Inspection on 20/06/06 for Elizabeth House

This inspection was carried out on 20th June 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 01/11/07

Elizabeth House 15/12/05

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 Michelle Haller Unannounced Inspection 20th June 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 DS0000062775.V294545.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 DS0000062775.V294545.R01.S.doc Version 5.2 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.V294545.R01.S.doc Version 5.2 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. 15th December 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 en-suite rooms and four shared en-suite 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.V294545.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection visit for Elizabeth House took place over one day for a period of 7 hours and 15 minutes. The manager did not receive prior notice of this visit. The method of inspection included in depth examination of five service users files and other records concerning the support and care of these and other service users, assessment of policies, procedures and other documents concerning the running of the home, three service users, one service user representative and two members of staff were also interviewed. The interactions between service users, their representatives and staff were also observed over lunch, during organised activities and in the course of walking about the property. A tour of the private and communal areas of the building was also undertaken. The overall impression of the home is that there have been improvements relating to the environment and activities taking place in the home. What the service does well: The atmosphere in the home was lively and interactive with both service users and staff. A good standard of en-suite accommodation is provided for service users. Service users receive appropriate health care. Service users stated that they could please themselves in relation to going out and participating in activities. The home provides a choice of plentiful, varied, balanced and well prepared meals and snacks for service users to enjoy. Assessments of service users needs are obtained prior to admission and reflected for the most part in care planning. Service users reported that they felt cared for and confident in staff’s ability. Staff are employed in sufficient numbers to ensure that group activities take place at least twice each day. Elizabeth House DS0000062775.V294545.R01.S.doc Version 5.2 Page 6 What has 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.V294545.R01.S.doc Version 5.2 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.V294545.R01.S.doc Version 5.2 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 and 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The statement of purpose and service user guide is in place, but this is not freely available to service users or their representative. Therefore, potentially, some service users may be admitted without being fully aware of the facilities and services provided by the home. The home ensures they receive accurate written information about the service users physical and immediate psychological needs prior to or very soon after admission ensuring that service users can be confident that their needs can be met. EVIDENCE: The home has in place a Statement of Purpose and Service User Guide. These documents are made available on request, and are generally kept in the office. Elizabeth House DS0000062775.V294545.R01.S.doc Version 5.2 Page 9 The provider said he intended to make the publications more available by placing them in the entrance hall thereby allowing service users and visitors to freely read them as they wish, however as yet, he had not got round to doing this. Service users have not been provided with their own copy of the Guide, and the Provider said he was unaware of the requirement to provide each service user with their own copy of the Service User Guide (although this had been a requirement on previous inspections). However, following further discussion on this inspection, he said he would ensure that a copy of the guide is given to each service user for their retention. None of the service users spoken with had any recollection of seeing information about the home prior to their admission. Five service user files were checked and each contained a copy of the home terms and condition of residency. To assess this standard five service user care plans were examined. Those chosen reflected recent practice and records made concerning the admission and on going care to a cross section of service users, paying particular attention to the most recent admission and a service users with more complex physical needs. In addition an officer of the Local Authority who was visiting the home was also interviewed. Assessments were in place for all service users. These had been provided by the referring agency, and the home has also completes an additional assessment. The manager stated that service users and relatives were consulted, however there was little evidence of this. The assessment format is a proforma requiring the assessor to complete sections pertaining to activities of daily life. It was noted that information requested about the social interests of service users was not provided. The importance of this information in relation to ongoing social and psychological care, and in helping a person to settle into the home was discussed with the manager. The Local Authority officer spoken with during the visit had nothing but praise for the manner in which the home admits service users, indicating that extra care is taken to ensure the assessed needs are met. Elizabeth House DS0000062775.V294545.R01.S.doc Version 5.2 