Inspection on 22/05/07 for Elizabeth House

This inspection was carried out on 22nd May 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Elizabeth House 31/08/05

Elizabeth House 28/04/05

Elizabeth House 02/11/04

Elizabeth House 21/06/04

Similar services:

Flint House

Hillview Farm

Dalewood Respite Care

Orchard,The

REACH Upton Court Road

The Cotswold Home

Fairways

Treloar College

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

CARE HOME ADULTS 18-65 Elizabeth House MacCallum Road Enham Alamein Andover Hampshire SP11 6JS Lead Inspector Ms Sue Kinch Key Unannounced Inspection 22nd May 2007 12:00 Elizabeth House DS0000037083.V336107.R01.S.doc Version 5.2 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 DS0000037083.V336107.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 Adults 18-65. 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 DS0000037083.V336107.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elizabeth House Address MacCallum Road Enham Alamein Andover Hampshire SP11 6JS 01264 345800 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) lynne-hewitt@enham.org.uk Enham Mrs Lynne Hewitt Care Home 20 Category(ies) of Learning disability (2), Physical disability (20), registration, with number Physical disability over 65 years of age (2) of places Elizabeth House DS0000037083.V336107.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No additional service users may be admitted in the LD category Date of last inspection 31st August 2005 Brief Description of the Service: Elizabeth House is part of the Enham organisation, which is situated at Enham Alamein, Andover. The home is registered to accommodate and provide care and support for 20 physically disabled younger adults. The home was registered in January 2003 and was purpose-built. Elizabeth House provides physical and emotional support to individuals who have a physical disability, sensory impairment or learning disability. Additionally, service users participate in structured programmes at the work development resource centre, which is also on the same site and operates in tandem with the care programme. The purpose is to enable people with disabilities to realize their full potential, both by listening to their expectations, providing a structured work setting, assessing their needs and by providing advice and guidance from health care sources. Residential care rates vary from £574 to £596 per week. Additional costs are individually negotiated. Elizabeth House DS0000037083.V336107.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The evidence used to write this report was gained from a review of the information sent to the Commission for Social Care Inspection (CSCI) since the last visit. This information included an annual quality assurance assessment and comment cards from four people who live in the home and four relatives. A site visit to the home was made on 22nd May 2007. During this visit the inspector spoke individually with three people using the service, with others at lunch and observed the interactions between residents and staff. The inspector also spoke with the manager and three members of staff on duty. A partial tour of the building was made and documents relating to the running of the home were sampled. What the service does well: What has improved since the last inspection? What they could do better: The manager evaluates the practices in the care home and encourages change and improvements. No specific requirements have been made as a result of this inspection. However, it is recommended that staff deployment is Elizabeth House DS0000037083.V336107.R01.S.doc Version 5.2 Page 6 reconsidered and varied sufficiently to increase opportunities for people needing support to use the wider community more often and to avoid staff delays in providing personal care. 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 DS0000037083.V336107.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Elizabeth House DS0000037083.V336107.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The arrangements for assessing prospective resident’s needs are comprehensive and include a three-week residential assessment prior to admission. EVIDENCE: Comprehensive procedures for admissions to the home were recorded at the last inspection. At this inspection the home was involved in the open day for prospective residents and their relatives. The chair of the residents meetings at the home is involved in this process regularly and is a useful support to people planning to use the service. Since the last inspection some admissions have been made to the home and records for two people were viewed. Any person admitted to the home has already had a three-week assessment in another registered care home run by this organisation and the assessment information is passed to the home. Information obtained from relevant professionals is also gathered. The manager said that since the last inspection, work had been done to improve the admissions process and gave an example of this such as obtaining full details about equipment each person needs so that it is available on admission. Elizabeth House DS0000037083.V336107.R01.S.doc Version 5.2 Page 9 Prospective residents are provided with information and are able to visit Elisabeth House while they are having their initial assessment. All feedback from residents confirmed that they were asked if they wanted to move into the home and received enough information to decide on its suitability before coming. One person explained that initially a room was allocated but subsequently they had been able to choose an alternative one which had been decorated first. Procedures are in place to offer reviews to new people using the service in line with the three-month policy. This was discussed with one resident who confirmed that a review had taken place. Work had also taken place to establish key support needs in the care plans and risks were under assessment. Elizabeth House DS0000037083.V336107.