Inspection on 21/11/06 for Elizabeth House

This inspection was carried out on 21st 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 24/03/06

Elizabeth House 02/11/05

Elizabeth House 09/03/05

Elizabeth House 01/11/04

Elizabeth House 12/03/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Elizabeth House 147-155 Walshaw Road Bury Lancs BL8 1NH Lead Inspector Stuart Horrocks Key Unannounced Inspection 09:05 21st November 2006 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 DS0000008401.V308909.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 DS0000008401.V308909.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elizabeth House Address 147-155 Walshaw Road Bury Lancs BL8 1NH 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 762 9394 0161 764 6700 Canbra Care Limited Ms Lynn Parsons Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Elizabeth House DS0000008401.V308909.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th March 2006 Brief Description of the Service: Elizabeth House is owned and managed by Ms Lynn Parsons. The home can provide 24-hour care for up to 18 older people. The property is on Walshaw Road Bury and is about one mile from the town centre. There is a bus stop on the main road close to the home and there are shops nearby. The accommodation is provided on two levels with a lift giving access to the first floor. The home has ten single bedrooms and four rooms that are shared all of which have an en-suite toilet and hand basin. There is a well-furnished and comfortable lounge, a dining room and a conservatory that can be used all year round. Toilets and bathrooms are provided on both floors. The home has a garden area with seating that can easily be reached from the conservatory. Ample car parking is available at the back of the home and there is easy wheelchair access. A Service User Guide (Residents Information Guide) and a Statement of Purpose describing the home’s services is available and the provider gives other information about the home to new and prospective residents and their families verbally. A copy of the latest inspection report is available on request. As of June 2006 the weekly charge for accommodation and services is between £345:00 and £370.00 with an additional charge being made for hairdressing and personal newspapers. Elizabeth House DS0000008401.V308909.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection, which included a site visit that was started at 9.05am on the 21st November 2006. It took place over one day and it lasted for about eight hours. The time was split between talking to the Owner/Manager and checking records, looking around the home, watching what was happening and talking to residents, a relative and other staff. Three residents, one relative and four staff were spoken with. A completed pre-inspection questionnaire was received along with feedback surveys from relatives and doctors. Of the surveys sent out four were returned by relatives and five by doctors. The care services (case tracking) provided to three specific residents were used a basis for the process of the inspection. What the service does well: What has improved since the last inspection? Good progress has been made by the manager and the staff to make sure that the things, which needed improving from the last inspection, have been done. Elizabeth House DS0000008401.V308909.R01.S.doc Version 5.2 Page 6 The required fire safety work has been done; staffing levels have been adjusted, families have been asked to give their opinions about how well the home is looking after their relatives and safe hot water temperatures are now being regularly checked. 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 DS0000008401.V308909.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 DS0000008401.V308909.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): 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are properly assessed before admission so that all parties are assured that that identified needs can be met by the home. The home does not provide intermediate (rehabilitative) care so Key Standard 6 does not apply. EVIDENCE: The care files of two recently admitted residents were checked for the required pre-admission needs assessment information. One of these contained a local Social Services needs assessment and the other a hospital needs assessment. From this information the home is then able to assess whether these people’s needs can be met and a care plan and a range of other care delivery information is then put together. The inspector was informed that all new residents routinely have an in-house pre-admission needs assessment done irrespective of whether they are selffunding or funded by the Local Authority. These were seen in the above checked files. Elizabeth House DS0000008401.V308909.R01.S.doc Version 5.2 Page 9 The manager usually visits new residents either at home or in the hospital as a part of the pre-admission needs assessment process. The manager said that new residents and their families are welcome to visit the home where they can spend some time, meet the residents and the staff, and have a meal before deciding to live there. This visiting opportunity is described in the useful and informative Service User Guide (Residents Information Guide) and was also confirmed in discussion with residents’ and staff. Elizabeth House DS0000008401.V308909.