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 and 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The information contained in care plans provides information so that care-staff know what actions to take in order to promote the general health of service users, however care plans do not consistently provide information pertaining to specialist care and the social needs of service users, which could potentially leave some service users with unmet needs. The homes policy and procedures for dealing with the administration and storage of medication is safe. In the main the home ensures that care staff are able to preserve the privacy of service users at all times. EVIDENCE: In the course of this inspection five service users files were examined, along with other reports and records concerning the wellbeing and welfare of those living in the home. Elizabeth House DS0000062775.V294545.R01.S.doc Version 5.2 Page 11 Staff, service users and an officer from the local authority were also interviewed. Observations of the interaction between service users, staff and other visitors to the home were also undertaken. Information in the care plans and daily record sheets was limited and did not consistently demonstrate that all routine health care were met. Despite this there was evidence in other documents such as weight charts, letters and pressure area care charts that in general appropriate intervention is undertaken. Nursing files and discussion with the local authority worker confirmed that the home has developed effective professional relationships with nurses, general practitioners and other health and social work professionals. Service users were observed wearing glasses, hearing aids and using walking aids such as sticks and Zimmer frames, in addition specialist protective equipment such as ‘safe hips’ was applied as directed by the falls clinic. The recording of specialist health care monitoring and the response to this monitoring needs to be improved, in that the reviews of care plans did not include updates on the condition of service users. Care plans did not relate to the needs of those with specific diagnosis concerned with mental health or dementia. Furthermore the information in care plans at times lacked detail and on one occasion contained information that contradicted the instructions of health professionals. Despite these problems with records and written information, service users were content with the care provided in the home and the general impression is that appropriate health care is provided for the most part. Examination and observation of the homes practice in distributing medication demonstrate that pictures of the service users had been placed in the medication file. The home now needs to include sample signatures of all staff that administered medication to make identifying who has given out medication possible. The medication policy and guidelines were examined and provides appropriate guidance and information, however it was noted that there was noncompliance with these guidelines because the medication trolley was left unattended for a short period of time at the commencement of the inspection site visit. This matter was discussed with the manager and staff on duty. Observation and discussion with service users indicated that personal care was provided in a private, respectful and discreet manner. Privacy screen were available in all shared rooms and locks in place on all bathrooms and toilet doors. Elizabeth House DS0000062775.V294545.R01.S.doc Version 5.2 Page 12 Observation also indicated that toiletries were being stored communally, this suggested a likelihood that toiletries were being shared. The importance of service users having their own individual toiletries stored in their rooms and of their personal choice was discussed with the manager. Discussion with staff confirmed that service users receive good palliative care at Elizabeth House. Although specialist training has not been received those interviewed had covered the topic during NVQ training. Staff explained the importance of a calm environment and to direct all conversation to the service user and they stated that palliative care included one-to-one support at all times and that this meant that on occasion extra staff had been rostered to ensure that this has been provided. Elizabeth House DS0000062775.V294545.R01.S.doc Version 5.2 Page 13 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 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The provision of group social activities ensures that service users live in a stimulating and lively environment. A sense of wellbeing and continued belonging is promoted as service users are supported and enabled to maintain contact with friends, family and the local community. The dietary needs of service users are well catered for with a balanced and varied selection of food available that meets the service users tastes and choices. EVIDENCE: Discussion with service users and staff confirmed that daily group activities do occur. However, there is no formal programme to support the range of activities provided or their frequency. Elizabeth House DS0000062775.V294545.R01.S.doc Version 5.2 Page 14 The provision of activities tends to be group focused i.e. sing-a-longs, armchair exercises, dominoes, ball games etc. One carer has recently been given responsibility for developing the “social side” of the home, and whilst she has lots of enthusiasm and ideas, the Manager needs to ensure that what the home offers is linked to the social needs of the service users. A formalised programme needs to be developed which includes one to one focused activities as well as group activities, and must originate from the identified social needs of service users. The Provider has recently acquired the services of an occupational