Inspection on 20/11/06 for Elizabeth House

This inspection was carried out on 20th November 2006.

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 21/04/09

Elizabeth House 12/01/09

Elizabeth House 09/06/08

Elizabeth House 25/10/05

Elizabeth House 25/05/05

Elizabeth House 15/03/05

Elizabeth House 31/08/04

Elizabeth House 12/02/04

Similar services:

Applegarth

Trevayler Residential Care Home

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

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

CARE HOMES FOR OLDER PEOPLE Elizabeth House Perth Avenue New Parks Estate Leicester Leicestershire LE3 6QR Lead Inspector Rajshree Mistry Unannounced Inspection 20th November 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 DS0000037621.V319496.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 DS0000037621.V319496.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elizabeth House Address Perth Avenue New Parks Estate Leicester Leicestershire LE3 6QR 0116 2871031 0116 2871031 socis218@leicester.gov.uk socis209@leicester.gov.uk Leicester City Council 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 John O`Dell Care Home 37 Category(ies) of Dementia - over 65 years of age (20), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (20), Old age, not falling within any other category (37), Physical disability over 65 years of age (8), Sensory Impairment over 65 years of age (10) Elizabeth House DS0000037621.V319496.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service User Numbers DE(E) & MD(E) No one falling within category DE(E) or MD(E) may be admitted into Elizabeth House when 20 persons who fall within categories/combined categories DE(E) or MD(E) are already accommodated within the home Service User Numbers PD(E) No one falling within category PD(E) may be admitted into Elizabeth House when there are 8 persons of category PD(E) already accommodated within the home Service User Numbers SI(E) No one falling within the category SI(E) may be admitted into Elizabeth House where there are 10 persons of category SI(E) already accommodated within the home 25th October 2005 2. 3. Date of last inspection Brief Description of the Service: Elizabeth House Residential Home provides accommodation for thirty-seven older people and is owned by the Adult and Community Services Department, Leicester City Council. The home is located in a quiet residential area. Public transport service can be accessed near to the home. The home is ten minutes car ride from the city centre, Fosse Park and the M1 motorway. Elizabeth House is a large modern and purpose built property. Accommodation is offered on ground and first floor level, which can be accessed by a passenger lift. Bath/shower and toilet facilities are located throughout the home. Car parking space is located to the front of the home. There is a large patio area to the centre of the building. All areas of the home are accessible to people using mobility support, aids and equipment. Information is located on site detailing the range of services offered, which includes the Statement of Purpose. Elizabeth House has copies of the Commission of Social Care Inspections (CSCI), Inspection Reports, are located in the foyer along with the displayed registration certificate. The residents are informed of the findings of the CSCI inspection at the ‘Residents Meetings’ or individually. The maximum weekly fee is £373, and confirmed on the day of the inspection. There are additional individual expenditure such as hairdresser, chiropodist, newspapers, magazines and personal toiletries and the fee will depend on the services received. Elizabeth House DS0000037621.V319496.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) inspected the Elizabeth House using the method ‘Inspecting For Better Lives’, which is based on outcomes for the residents. The inspection process consisted of pre-planning the inspection, reviewing the last inspection report and the reviewing of the Pre-Inspection Questionnaire and Comment Cards/Surveys distributed to residents and General Practitioners by the CSCI along with the reviewing of significant events. Ten Comment Cards were sent out to residents, and three to a General Practitioner. The unannounced site visit commenced on the 20th November 2006 and lasted 1 day. The focus of the inspection is based upon the outcomes for the residents. The method of inspection was ‘case tracking’. This involved identifying residents with varying levels of care needs and looking at how these are being met by the staff at Elizabeth House. Four residents were selected and discussions were held with three of them and the relative of one resident to ascertain their views about the care provided. The method of case tracking included the review of residents’ individual care records, discussions with staff of various delegated responsibilities within the home and reviewing the records, training records and the minutes of residents and team meetings. A 50 of Comment Cards were received. The majority of the comments received were complimentary about the care. Comments incorporated within Service User Comment Cards included: I’m very happy here I find wallpaper in room drab and depressing and some at the sides of the windows is peeling off. This has been mentioned at reviews and inspections without any action. Comments received from the General Practitioners