised toilet seats and grab rails available. There were pressure mattresses and pressure cushions in use for residents at risk of developing pressure sores. Elizabeth House DS0000004507.V284206.R01.S.doc Version 5.1 Page 15 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 Staffing levels and competencies were such that the needs of the residents could be safely met. The recruitment process was generally well managed but the records needed to support the process. EVIDENCE: There were 3 care assistants on duty throughout the day in addition to the manager. Additional staff were on duty to undertake cleaning and cooking duties. During the night there were two members of staff on duty. There was a stable staff team that provided continuity of care for the residents. Two staff files were sampled, one for a member of the care staff and the other for an ancillary worker. There were application forms, CRB clearance and references available on the files. It was not possible to evidence from the files that POVA checks were undertaken before all staff were allowed to work in the home. The manager also needed to ensure that any discrepancies in work histories were queried with the member of staff and a record maintained. The majority of the staff had undertaken NVQ level 2 training and ongoing mandatory training was provided. Staff were undertaking the appropriate induction training. Elizabeth House DS0000004507.V284206.R01.S.doc Version 5.1 Page 16 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, 33, 35, 36, 38 The manager ensured the smooth running of the home in a competent manner. The health and safety of the residents and staff was generally well managed. EVIDENCE: The manager had worked at the home for several years and was undertaking the Registered Managers Award. The home was managed so that care of the residents was a priority. The home was not registered for residents with dementia or specific mental health needs but several residents were showing signs of forgetfulness as part of the ageing process. The manager needed to ensure that the recruitment records were complete before staff took up employment and that the records identified during the inspection was put into place. Elizabeth House DS0000004507.V284206.R01.S.doc Version 5.1 Page 17 During the inspection it was noted that a resident was late in having a bath but the resident had been kept informed of the reasons for this and was satisfied with the reasons, also another resident tripped and sustained a facial injury. The home managed this incident in a calm and professional manner. The home had not yet reached the required level of supervision for the staff but was working towards reaching the targets. The home has not yet got a working quality assurance system in place but is working towards this. The records for monies being looked after by the home were examined. All balances checked were correct. The manager needed to ensure that there were receipts in place for all purchases made on behalf of the residents and for all services provided to them including hair dressing and chiropody. The manager needed to ensure that there were records of monies raised for the use of residents and clarity about what these funds were to be used for. Funds were being raised for the provision of a conservatory for the residents’ use. It was advised that separate records were maintained for this fund raising activity. Health and safety were well managed in the home with servicing documents available to ensure that all equipment was being maintained in good working order. Fire checks were being undertaken on a regular basis, unfortunately there was no record that the fire alarms had been checked since the 31st January 2006. Elizabeth House DS0000004507.V284206.R01.S.doc Version 5.1 Page 18 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X 3 X X 3 X X 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 2 X 2 Elizabeth House DS0000004507.V284206.R01.S.doc Version 5.1 Page 19 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 OP3 Regulation 14(1)(b) Timescale for action A copy of the assessment carried 01/06/06 out by the placing authority must be obtained by the home prior to admission of a resident to the home. Previous timescale given 15/10/05. Compliance not assessed at this inspection as no placements had been made. 01/05/06 The residents’ care plans must identify all their care needs and how they are to be met by the staff. All risk assessments must have strategies to manage them and be cross-referenced to the care plans. Care plans must be reviewed on a monthly basis. All residents must have a manual 01/05/06 handling assessment in place that shows how staff must assist them and how staff must assist residents off the floor if they are uninjured. Arrangements must be made to 01/04/06 enable the weights of residents DS0000004507.V284206.R01.S.doc Version 5.1 Page 20 Requirement 2. OP7 15(1) 3. OP7 13(5) 4. OP8 12(1)(a) Elizabeth House 5. OP9 13(2) to be monitored regularly. Previous timescale of 01/11/05 not met. The manager must ensure that medicines are administered to residents according to the prescribing instructions. The manager must carry out audits of staff administration of medicines to ensure that residents receive the correct amounts. The manager must ensure that there are instructions for staff detailing when PRN medicines are to be given. Staff must check that residents have not taken prescribed medicines containing paracetemol before paracetemol is given from the homely remedies supply. The record of food must indicate any special diets being provided. The complaints procedure on display in the home must include the timescales for response and indicate that a complaint can be referred to the CSCI at any point in the procedure. All recruitment checks must be in place before employees take up employment. Previous timescale of 01/10/05 not met. The manager must ensure that any discrepancies in the records are checked and responses recorded. The manager must ensure that they achieve the Registered Managers Award. The manager must ensure an effective quality assurance and DS0000004507.V284206.R01.S.doc 15/03/06 6. 7. OP15 OP16 17(2) Sch4(13) 22(1) 01/04/06 01/04/06 8. OP29 19 Sch 2 01/04/06 9. 10. OP31 OP33 18(1)(a) 35(a, b) 01/06/06 01/04/06 Page 21 Elizabeth House Version 5.1 11. OP35 17(2) Sch4(9a) quality monitoring system is implemented within the home to measure the aims, objectives and statement of purpose of the home. Previous timescale of 01/01/06 partly met. The manager must ensure that there are receipts available for all purchases of goods and services made on behalf of residents. There must be records of all monies donated to the home and any funds raised to provide extras for the residents. Staff must receive a minimum of 6 supervision sessions a year. Previous timescale of 01/04/06 not yet elapsed. Fire alarms must be tested on a weekly basis and records kept. Previous timescale of 31/08/05 not met. The registered manager must ensure that kitchen staff label and date all decanted food packets stored in the pantry or freezer. Not assessed for compliance at this inspection and carried forward. Previous timescale given 01/10/05. 01/04/06 12. OP36 18(2) 01/04/06 13. OP38 16(2)(j) 21/02/06 14. OP38 16(2)(j) 01/03/06 Elizabeth House DS0000004507.V284206.R01.S.doc Version 5.1 Page 22 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 OP35 Good Practice Recommendations A record should be made of the assessment carried out by the home at the pre-admission visit. A separate record should be maintained of the monies raised to provide a conservatory. Elizabeth House DS0000004507.V284206.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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. 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