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are involved in a care planning and risk assessment process which promotes and supports their choices needs and independence. EVIDENCE: Three files were sampled and comprehensive care plans were in place covering a wide range of issues for each person including personal aims with evidence of regular monitoring and recent reviews. People using the service are aware of their care plans and have been involved in planning and reviewing their care. Key workers are involved in the care planning process and say there is one to one time to spend discussing matters with people that they are key worker for. The manager reported that improvement plans include developing a project to examine the review process to consider how it could be more userled. People using the service are supported to make decisions. As part of this process they have also been asked to sign agreements concerning various Elizabeth House DS0000037083.V336107.R01.S.doc Version 5.2 Page 11 aspects of their care. Several signed agreements were noted to be in each file. People are able to make day-to-day decisions such as about going out, what time to get up or go to bed, or whether to spend time alone or with others. Staff support people using the service making decisions and gave examples of how they do this. Risk assessments are also included in the files and information in the plans guide staff on action to take for specific individuals. Risk assessment is used for maintaining safety and promoting independence. Key issues for support discussed with people using the service were identified in the care plans. A conversation was held with a member of staff about rights of individuals in risk taking, people breaking agreements and appropriate care practices in relation to this. The member of staff had received training in risk assessment and showed good understanding of how to provide support. Written feedback from people using the service and relatives confirmed that needs were always or usually met. They said that where there have been some shortfalls from time to time matters have been raised and dealt with. However insufficient activities particularly off site at weekends was raised during the visit and in written feedback. This is discussed in the lifestyle section of this report. Elizabeth House DS0000037083.V336107.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported to make decisions about their lifestyles and to enjoy a range of experiences and activities and this will be enhanced by greater use of the community. EVIDENCE: In the statement of purpose it states that ‘Every person at Elizabeth House is encouraged to become as independent as possible in all areas of their lives. This includes social activities, hobbies and leisure activities.’ There is evidence of this being planned for in the care plans and risk assessments which include, for example consideration of independent, use of transport, use of the community and management of finances. Other examples of personal development were raised during the inspection. One person using the service spoke of support with plans to move out of registered care into a supported Elizabeth House DS0000037083.V336107.R01.S.doc Version 5.2 Page 13 living scheme. Another was being provided with additional one to one support with daily living skills. In the pre inspection survey people using the service said that they made decisions about what to do each day and that they can do what they want to do in the day, weekends and in the evenings. One relative wrote that ‘personal development support v good and flexible and the home does this well’. Personal and family relationships are supported. Relatives fed back that the home does keep in touch and that support is provided if needed. They feel that the amount information provided to them or their relative is usually adequate. One relative said that they are encouraged to visit and another that home visits are encouraged. There are many structured activities offered during the day when most people attend the workshops on the Enham Alamein site in which the home is situated. The people using the service spoken with over the lunch period spoke very positively about the activities that they were engaged in that day. During the evening activities such as films and curling are offered away from the home on site. Some activities are offered in the home in the evenings such as craft but staff said that group activities are hard to establish with most people preferring to do things of their choice. The local village is also accessed regularly for shopping and use of the local pub. At weekends, when the care staff level is the same as in the week, some people who use the service go out with or to stay with relatives and some go out alone. But for others, trips out or supported use of the community, are limited and need to be planned in advance such as to the cinema or for shopping further away from the village. One person said that’ Friday to Monday is dull’. Other comments were received about there being limited trips out. These points were raised with the manager who in light of the feedback said that she would consider an additional member of staff at weekends to address this issue. In the information sent in before the inspection the manager spoke in general of plans to improve community access for people using the service. Independence in the management of personal finances is promoted and some people are fully independent. Others need support and this is documented in the care plans. However, as money held for people using the service is not currently stored in the home, independence and choice is not fully supported. Staff are not fully aware of the current position of peoples finances and therefore assistance with budgeting and decision-making could be affected. This was discussed with the manager who stated that plans were in place to address this. Elizabeth House DS0000037083.V336107.R01.S.doc Version 5.2 Page 14 Improvements to the food were noted when last inspected and during this visit at lunch positive comments were received again from a number of people who were dining in a relaxed environment. Comments about it were that is ‘perfect, good cook, good choice’, ’more fresh food’ and ‘very good’. The food looked attractive and choices had been given. Fresh food was included. Some diets are catered for and records of food provided are held including variations. There were comments about the dining room not being big enough and the management have looked in to ways of addressing this. This is an ongoing issue. Elizabeth House DS0000037083.V336107.