Inspection on 24/03/06 for Elizabeth House

This inspection was carried out on 24th March 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 21/11/06

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 Unannounced Inspection 24th March 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 DS0000008401.V286342.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Elizabeth House DS0000008401.V286342.R01.S.doc Version 5.1 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.V286342.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd November 2005 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. Elizabeth House DS0000008401.V286342.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and was started at 9.30am.It took place on one day and it lasted for about five and a half hours. The time was split between talking to the Manager and checking records, and looking around the home, watching what was happening and talking to residents and other staff, four residents and three staff were spoken with. What the service does well: What has improved since the last inspection? What they could do better: When new staff are employed who bring a police check with them, this has to be done again to make sure that the information about them is up to date. The way that the residents are asked about their opinions as to how well the home looks after them needs to be used regularly. This should also be used with the resident’s families and with other people such as their doctor or social worker. Elizabeth House DS0000008401.V286342.R01.S.doc Version 5.1 Page 6 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.V286342.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Elizabeth House DS0000008401.V286342.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Pre-admission visits, and the initial assessment process, enable all parties, including potential residents and their relatives, to reach a decision as to whether the home will be able to meet their needs. Elizabeth House does not provide intermediate care services (key Standard 6). This standard does not therefore apply. EVIDENCE: The home’s admission procedure is included in the resident’s information guide. This gives useful information to prospective residents and their families about the home’s admission criteria, a trial period of residence and the fact that they are welcome to visit the home to meet the residents and the staff. The inspector checked the files of the three most recently admitted resident. All of theses people were self-funding with their needs having been properly assessed before admission. The inspector was told that local Social Services Department does provide good information before making a placement at the home so that the home is able to decide if the residents care needs can be met. Elizabeth House DS0000008401.V286342.R01.S.doc Version 5.1 Page 9 All prospective residents have their needs assessed in-house irrespective of whether they are self-funding or funded by the Local Authority. Elizabeth House DS0000008401.V286342.R01.S.doc Version 5.1 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): 9and 10. The medication arrangements are generally well managed thus ensuring that residents receive their medicines as prescribed. Care practices in the home ensure that the residents are treated with respect and their privacy and dignity is upheld. Key standards 7 and 8 were examined at the time of the last inspection and they were largely met. These standards were therefore not checked at the time of this visit, but requirements made previously regarding Standard 8 were followed up. EVIDENCE: The medicines are provided in pre-filled blister packs with pre-printed prescription/recording sheets also provided. Medicines are properly and safely stored. All medicine when given is recorded on the residents’ drug sheets, these records were properly filled in and they were up to date. Although six of the staff have been trained to give out medicines the manager feels that this training needs to be updated which she intends to arrange shortly. Elizabeth House DS0000008401.V286342.R01.S.doc Version 5.1 Page 11 Records looked at emphasised the need for the residents privacy and dignity to be respected at all times, and the staff gave examples of how the residents privacy and dignity were promoted in the home, such as when giving personal care. Residents said that the staff treat them with respect and that their dignity is valued, for example they said that the staff knocked on their bedroom doors before entering. Those residents spoken with said that the staff were “respectful”, “considerate”, “pleasant” and that “they (the staff) talk to us properly”. The staff were seen to deal with the residents in a friendly, comfortable and respectful way. A requirement made at the time of the last inspection was that “The registered person must ensure that the’ manual handling and moving risk assessments for residents’ are reviewed and up dated regularly”. These have since been updated in January 2006 with this requirement now being complied with. A further requirement also made at the time of the last inspection was that “The registered person must ensure that the use of bed rails is both risk assessed and recorded thus ensuring that the use of such equipment is safe”. The manager told the inspector that no bed rails were in use at the time of this inspection and that they are rarely used. The inspector gave advice and written information about the safe use of such equipment. Elizabeth House DS0000008401.V286342.R01.S.doc Version 5.1 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): 14. Residents have choice about their daily routines, spending their time doing whatever they prefer. Where residents are unable to make choices the staff offer support in such a way that promotes the residents dignity and independence. The above key Standards 12, 13 and 15 were not examined at this inspection. It should however be noted that these Standards were met at the time of the previous inspection (November 2005). EVIDENCE: The issue of residents being able to make choices is described in the home’s Statement of Purpose and also the Service User Guide. Residents 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 and how they spent their day. They said that were comfortable living at the home and that the home was “relaxed” and “restful”. For those residents who may have a limited ability to make decisions and choices about their day-to-day living arrangements the staff said that they try Elizabeth House DS0000008401.V286342.R01.S.doc Version 5.1 Page 13 to assist the them with this by offering choices about such things as what clothing to wear, when to rise and retire and helping to choose from the menu. The inspector saw this in the early afternoon when he spent some time in a lounge near to the dining room when the staff were seen to offer the residents assistance with deciding what they wanted to do and with what they wished to drink. The residents are able to, and do bring personal items in to the home such as televisions, radios, photographs, pictures and mobile ‘phones. Elizabeth House DS0000008401.V286342.