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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Proper arrangements are in place that ensures the residents health care needs are monitored and met. Individual care plans are also in place, which were up to date, regularly reviewed and provided the staff with the information needed to give a good standard of care. The home’s medication systems are satisfactory in ensuring that residents received medication as prescribed and care practices in the home ensure that the residents are treated with respect and their privacy and dignity is upheld. EVIDENCE: The care files of the three case tracked residents were looked at. Each of these files contained a detailed and comprehensive care needs assessment that describes the help that the resident needs with everyday living including health, personal and social care needs. All of this paperwork had been reviewed at the required monthly interval using a separate document that described any changes in the way that the resident needed to be looked after. The staff said that they knew each residents needs by reading the care plans, which are readily available to them. Elizabeth House DS0000008401.V308909.R01.S.doc Version 5.2 Page 11 Talking to residents, the manager and the staff and looking at records showed that the resident’s health care needs are taken care of and that when necessary health workers such as doctors, nurses and opticians are called. A number of risk assessments were in place. These included an up to date manual handling assessment and a nutritional assessment tool that is used at the time of the resident’s admission to the home and then afterwards as required. Nutritional wellbeing is also assessed by direct observation and by regular and up to date weight checks. Pressure area condition is also checked by direct observation with a pressure area care plan being available if required. All medicines are safely and securely stored. The residents’ medicines are provided in pre-filled cassettes with pre-printed prescription/recording sheets also provided. These records were found to be properly completed and to be up to date. The medications supplied are checked in to the home , and medicines returned to the pharmacy are also recorded. Identification photographs of each resident are kept with the medication administration records. Those staff that give out medicines have been given the necessary training for this task, which was up-dated in July 2006. The home has a satisfactory medicines policy and procedure that includes guidance for the self-administration of medicines. No resident was dealing with his or her own medicines at the time of this visit. The displayed “Residents’ Charter of Rights” and various other documents reinforced the importance of staff treating residents with respect and dignity. Residents spoken with were all complimentary about how staff assisted them with personal care tasks and felt their privacy and dignity was respected at all times. This was also observed during the inspection. The care assistants interviewed were able to give good examples of how they promoted privacy and dignity in their daily care routines, for example knocking on bedroom doors before entering. The residents said that the staff had a “kind and considerate” manner and that the staff spoke to them in a “civil and courteous” way. Elizabeth House DS0000008401.V308909.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activities offered within the home mean that residents have opportunities to participate in stimulating and motivating activities. The visiting arrangements are flexible thus enabling residents to have good contact with family and friends as they please and the meals at this home are good, offering choice and variety, and catering for individual dietary needs. Although most residents have a choice about their daily routines the home must make sure that the choices of the less able residents are not compromised. EVIDENCE: The home provides a number of recreational and stimulating activities (e.g. quizzes, exercises, crafts, reminiscence sessions, shopping trips) that the residents are encouraged to join in with. An entertainer visits the home monthly and community contact is enabled by pupils from a local school who visit the home on Wednesday afternoons when they help the residents with arts and crafts activities. At the time of this inspection early preparations were being made for the Christmas celebrations with various sorts of outings and entertainment being considered. Elizabeth House DS0000008401.V308909.R01.S.doc Version 5.2 Page 13 The home has sponsored a donkey named “Molly” that lives at a local sanctuary with Molly visiting the home recently, which the residents greatly enjoyed. The resident’s social and recreational preferences are recorded in their care notes and a record is made of the activities that they have joined in with. Those residents that the inspector spoke with were aware of the abovedescribed activities although some chose not to take part. Some of the residents showed little interest in joining these events with the manager and the staff being well aware of the difficulties in finding stimulating activities for these people who they do encourage to join in. The homes visiting arrangements are described in a variety of documentation including the home’s Statement of Purpose. In discussion the residents, a relative and staff confimed unrestricted visiting arrangements with visitors seen to be coming and going from the home at will and a visitor confimed that they were made welcome and that they could have a warm drink if they so wished. Issues regarding residents choice are described in a variety of documentation including the home’s Service User Guide and Statement of Purpose. Those residents spoken with said that they had choice about such things as going to bed and getting up times, which clothes to wear, which lounge they sat in, how they spent their day and whether or not to participate in activities. The staff described how they assisted residents with choices such as choosing clothing and food etc. The residents