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Systems are in place to meet the health and personal support needs of people using the service. They are supported individually to either manage their own medication based on risk assessment or to be provided with their mediation through a carefully managed system. EVIDENCE: Individual care plans include sections stating how each person receiving a service wishes their care and support to be carried out. Residents have the technical aids and equipment they need for maintaining independence, determined by professional assessment. Staff continue to be trained in the principles of care and moving and handling techniques. Routines and support required were discussed with some people using the service. Their comments and those received from relatives, showed general satisfaction with the support received. One person said they ‘normally get support when needed’. Another said ‘ dignity is respected here’. One person sometimes felt rushed with personal care and two commented on the varying needs of residents and the staff level sometimes affecting needs being Elizabeth House DS0000037083.V336107.R01.S.doc Version 5.2 Page 16 met on time or at preferred times. There was an understanding though that at times some negotiation was needed. The manager was aware of these issues and said that she had planned start to address the matter initially through the residents meeting. Health care details are also recorded in the care plans and there are records to show that this is monitored. One person using the service spoke of regular support from the district nurse. The staff are aware of appointments and these are recorded in the homes diary. Outcomes of appointments are also recorded. The manager said that that staff frequently support people using the service to health appointments each week. A relative said ‘ we have found the manager and care staff to always be helpful and co-operative on care and health matters.’ The manager said that health care support had been improved by employing a part time occupational therapist to the therapy team supporting the home. The home has policies and procedures for dealing with self-medication. People using the service and staff confirmed this. Individual risk assessments for selfmedication are in place. Staff are trained in medication and assessed as competent before being able to carry out administration and a senior member of staff has specific responsibilities for medication processes in the home. Medication is held securely in the home. A sample of medication administration sheets was viewed and had been fully completed as required by the homes procedures. Staff spoken with were able to explain procedures clearly. A person using the service said that medication was provided regularly and on time. Elizabeth House DS0000037083.V336107.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are encouraged to raise any issues and concerns and these, as well as formal complaints, are responded to. Training, policies and procedures are in place to ensure a response to any suspicion or allegation of abuse. EVIDENCE: The home has a complaints policy and procedure available to people using the service that includes response timescales, details of who to complain to and the appeals procedure. A record is kept of complaints received by the home, action taken and the final outcome. One complaint had been received in the last twelve months and there was evidence that this had been followed up. In conversation one resident confirmed they were aware of the procedure and felt able to raise issues with the staff or the manager. Another person said that some issues had been raised with the staff but these had been sorted out and the person was confident that the manager would get involved if needed in such situations. People using the service are also able to raise issues in residents meetings, details are passed to the manager and a response is fed back at a future meeting. All residents and relatives who returned comment cards stated that they knew who to speak to if they were unhappy with their care. Relatives said that concerns raised are usually responded to appropriately although one comment was received stating that the response to the heating going wrong earlier in the year was slow. Elizabeth House DS0000037083.V336107.R01.S.doc Version 5.2 Page 18 The manager reported to have received training in adult protection for managers and that it is also covered in staff induction. She reported that she promotes an atmosphere where people can raise concerns. Policies and procedures are also available. She was clear about the role of social services in co-ordinating investigations. In staff records observed there was evidence that staff are also provided with training in this area. The manager said that further refresher training is planned for staff. Adult protection was discussed with a member of staff who was aware of procedures to follow if such an allegation were made and this included bringing it to the managers attention or the on call person straight away. They were less clear about the process that follows and the manager was advised to consider including this in future training. The manager said that she thought the policy was not completely clear and would consider improvements. Elizabeth House DS0000037083.V336107.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The provision of modern, purpose built accommodation ensures that service users live in a homely, safe and comfortable environment, with suitable private space to suit their needs and promote independence. EVIDENCE: People who use the service are provided with spacious accommodation in individual areas, which include ensuite facilities, lounge space, and a kitchen area. All viewed during a partial tour of the home are well maintained, clean and equipped with adaptations based on individual needs with the aim to promote independence. The home is comfortable, bright, well decorated free from odours and furnished with furniture of good quality. The building is modern and purposebuilt and able to accommodate wheelchair users with ease. Shared areas include two lounges on the first floor and a dining room/ conservatory on the ground floor. All windows are restricted and radiators covered. Plastic Elizabeth House DS0000037083.V336107.R01.S.doc Version 5.2 Page 20 protectors have been fitted at the base of walls throughout which act as a buffer for wheelchair footplates and protect the walls. Security lighting is provided. Stair rails are available throughout the establishment and there is an automated passenger lift. Most people using the service like to use the shower facilities but one person spoke of an assisted bath available for those who prefer it. Call bell systems are in place and are answered promptly. There is a continual planned maintenance programme. A maintenance team is available within the main site and a system is in place to ensure that any problems are passed over and attended to. During the inspection work was carried out to fill a hole, which was providing an uneven surface just outside the front door. Repairs were discussed with two people who confirmed that they are usually carried out promptly although there were mixed views about the speed at which the heating was fixed earlier in the year. Relevant information with regard to health and safety, hygiene and control of infection is reported by the manager to be available within the establishment. People who use the service say that the home is fresh and clean. Protective clothing and equipment are in use to minimise cross infection. There is a contract for the collection of clinical waste. Training in infection control is provided. The manager reported that twelve staff received such training and others have been nominated for it. Elizabeth House DS0000037083.V336107.