indicated that they are well informed; staff demonstrated a clear understanding of care needs of residents, managed medication appropriately and no had complaints. Overall, the General Practitioners were satisfied with the care provided to the residents in the home. What the service does well: Residents are involved in the planning of the care to meet their individual care needs. All the residents have a named care staff known as a ‘key worker’ who is responsible for making sure all aspects of their care, living arrangements are Elizabeth House DS0000037621.V319496.R01.S.doc Version 5.2 Page 6 accommodated and personal toiletries are available. Residents receive a variety of good meals including special diets. Residents live in a well maintained home that is clean and homely. Visitors are welcome at the home at any time. Residents’ benefit from a group of staff that are well trained, a large proportion of which having attained a National Vocational Qualification in Care. In addition, staff receive training in a variety of health and safety topics as well as training involving specific types of care such as Dementia and Activities for Older People. The home is well managed by the management team who have specific areas of responsibility. 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. The summary of this inspection report can be made available in other formats on request. Elizabeth House DS0000037621.V319496.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 DS0000037621.V319496.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. Standard 6 is not applicable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents care needs are well assessed before they move into the home to ensure their needs can be met. EVIDENCE: Since the last inspection, the statement of purpose has been revised to reflect the departmental changes in the Leicester City Council and is now known as Adult and Community Services Department. The document sets out the details of the type of care that will be provided at the home, the experience and training of the management team and staff, the aims and objectives of the home, the key policies, procedures and the complaints procedure, indicating the management and guidance followed. The information is in an easy to read style. Elizabeth House DS0000037621.V319496.R01.S.doc Version 5.2 Page 9 The admission procedure was explored for the four residents tracked, including two new residents, of which one was a planned admission and the other an emergency admission. All care files contained a copy of the social worker’s assessment of needs undertaken as part of the referral process. The assessment form contained written information of the residents care needs, history such as medication, mobility, special diets and meals, communication needs, mental wellbeing and social, religious and cultural needs. The assessment also included details of any health care needs to be met by heath care professionals such as the District Nurse. Residents said they were involved in choosing the home and the admission process to ensure their wishes were made known. The new resident said that the family visited the home to ensure that it was suitable and confident that they would be well cared for. The resident admitted to the home in an emergency said they and their relatives were fully informed before and during the admission process about the home and the provision of care. Staff said they were informed of new residents and significant events affecting residents at the handover meetings. The home does not provide intermediate care. Elizabeth House DS0000037621.V319496.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are well cared for having their tailored health and daily care needs met to promote and support their choice of lifestyle. EVIDENCE: The care plans and records of four residents, which included one new resident and another admitted in an emergency, were viewed. The care plans were generally well written and were presented to a good standard. The care plan developed by the social worker was used for the resident admitted in an emergency, in the first instance. The care plans seen were personal to the residents, setting out the level of assistance required. Care plans detailed information as to residents’ health care needs, daily living arrangements, which outline residents, preferred daily routine and the impact of cognitive skills such as dementia, on the individual. Care plans gave information in relation to identified risks and how these should be minimised. Elizabeth House DS0000037621.V319496.R01.S.doc Version 5.2 Page 11 All the care files viewed contained good evidence of the involvement of General Practitioners, District Nurses, Chiropodists and Community Psychiatric Nurses. Residents described how their care staff supports them with daily tasks. All residents have a named care staff known, as a ‘key-worker’ to support their care needs, daily routines and keeping their bedroom and clothes tidy. Care records showed the key workers carried out review of the care needs with the resident on a monthly basis, which is recorded. The information received from the residents and care staff spoken with was consistent with the records made in the residents care file. Key worker demonstrated a good understanding the residents care needs and their responsibilities. The Inspector spoke with