therapist that visits the home once per week (Monday) and undertakes exercises and games with service users. If this proves popular, the provider said he would extend the provision to twice weekly. During the inspection, the Inspectors observed lots of interaction between staff and service users, with singing and dancing, and dominoes played by several male service users in the afternoon. Positive relationships were evident, and the atmosphere within the home was relaxed, but lively. Service users spoken with confirmed they could choose whether to join in or not, and several choose to sit and observe the activities rather than take part. Of the 4 lounge areas, 3 have the provision of a TV and one has no TV but music is played in here and of all the lounges this was the liveliest. Service users stated that they were able to come and go as they pleased and there were no restriction on visitors to the home. Discussion with the manager demonstrated that this philosophy is to accommodate and support service users in the lifestyle choices they make. The menu is based on a four weekly rotation and indicates that service users have a choice from a variety of mostly traditional British foods. Meals included liver and onions, rag pudding, sausage and mash, braised steak, fish and cheese and onion pies and patties, in addition to home made soups, sandwiches, roasts and casseroles. The vegetable choices were not included on the menu however the manager asserted that vegetables were offered at every meal. Service users spoken with said they “enjoyed the food,’ and that “you got plenty to eat”. On the day of this inspection, the cook was on a day off, and the arrangements the Provider had in place for the cooking to be covered, did not materialise owing to some confusion between the manager and the Provider. Nevertheless, the Manager improvised by cooking the breakfast herself, and arranging for the lunchtime meal to be a “chippie dinner”. Each service user was asked what they would like from the Chippie, and arrangements were made for the meals to be delivered. Service users enjoyed this impromptu arrangement and one said “its nice to have a chippie dinner for a change”. Service users were observed to enjoy the meal, which was followed by a fruit cocktail dessert. Service users confirmed they do have a choice of food for each mealtime, and that staff would always ensure “you had something you liked”. Elizabeth House DS0000062775.V294545.R01.S.doc Version 5.2 Page 15 Drinks are served at regular intervals in the home, and a selection of squash drinks are made up and left for free access on the kitchen server in the dining room. The stock of food in the kitchen was sufficient, and the Provider has deliveries set up for bread, eggs, milk, meat etc to be delivered to the home weekly. Elizabeth House DS0000062775.V294545.R01.S.doc Version 5.2 Page 16 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 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users were confident that their views/complaints would be listened to and acted upon. Adult Protection arrangements were in place and adequate, although plans for additional training would strengthen staff awareness in this area, thereby improving protection for service users. EVIDENCE: The provider said that the home has a complaints procedure, which asks that in the first instance anyone with a complaint speak to the Manager or senior staff of the home. Information regarding contacting the CSCI is also included. However, on this site visit no evidence could be found that this procedure is displayed for visitors or service users. The provider said that normally he has this procedure on the back of the bedroom doors, however of the 7 bedrooms inspected this procedure was not in evidence. The procedure is contained in the Service User Guide, and should everyone be given a copy of the guide, this would ensure that all service users do have access to the procedure. Service users spoken with were clear they would speak to “Susan or Jean” if they had a complaint, and all expressed confidence that such a complaint would be taken seriously. Elizabeth House DS0000062775.V294545.R01.S.doc Version 5.2 Page 17 None of the service user spoken with said they had any reason to complain. The provider was asked at the last inspection to develop a system of recording complaints brought to his or the Manager’s attention. This has partially been done, in that it would be documented on a service user’s file. However, no other system is in place, which shows the nature of the complaint, and how it has been investigated. In some instances the complaint may be about the home in general rather than regarding one particular service user and as such the provider and the manager currently have no system for recording such complaints. The home has in place the Inter Agency Guidelines on the Protection of Vulnerable Adults issued by Oldham Council, and the Manager was conversant with the procedure to be followed. Only a small ratio of staff have undertaken Adult Protection training, however, the home has nominated 4 members of staff for the Protection of Vulnerable Adult (POVA) training provided by the Council. The Manager has purchased a training video about the Protection of Vulnerable Adults, which she intends to use to provide some in house training for staff. 