are able to, and do bring personal items in to the home such as televisions, radios, photographs, pictures and ornaments. However, information received before the inspection indicated that choice for some residents might be being compromised. The caller alleged that whilst visiting the home at 3:30 in the afternoon that five residents were seen to be dressed in their nightclothes with the caller feeling that it was odd that these people were ready for bed at that time of the day. Upon making enquiries the staff told the inspector that the above-described situation does occur. This apparently happens when these residents have either had physical problems and/or have been bathed and they are then dressed in their nightclothes. The inspector finds this situation to be in the main undesirable, normal domestic daily living routines should be followed and residents should only be prepared for bed at this time if it is entirely of their choice. The home has a three weekly menu that offers good nourishing food with the main meal served at lunchtime and a lighter meal at teatime. Warm food is always offered at midday and is often available at teatime. This menu provides a single choice but alternatives to the main menu are also available and it was Elizabeth House DS0000008401.V308909.R01.S.doc Version 5.2 Page 14 apparent in discussion with the cook that she is well aware of individual resident’s likes and dislikes. The residents praised the food served generously saying that the food was “good and warm” and they told the inspector that they had “enjoyed the meal”. and that “you can have something else” if you don’t want what is on the main menu. The residents also said that drinks and snacks were available at most times if the day. The inspector had a meal at lunchtime with the food found to be well presented and to be to a good standard. Meals were seen to be presented in an appealing manner with good portions offered. They are eaten in comfortable and attractive dining room that is situated close to the main kitchen. Elizabeth House DS0000008401.V308909.R01.S.doc Version 5.2 Page 15 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 & 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints system that ensures that concerns are properly dealt with and although good protection of vulnerable adults guidance is available some staff need training in this topic to make sure that residents are protected from abuse. EVIDENCE: The home has a satisfactory complaints procedure that states how a complaint is to be made, who to and that response will be provided within 28 days. The facility of making concerns known directly to the CSCI is also included in this paperwork. The complaints procedure described above is included in the Service User Guide, a copy of which was available in the home’s dining room. A copy of this complaints procedure was previously displayed in the home but this now seems to have been removed. It was agreed with the manager that this procedure would again be displayed with a requirement being made to this effect in this report. Discussion with residents and a relative showed that they would feel comfortable about raising concerns and that they would “talk to the staff” or Lynn (the manager) if they had any worries. It was clear in discussion with staff that they also knew what steps to take should a resident make a complaint. The home has a proper record for writing down complaints. No complaints have been made to the home since the last inspection in March 2006 but one Elizabeth House DS0000008401.V308909.R01.S.doc Version 5.2 Page 16 concern has been raised with the CSCI. The issue arising from this concern have been examined above under the National Minimum Standards outcome group “Daily Life & Social Activities”. There are written procedures and policies covering adult protection, whistle blowing, the none acceptance of gifts, borrowing money and legacies and the home has a full copy of the Department of Health’s “No Secrets” document (detailed guidance on dealing with abuse). Staff training in the recognition of and dealing with abuse was due to be provided on the 10th and 17th of May 2006 but unfortunately this did not take place so many of the staff still require training in this subject. The inspector was told that this training has now been rearranged for January 2007 with ten places having been booked. Discussion with the staff however, showed that they have some awareness of the different sorts of abuse and they also understood what they should do if they suspected that someone was being abused. At the time of the last inspection the inspector and the manager talked about the home obtaining a copy of the local inter-agency adult protection policy, which it was agreed would further support the homes existing policies. The manager said that she had had some difficulties in getting a copy of this document and as yet has been unable to obtain this. The inspector again recommends that a copy of this policy be acquired. Elizabeth House DS0000008401.V308909.R01.S.doc Version 5.2 Page 17 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 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Following the refurbishment work described below the standard of furnishing, fittings and decoration within the home has been further improved providing a homely, clean and comfortable environment for residents. EVIDENCE: Elizabeth House is well maintained to both the inside and the outside. A considerable amount of refurbishment work has taken place during 2006. This has included the fitting of new double glazed units throughout to all of the windows to the back of the home. A new fitted kitchen has been installed with new flooring provided, various rooms in the home have been