relatives who were visiting at the time of the inspection, who confirmed that the staff were helpful, always available, polite and that they had no concerns. Residents said that the care staff have called the General Practitioner’s when needed. Relatives spoken with said they have been contacted when their relative needed emergency medical attention. Comments received included: “involved in planning and . . . . knows how I like things done” and “the staff are very good, . . . got to my know my preferences by observations mainly and would ask me if they were unsure”. Observations made during the inspection showed care staff are vigilant to the residents needs and responding to call bells promptly. The Inspector saw residents being assisted to their bedroom or to the toilet when requested. Care staff were seen addressing residents by their preferred names, being near to residents when speaking with them and enjoying conversation. Residents said they received their medication on time. Trained senior carers and the manager administer medication. At lunchtime, the senior carer was seen giving medication to residents individually and completing each record. The medication checked against the medication records for three residents indicated medication and records were correct and up to date. All medication and respective records are checked monthly. Elizabeth House DS0000037621.V319496.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents continue to make choices about daily living and offered variety of balanced meals and some social and cultural activities of interests. EVIDENCE: The residents have a choice of lounges on the ground and first floor, which includes a smoking lounge. Residents were seen receiving visitors throughout the day. Residents care plans viewed showed the involvement from family such as going to Bingo on a Wednesday, receiving daily newspaper, watching quizzes and game shows, reading books or going out with family. The care plans showed the resident’s cultural needs and special diets such as diabetic, soft or vegetarian meals, required. Residents were aware of their right to look at their care file at any time. A resident said they were from the Methodist church and staff had arranged to have their religious needs met. The Registered Manager said contact had been made with the newly appointed minister at the local church to arrange Holy Communion for those residents who had made a request. Visiting relatives and Elizabeth House DS0000037621.V319496.R01.S.doc Version 5.2 Page 13 friends spoken with said they visit frequently; enjoyed spending time with their relative; and felt there was no restrictions on the visiting times. Residents were observed reading the newspapers, watching television in the lounges or had retired to their own rooms. Information received from the home before the inspection indicated that residents are offered a range of social activities such as: games, cards, barge trips and outings, entertainers, bingo and film nights. Care staff are responsible for doing activities that would stimulate the residents, albeit one-to-one activity or small group activities as there is no designated activities organiser. Two staff recently had training in ‘activities for older people’. The Registered Manager said there were no plans to have designated ‘activities organiser’. There was a Christmas Raffle organised to raise money towards the residents’ fund. Residents were aware of the events planned for Christmas such as the party and the carol singers. Daily records evidenced the choices made by residents, examples of which being their choice as to whether they participate in such as Bingo, where they wished to eat their meals and whether or not to have a bath or shower. Residents’ spoken with said they are not restricted with the timing of their day such as, the time for breakfast, how they chose to spend the day to what time they go to bed. Care staff were aware of residents preferences and routines. Residents’ described how care staff helps them maintain their independence, and comments received “let me wash my top half and they help me with the lower part”. All residents spoken with said how much they enjoy the food. Meals were observed being served at the dining tables. The majority of residents enjoyed a choice of meatloaf or turkey with vegetables and a choice of deserts. The cook was seen preparing sandwiches for residents who preferred a lighter snack. The Inspector observed how residents were supported to maintain their own independence by having specially adapted cutlery and plate guards. Elizabeth House DS0000037621.V319496.