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service benefit from a skilled, supported and trained workforce recruited through a rigorous procedure but a review of staff deployment is needed to ensure that levels are always sufficient to provide the service needed. EVIDENCE: Some records related to recruitment are held at the main office but adequate information is held in the home. A sample was viewed for some of the staff recruited since the last inspection and there was sufficient evidence that appropriate recruitment procedures are used and pre employment checks are carried out before staff start to work at the home. New staff members are given induction training based on national standards and an example of a completed workbook waiting for assessment was available. Staff confirmed that they have regular supervision and are offered training. Records are held for each staff member and these were sampled. These demonstrated that a range of training courses including equality and diversity, health and safety, medication, moving and handling, first aid, Elizabeth House DS0000037083.V336107.R01.S.doc Version 5.2 Page 22 infection control risk assessment, disability awareness, adult protection and management of aggression and violence, is regularly provided. Refresher training is also provided. A staff training plan is posted on the manager’s office wall offering dates for various training sessions. Staff training needs are identified through supervision. National Vocational Qualification ( NVQ) assessments are encouraged and the manager reported that eight of the fourteen permanent staff and all bank staff have been assessed to NVQ level two or above. A sample of rotas was viewed and it was noted and confirmed by staff that generally that three carers work on each shift. However, staff are deployed flexibly and at times this level is higher. A fourth waking care staff member is on shift from 7.30 or 8pm each night and sometimes staff are planned for specific activities. Some people have support workers working with them individually. There are also cleaning staff and there is a chef that works split shifts in the week. Four comments were received during the inspection process and from different sources questioning whether the staff level was always sufficient to meet needs to the level expected. A comment was received about relations between staff and residents mostly being good but at times being strained. This was attributed to staff sickness, or staff having a lot to do. Another person said that at times staff were ‘stretched’. As commented on in the sections on personal care and lifestyle this can mean that support is sometimes delayed or limited. The manager said that she would look into this and, at the end of the inspection visit was considering options to make improvements. Elizabeth House DS0000037083.V336107.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people using the service benefit from a manager who provides channels of consultation, is receptive to ideas and is expecting to make improvements to the home. Systems are also in place to promote their health and safety. EVIDENCE: The manager is experienced, registered and is undertaking the Registered Manager’s Award. She is committed to her own training and there is evidence of this in the home. All people who use the service asked during the inspection process said that the manager is approachable and willing to act on matters raised. Staff asked agreed and they feel supported by the manager and are provided with supervision. One comment was that the manager is good at staff management and does address care practice issues. Elizabeth House DS0000037083.V336107.R01.S.doc Version 5.2 Page 24 The residents’ meeting that takes place monthly is a forum in which people using the service are encouraged to take part. The chair and vice chairpersons are residents. There is a system in place for consultation with the manager following these meetings and information is fed back to the meeting. Minutes are produced and shared. The manager carries out an annual survey and the responses from people using the service are collated and shared. The last survey was completed in 2006. Comments from the manager and a resident were received about improvements to the service as a result of consultation such as; sharing details about staff responsibilities, more fresh home cooked food, plans to offer more activities in the holiday periods and to include people using the service in recruitment of staff, disposal of the fish tank, and moving the location of residents meetings. Other quality assurance systems include monitoring through supervision and monitoring by the responsible individual through monthly visits but the manager said that a new full quality assurance system is planned for the home. Aspects of the management of health and safety were considered during the visit and it was found that attention is given to the promotion of safe working practices and residents’ safety. Records were sampled and those requested to be seen in relation to fire, gas servicing, and clinical waste were available and where necessary showed that recent tests had taken place. Testing of portable equipment was overdue but the manager was able to confirm that this was arranged for the week after the inspection. Fire evacuation procedures are posted throughout the home and fire exits are clear. There is evidence in staff records that they are receiving training in health and safety such as: manual handling, first aid, general heath and safety, fire, and food hygiene. Evidence of nominations for forthcoming courses was noted. Elizabeth House DS0000037083.V336107.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 x 2 x 3 4 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x Elizabeth House DS0000037083.V336107.R01.S.doc Version 5.2 Page 26 NO Are there any outstanding requirements from the last inspection? 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 DS0000037083.V336107.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 DS0000037083.V336107.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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