re-carpeted and redecorated and some bedding has been replaced. The laundry has been transferred to a new prefabricated building that is sited in the back garden and various items of kitchen and laundry equipment have been either replaced or repaired. Elizabeth House DS0000008401.V308909.R01.S.doc Version 5.2 Page 18 The work previously required (smoke seals to fire doors) by the Fire Service has been completed in the period since the last inspection. The three case-tracked resident’s bedrooms were checked. All were found to be properly decorated, furnished and equipped and these residents and the relative spoken with were satisfied with the standard of the accommodation provided. There is good accessibility around the building with ramps,assisted baths and other equpment provided. There is a well-kept garden area at the rear of the home that is provided with seating, which is easily accessible from the conservatory. The home has a properly equipped laundry and good information regarding the control of infection is available. Residents clothing is marked to enable easy identification and the residents had no complaints about the laundry service provided by the home. The home was clean and tidy throughout and was free from any offensive odour therefore providing a pleasant place to live. Elizabeth House DS0000008401.V308909.R01.S.doc Version 5.2 Page 19 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. Quality in this outcome area is good. . This judgement has been made using available evidence including a visit to this service. Staffing levels are satisfactory, staff training is provided, and the recruitment method ensures that the residents are looked after by staff that are suitable to carry out care work. EVIDENCE: Looking at staff rotas showed that as well as employing care staff, the home also employs domestic, catering and maintenance staff. The manager and the staff described a largely stable staff group some of whom have worked at the home for a considerable time, which ensures that residents are cared for by people they know and are familiar with. Staff morale was good with staff saying that “there is a good atmosphere” and that “we work together well as a group”. The residents said that the staff are “kind”, “happy to help” and that they were “patient and considerate”. The staff were seen to have a natural and comfortable understanding with the residents and they had time to sit and talk with them. On the day of this inspection enough staff were on duty to meet residents care needs. Rotas showed that staff were regularly available in sufficient numbers by day and by night to ensure that care was properly provided. The staff and Elizabeth House DS0000008401.V308909.R01.S.doc Version 5.2 Page 20 the manager said that in their opinion there was enough staff to meet the needs and dependency levels of the residents living at the home. A requirement made at the time of last inspection was that evening time staffing levels be reviewed with consideration to be given to providing an additional member of staff (total of three staff) at that time. Such a third member of staff was provided, but after a period of time the staff felt that the extra staff member was not required, but that assistance with housekeeping duties between 4:00pm and 6:00pm would be sufficient with this cover now having been provided. The home is required to have 50 of the care staff with NVQ level 2 qualifications or above by the end of 2005. Of the 12 care staff employed at the home all have got a National Vocational Qualification in Care at Level 2 with 100 of the staff are therefore trained to the required level so the above target is exceeded. No new staff has been employed at the home since the last inspection, the inspector therefore looked at a random sample of two existing members of staff files to check for safe and proper recruitment. These showed that these people had been correctly recruited, job application forms had been completed, health and criminal convictions declarations were present, two references had been obtained, police check done and a photograph of the employee was on file. The home has however taken on a volunteer worker who carries out housekeeping duties in the evening time from Monday to Friday. This issue was discussed with the manager who was informed that this person’s ‘employment’ must be safe and that they must have a police check done. The staff gave examples of the training that they had done. This included induction to the job training, NVQ assessment, the giving out of medicines, safe moving and handling, fire safety, food hygiene and first aid. The provision of this training was confirmed when looking at staff training records. The inspector and the manager discussed the way that staff training is presently recorded. The inspector suggested that the development of a staff training matrix would assist the manager in seeing what training had been completed, the date it had been done and what other training the staff needed to undertake. Elizabeth House DS0000008401.V308909.R01.S.doc Version 5.2 Page 21 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 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager of the home provides leadership and support for the staff to ensure that the residents receive a satisfactory standard of care and a satisfactory accounting method is used, which protects the resident’s interests. Procedures and practices within the home promote and safeguard the health, safety and welfare of the people living and working in the home. EVIDENCE: The home manager/proprietor (Ms L Parsons) has been approved and registered by the CSCI and she has over 20 years experience of working in care settings both in residential and community situations. Ms Parsons has been the registered manager of Elizabeth House for approximately the last six years and she has successfully completed the required NVQ Level 4 Registered Managers Award. Elizabeth House DS0000008401.V308909.R01.S.doc Version 5.2 Page 22 Discussion showed that Mrs Parsons knows the residents and the staff well and the home is well run and residents, staff and a relative said that Mrs Parsons is “easy to talk to” and that she “listens and is approachable”. A requirement of Standard 33 is that care homes must use quality assurance systems that are largely based on seeking the views of residents to measure their success in meeting the home’s aims and objectives. In March and April of 2006 the home sought the views of the residents’ families and health care workers by the use of survey questionnaires. 