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by a robust and accessible complaints procedure and by staff trained in safe guarding adult processes. EVIDENCE: Residents and their relatives said they were informed of how to complain when they first visit the home. Details of how to complain are displayed on the notice board near the entrance to the home and by the public telephone. The complaints procedure is available in other languages, symbols and formats. Advocacy Services contact details are listed with the complaints procedure. Residents said they felt confident to complain directly or through their relatives, to a member of staff or the managers. The new resident said after mentioning that the pillows were uncomfortable, alternative pillows were provided promptly without having to make a complaint. The complaints log viewed showed one complaint received was investigated through the home’s procedure and concluded satisfactorily. The Commission for Social Care Inspection has not received any expressions of concern regarding Elizabeth House. The Registered Manager demonstrated that actions had been taken to address practice and recording issues found following a safeguarding adult investigation. Elizabeth House DS0000037621.V319496.R01.S.doc Version 5.2 Page 15 Elizabeth House has received compliments and commendations in the form of cards, letters and formal notification through the social work teams. Records of the compliments received are kept in a log although dates of when these were received are not maintained. Care staff and seniors spoken with had a good understanding of their responsibility and procedures to follow in relation to safeguarding adults and were confident to whistle blow on poor or bad care practices. Staff files examined contained evidence to show that staff have received training in safe guarding adults as part of the home’s induction training, and as part of attaining a National Vocational Qualification (NVQ) in Care. Elizabeth House DS0000037621.V319496.R01.S.doc Version 5.2 Page 16 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, 20, 24 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents’ generally benefit from having a clean, safe and maintained accommodation, which individually and collectively meets the residents’ needs. EVIDENCE: Elizabeth House is well maintained, decorated and furnished to a good standard, providing a comfortable and homely environment. The corridors throughout the home are brightly lit with handrails to help residents walking independently. The environmental improvements taken place since the last inspection, which includes the installation of the new front entrance with automatic doors and all the double-glazing to the external windows and doors is completed. Elizabeth House DS0000037621.V319496.R01.S.doc Version 5.2 Page 17 Elizabeth House benefits from a large lounge and dining room to the ground floor, smaller lounges can be found on the ground and first floor, one being designated as a ‘smoking lounge’ for those residents wishing to smoke. The Inspector observed residents relaxing in all lounges after breakfast, whilst others relaxed in their own rooms. Residents were seen using the passenger lift independently and walking using their walking aids., Comment received from a resident “ laundry’s done daily, cleaners clean bedroom daily usually when I’m out for breakfast”. The Inspector viewed three resident’s bedrooms, which were clean and reflect resident’s preferences, included personal furnishings and pictures. Residents felt they had sufficient private space for their personal belongings and to store walking aids. Bathrooms and toilets were clean and equipped with specialist equipment for the moving and handling of residents and protective clothing such as gloves and aprons. The garden and the surrounding areas near the home are well maintained and residents can enjoy looking out or being out in the garden on warmer days. The comment received in the comment cards regarding the peeling wallpaper was followed up with the Registered Manager. It was said that a list of issues regarding the environment had been identified including the peeling wallpaper. The monthly visits carried out by the representative for the Registered Person highlighted the cracks appearing to the external walls. The Registered Manager gave assurances that the environmental issues were being addressed with the assistance of the maintenance team within the local authority. The laundry room is away from the kitchen with a team domestic and laundry staff responsible for the laundry and cleaning. Staff spoken with described the arrangement for collecting residents’ laundry and the procedures followed for soiled clothes when handling clothing to avoid spreading infection such as MRSA. Care staff spoken with demonstrated a good understanding and knowledge of their responsibilities to prevent the spread of infection and health and safety guidelines. Elizabeth House DS0000037621.V319496.R01.S.doc Version 5.2 Page 18 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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Trained and qualified staff are employed following thorough recruitment checks and employed in sufficient numbers, with the use of agency staff to meet the needs of the residents. EVIDENCE: On the day of the inspection, the care and ancillary staff on duty was as per the staff rota. The home uses agency care and ancillary staff, whilst permanent care staff continues to be recruited. The Senior Carer said the agency staff are regular and familiar with the residents and the procedures in the home. The local authority’s recruitment procedure is robust, which is managed by the Human Resource Team. The information received from the Registered Manager before the inspection showed staff have satisfactory pre-employment checks including Criminal Records Bureau (CRB) and references. The Inspector examined three care staff’s file, which contained confirmation of the completed induction training and job specific training. All staff files contained records of the supervision meetings and staff meeting from domestic