18 of 20 staff hold their NVQ2 an element of training does cover adult protection issues. Elizabeth House DS0000062775.V294545.R01.S.doc Version 5.2 Page 18 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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean and comfortable and provides service users with a homely environment in which to live, however some issues concerning health and safety needs to be addressed, to ensure that the safety of all service users is not compromised. EVIDENCE: The home has had a lot of building work undertaken recently as it has been converted from two separate care homes into one care home. The work has been extensive and has provided for all bedrooms to have en-suite facilities, and for single bedrooms to also be 12 square metres. The communal areas, bathrooms and toilets and 7 bedrooms were inspected. Elizabeth House DS0000062775.V294545.R01.S.doc Version 5.2 Page 19 In the main the home was seen to be clean, tidy, and comfortable for service users. The provider has invested in new chairs, new carpets, a new lift, new bedding etc. A number of areas still need some attention and the Provider largely had these matters in hand – i.e. curtains are needed to the windows in the lounge (these have been measured), signage to the toilet and bathroom doors is required (he is in the process of organising this), some decoration in bedrooms (a maintenance person is due to start in a fortnight and he will have a re-decoration programme to work to), some of the bedrooms whilst adequate looked bare and would benefit from the provision of pictures etc (he was aware of this, and knew that the “finishing touches” were now required). It was identified that some matters of health and safety need to be addressed for instance bedroom 23 – the Yale lock still had the snicker device in place which meant the door could be deadlocked from the inside and not therefore the room was not accessible to staff in an emergency; the hot water to a number of sink and bath outlets exceeded 43c; 2 lounge areas and the dining area did not have the provision of a call system and the alarm in one of the lifts was not working. Locks were fitted to toilet and bathroom doors, and privacy screens in double rooms evident. Radiator covers have been fitted to most radiators and this was evidenced during the tour of the premises. The manager said risk assessments were undertaken and those at greatest risk were provided first. Despite new carpets a small number of bedrooms entered did smell. The provider and manager are mindful of the need to have a odour free home and it was suggested to the Manager that she speaks with the service users, families and care managers of the rooms which do smell to see if they would agree to a more suitable less permeable form of floor covering. Service users said they could freely move around the home and several said they enjoyed sitting outside at the front (overlooking the park) in the recent good weather. A maintenance person is due to commence within the next 14 days and will undertake a full programme of re-decoration to bedrooms. Elizabeth House DS0000062775.V294545.R01.S.doc Version 5.2 Page 20 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are employed in sufficient numbers and with the relevant skills to meet the general needs of the service users. The home operates a recruitment and selection process that promotes the safety of service users. Over 50 of the staff group are trained to NVQ2, which provides service users with a skilled workforce. EVIDENCE: The standards concerning staffing were inspected through interviewing two members of staff, observation of staff interaction with services users, examination of the contents of four staff files and scrutiny of the duty roster. On the day of this site visit there were 28 service users residing in the home. The manager stated that there were four carers and one domestic on staff, and as the cook was unexpectedly, off duty, she was prepared to cook lunch. There was some confusion in relation to the duty roster as this indicated that the cook’s absence had been planned for and that one of the care staff had been identified as the cook for the day. Neither the manager nor the designated care staff were aware of this. It transpired that both the manager and registered provider took charge of updating the duty rosters and there had been a break down in communication. Elizabeth House DS0000062775.V294545.R01.S.doc Version 5.2 Page 21 Examination of the roster indicated that there were usually four care-assistants a cook, domestic staff and the manager on duty. Staff also stated that the registered provider also worked in the home on a daily basis. This staff ratio promotes a caring and supportive and atmosphere in the home. The provider stated and certificates confirmed that in the last 12 months staff have completed training courses including manual handling, dementia care, infection control; Falls prevention, Food Hygiene, Parkinson’s update; Optical care; First Aid, Fire safety; Challenging Behaviour and Pressure Ulcer awareness. 18 of the 20 staff employed have achieved National Vocational Qualification (NVQ) in care levels 2 and the cook is a trained chef. The manager plans to introduce a program of in-house training concerning caring for the confused and adult protection. The manager needs to develop a training matrix so that she can readily identify the training required by staff, she should also ensure the provision of approved adult protection training, training concerning activities for those in residential homes and training relating specific to the health needs of those in their care. Four staff files were examined and it was noted that a Criminal Record Bureaux (CRB) checks, two references and proof of identification was in place for each. A record of induction was also on the file of the most recent recruit. Staff who were interviewed were very complimentary about the home and the management style, they felt that service users could have do what ever they liked. Service users spoken to supported this saying, “you can do what you want here” and “I go for a walk round and no one stops me”. Service users spoken to said staff “are good, nice girls they are” Staff felt that they were given every encouragement and