13 survey forms were returned with most of them scoring positively for the questions that asked about how well the home is meeting the residents’ needs. A number of people made comments about the home such as “If it was an hotel it would be a five star establishment” and “My mother has received excellent care” and also “It strikes me as being an extremely well organised operation”. A community nurse also commented that she was “made to feel welcome” and that “the care of the residents is excellent”. The inspector understands that this survey is routinely repeated at annual intervals. The inspector reminds the manager that at the time of the next survey the views of the residents should also be sought. A number of survey questionnaires were sent out to the residents, relatives and health workers (GP’s, district nurses etc) by the CSCI before the inspection. These questionnaires give these people the opportunity to comment upon various aspects of the services provided by a care home. At the time of writing this report nine questionnaires had been returned; the bulk of these were generally complimentary about the accommodation, the services and the care provided at Elizabeth House. One person said that they had “Observed a high level of care being provided” and another said, “The owners and the staff are very good”. The home holds money for a number of residents for safekeeping. This system was checked with the details found to be properly written down and with the correct amounts of money kept. Secure storage is available for the safekeeping of money and of any valuable items. Information obtained from the pre-inspection questionnaire showed that the homes fixtures, fitting and equipment is properly maintained and regularly serviced apart from that for the home’s fire alarm system where the certificate had just expired. The inspector was told that this work had been done recently but that the engineer had not provided the required certification. The manager told the inspector that a copy of this certificate would be sent to the CSCI shortly. Apart from the above the home is safely maintained with fire precautions tests done weekly and the details of accidents are properly recorded. Elizabeth House DS0000008401.V308909.R01.S.doc Version 5.2 Page 23 Looking at paperwork and conversations with staff confirmed that they had been provided with the necessary training so that they can work safely. The home does not at this time have any equipment for the staff to use for the lifting and moving of residents. The inspector was told that there is no need for such equipment at this time. However the inspector suggests that consideration be given to obtaining such equipment (e.g. a mobile lifting hoist) so making sure that residents can be moved safely and also making sure that the staff can undertake this task safely. Elizabeth House DS0000008401.V308909.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 X 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 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Elizabeth House DS0000008401.V308909.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No. STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP16 Regulation 22 Timescale for action The registered person must 31/12/06 ensure that a copy of the home’s complaints procedure is clearly displayed in the home. The registered person must 31/01/07 ensure that the staff are provided with training in adult protection issues. The registered person must 19/01/07 ensure that the ‘employment’ of the recently recruited volunteer is safe and that an enhanced CRB check is done. The registered person must 19/01/07 ensure that a copy of the certificate verifying the servicing of the home’s fire alarm system is sent to the CSCI. Requirement 2 OP18 18 3 OP29 19 4 OP38 13 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 DS0000008401.V308909.R01.S.doc Version 5.2 Page 26 1 2 OP14 OP18 3 OP30 4 OP38 The inspector strongly recommends that the registered person ensures that residents should not be prepared early for bed unless this is entirely of their own choice. The inspector strongly recommends that the registered person obtain a full copy of the Bury Social Services Adult Protection Policy so that local guidance is followed should an abuse situation arise. The registered person should give consideration to the development of a training matrix that can be used to show any gaps in staff training and also to show when training needs to be updated. The registered person should give consideration to the obtaining of lifting equipment (e.g. a hoist) so making sure that residents can be moved safely and also making sure that the staff can undertake this task safely. Elizabeth House DS0000008401.V308909.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 DS0000008401.V308909.R01.S.doc Version 5.2 Page 28 - 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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