staff and care staff meeting. Elizabeth House DS0000037621.V319496.R01.S.doc Version 5.2 Page 19 The information received from the home before the inspection of the service indicated that 75 of the care staff have achieved National Vocational Qualification (NVQ) level 2 in care. Staff training records showed training completed in moving and handling, food hygiene, fire training, dementia awareness, older people and mental health. All the staff training is co-ordinated by the staff development team. Care staff confirmed training is identified through the supervision meetings. Care staff described the induction training undertaken, which included the home’s policies, procedures, adult protection, health and safety and principles of care. Care staff demonstrated a good awareness of the residents’ care needs, how to support and assist residents to maintain and continue living independently as far as practicable. The residents and their visiting relatives said the care staff are always available and residents were familiar with them. Comments received included: “very happy with the care provided to mother, staff are kind and helpful; home is clean; any concern staff do sort it out quickly” “the staff are very good they know me but I can’t always remember their names” Elizabeth House DS0000037621.V319496.R01.S.doc Version 5.2 Page 20 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 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager offers a clear sense of leadership, ensuring residents health; safety and welfare are promoted and protected by the home’s procedures. EVIDENCE: The Registered Manager has clear lines of responsibility and accountability for all the staff at the home, and is supported by the Assistant Manager. The Registered Manager attained the Registered Managers Award. The care staff said they key work the residents they are responsible for and work in the designated areas identified by the manager such as up/downstairs, assisting in Elizabeth House DS0000037621.V319496.R01.S.doc Version 5.2 Page 21 the dining rooms, assisting residents with personal care, attending appointments and supporting the District Nurse or General Practitioners. A representative of the management team of the Local Authority, who is external to Elizabeth House, visits the home on a monthly basis, representing the Responsible Individual. A report is generated following each visit, the purpose of the visit being to review documents, speak with residents, staff and the management team, to view the environment and deal with any specific issues. A copy of recent reports was viewed by the Inspector, which evidenced that the visits are unannounced, and include discussions with residents. Quality Assurance was discussed with the Registered Manager, who said that Adults and Community Service Department, Leicester City Council, currently does not do any quality assurance survey. There was no indication as to any plans in the future, to carry out any quality assurance survey. ‘Residents’ meetings’ are held every three-months and residents can choose to attend. The minutes of the meeting viewed showed the topics discussed at the last meeting meals, response to call bells, bedrooms, cleanliness and proposals for Christmas festivities. Residents said they have keys lockable drawer and keys to their bedrooms. Care plans detail as to how resident’s finances are managed; in some instances, this is by the resident or their family, whilst for some a Solicitor is involved. Resident finance records examined clearly showed good financial reconciliation for the transactions made, receipts, which were auditable against the sums of money kept on behalf of the resident. This demonstrated that there is a clear procedure for handling money in place. Care records showed the key workers review the care plan with the resident’s monthly, which was confirmed by the residents and their relatives involved. Copies of risk assessments carried out with residents for mobility, falls, dietary needs and the measures were reflected the their care plans used by staff. Residents spoken with indicated that they felt safe both in the home and with the care staff looking after them. The Pre Inspection Questionnaire submitted prior to the CSCI prior to the site visit detailed the regular maintenance of health and safety systems within the home, including fire systems and equipment, environmental health visits, central heating systems and emergency call systems. Elizabeth House a maintenance person, responsible for testing and repairing minor faults. Records randomly checked for fire drills and fire alarm tests indicated they were carried out and were up to date. The accident book viewed was consisted with the notifications sent to the CSCI detailing events that have affected the residents’ safety and wellbeing. Elizabeth House DS0000037621.V319496.R01.S.doc Version 5.2 Page 22 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 X X X 3 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 3 X 3 X X 3 Elizabeth House DS0000037621.V319496.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? N/A 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Elizabeth House DS0000037621.V319496.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 DS0000037621.V319496.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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