support to provide a good service. Elizabeth House DS0000062775.V294545.R01.S.doc Version 5.2 Page 22 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 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Satisfactory arrangements were in place for the safekeeping of service users monies ensuring that service users are protected from financial abuse. Service users have no formal means of influencing how the home is run, which means that their views and thoughts on how they live are not seen to be heard or acted upon. Health and Safety arrangements in respect of maintaining equipment were in place promoting the welfare of service users and staff. Elizabeth House DS0000062775.V294545.R01.S.doc Version 5.2 Page 23 EVIDENCE: The manager has successfully completed the registered managers interview with the Commission for Social care Inspection. Certification demonstrated that she keeps herself updated by attending training courses. The manager is part way through the Registered Managers Award and it is envisage that this will enhance her management skills. The home currently holds money for just 10 service users. This is money paid by the Council (Personal allowance) to the home weekly for service users to spend as they wish. Transactions show that service users generally spend their money on items such as cigarettes, hairdressing, underwear and sweets. The manager clearly records the amount in, amount out, and what for, and the balance and she signs to confirm the transaction. However, there is very little evidence (from the service user) on the record sheets confirming the transactions. Some of this may be due to incapacity of the service user (dementia) and the signing of monies would be meaningless. Monies are not held on site. Service users spoken with confirmed they received their cigarettes, and had their hair done, and none expressed any dissatisfaction with the arrangements in place. The manager said that recently Oldham Council have offered to manage this money for the home, and that all monies would be held by the Council with the home requesting money on behalf of service users as and when needed. No formal quality assurance system is in place. Discussion with the provider and the manager identified that they did undertake (in 2003) an independent survey of the service user views and relatives/visitors views of the home but there was no evidence that this has been conducted since 2003. There are no other formal methods of receiving such feedback in place within the home. The provider confirmed that he does ensure that all equipment and services within the home receive the servicing required, however, certificates supporting this were not available on this site visit, but were sent to CSCI following the visit. Of other records held on site, some were not up to date i.e. the fire log record, and the records in respect of the fridge/freezer and cleaning records for the kitchen. Elizabeth House DS0000062775.V294545.R01.S.doc Version 5.2 Page 24 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 1 3 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 X X 3 Elizabeth House DS0000062775.V294545.R01.S.doc Version 5.2 Page 25 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 OP1 Regulation 5 Requirement The registered person must ensure that the service user is provided with his or her own copy of the Service User Guide. The registered person must ensure that all items concerning personal care are used exclusively by one person in accordance with prevention of infection guidelines and to demonstrate that service users can exercise choice in this area. The registered person must ensure a planned programme of activities is developed for service users. (Timescale of 31/05/06 not met) The registered person must ensure that care delivery is recorded in care plans in sufficient detail. Staff must also receive training on how to complete daily reports. (Timescale of 31/01/06 not met) The registered person must ensure that the hot water is delivered at a temperature not exceeding 43c. DS0000062775.V294545.R01.S.doc Timescale for action 01/10/06 2. OP10 12 & 13 01/08/06 3. OP12 16 (2) m 01/09/06 4. OP7 15(1) 01/09/06 5. OP25 23 01/08/06 Elizabeth House Version 5.2 Page 26 6. OP37 7. OP9 8. OP12 9. OP30 10. OP18 The registered person must ensure that call bells are assessable to service users in all areas of the home. (Timescale 31/01/06 not met) 13(2)3 The registered person must ensure that staff follow the medication guidelines at all times. (Timescale 31/01/06 not met) 17(2) The registered person must ensure a system for recording complaints is maintained together with any action taken. (Timescale 31/01/06 not met) 18 ( c ) (i) The registered person must ensure that staff receive specialist training that is relevant to the Registration categories and the needs of service users living in the home e.g. dementia and mental disorder. 13 (6) The registered person must ensure that all staff receive training in the protection of vulnerable adults. 12(1) 01/09/06 01/08/06 01/09/06 01/10/06 01/08/06 Elizabeth House DS0000062775.V294545.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 3 Refer to Standard OP18 OP24 OP22 Good Practice Recommendations The manager speak to Oldham Council regarding them taking over the management of service user monies. The registered person must ensure that bedrooms are homely in accordance with the taste of the service user. The registered person must ensure that the independence of service users is promoted by providing appropriate signage to the toilet and bathroom doors. Elizabeth House DS0000062775.V294545.R01.S.doc Version 5.2 Page 28 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.V294545.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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