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18. Protection of vulnerable adults guidance is available and impending staff training in this topic will ensure residents are protected from abuse. The above key Standard 16 and was not examined at this inspection. It should however be noted that this Standard was met at the time of the previous inspection. EVIDENCE: There are written procedures and policies covering adult protection, whistle blowing, dealing with violence and aggression, the none acceptance of gifts, borrowing money and legacies. The home also has a 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.Progress with this training will be checked at the next inspection. However, discussion with the staff showed that they were aware of the different sorts of abuse and they also understood what they should do if they suspected that someone was being abused. 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. Elizabeth House DS0000008401.V286342.R01.S.doc Version 5.1 Page 15 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): The above key Standards 19 and 26 were not examined at this inspection. It should however be noted that these Standards were met at the time of the previous inspection. A requirement regarding Standard 19 was checked and is reported upon below. EVIDENCE: A requirement made at the time of the previous inspection was that “The registered person must ensure that the one outstanding item (smoke seals to fire doors) arising from the Fire Service inspection of 26th April 2005 is dealt with”. The manager told the inspector that the above-mentioned smoke seals had been purchased and were due to be fitted on Monday the 27th March 2006. This work was then due to be checked by a professional fire safety company on the 10th April 2006 when a full fire risk assessment would be done and the staff would be given fire safety training. Elizabeth House DS0000008401.V286342.R01.S.doc Version 5.1 Page 16 The inspector requires that the completion of this work be confirmed in writing to the CSCI. Elizabeth House DS0000008401.V286342.R01.S.doc Version 5.1 Page 17 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 and 29. Staffing levels are generally sufficient to make sure that the residents are properly cared for. Although the manager in the main follows recognised recruitment procedures; the home must ensure that all of the required checks are done when employing staff, therefore making sure of the safety and protection of the residents. The home has met the requirement to have at least 50 of the care staff trained to NVQ Level 2 or above by 2005 so contributing to a good standard of care for the residents. The above key Standard 30 and was not examined at this inspection. It should however be noted that this Standard was met at the time of the previous inspection. EVIDENCE: Looking at staff rotas showed that as well as employing care staff, the home also employs domestic and catering staff A number of the staff have worked at the home for a considerable time, which ensures that residents are cared for by people they know and are familiar with. The residents said that the staff are “kind”, “happy to help” and that they were “patient and considerate”. Elizabeth House DS0000008401.V286342.R01.S.doc Version 5.1 Page 18 Examination of staff duty rotas showed that care staff are regularly available. In discussion the staff said that in their opinion there was generally sufficient staff available at most times of the day to meet the residents care needs; however some staff felt that the staffing level was not always sufficient in the evening period to do all of the work expected of them. This issue was discussed with the manager who felt that evening time staffing levels were adequate and that an increase was not necessary at this time. However, the inspector requires that the adequacy of evening time staffing levels be monitored and if necessary increased. Of the 12 care staff employed at the home all have got a National Vocational Qualification in Care at Level 2 with two of these people also having achieved a Qualification at Level 3. This exceeds the requirement for the home to have 50 of the care staff with NVQ level 2 qualifications or above by the end of 2005. Looking at three staff files showed that they had in the main been properly recruited. Job application forms had been completed, health and criminal convictions declarations were present, two references has been obtained ands photograph of the employee was on file. However one person had brought their Police check with them from a previous employer. Police checks cannot be transferred between employers; they must be done again when staff are newly employed. A requirement is therefore made to this effect. Elizabeth House DS0000008401.V286342.R01.S.doc Version 5.1 Page 19 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 and 33. The manager is able and experienced and she manages the home well, therefore ensuring that the residents receive a good standard of care. The home must regularly consult the residents and their families about the way that the service is run so that both improvements can be made and problems can be dealt with. Key standards 35 and 38 were examined at the time of the last inspection and they were largely met. These standards were therefore not checked at the time of this visit, but the requirements made previously regarding Standard 38 (Health and Safety) were followed up. 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 Elizabeth House DS0000008401.V286342.R01.S.doc Version 5.1 Page 20 been the registered manager of Elizabeth House for approximately the last six years. Ms Parsons has successfully completed the NVQ Level 4 Registered Managers Award. Discussion showed that Mrs Parsons knows the residents and the staff well. The home is well run and residents and staff 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 May and June 2003 the home sought the views of both residents and their families by the use of survey questionnaires. The manager told the inspector that the home was in the process of repeating such a survey at the time of this inspection. The manager is reminded that these surveys should be done at least annually and that when the questionnaires are returned the answers must be brought together in the form of a report so that both good and not so good comments are highlighted and steps can then be taken to deal with any issues. A requirement of the previous inspection was that “The registered person must ensure that the risk assessments for upper floor opening windows and for the hot water outlets to baths are kept up to date and under review thus making sure that the residents are safe”. Such risk assessments were last done in December 2005 and were found to be satisfactory. These risk assessment must be done regularly and the inspector requires that hot water temperatures for the home’s two baths must be checked weekly with a record kept. Elizabeth House DS0000008401.V286342.R01.S.doc Version 5.1 Page 21 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 X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 3 28 3 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X X X X X Elizabeth House DS0000008401.V286342.R01.S.doc Version 5.1 Page 22 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 OP19 Regulation 23 Timescale for action The registered person must 31/05/06 notify the CSCI in writing of when the work required by the Fire Service of the fitting of smoke seals to fire doors is completed. The registered person must 31/05/06 monitor the adequacy of evening time staffing levels and if necessary institute an increase if this is so indicated. The registered person must 31/05/06 ensure that Criminal Records Bureau checks are completed for all staff at the time of their employment. The registered person must 31/05/06 ensure that the residents and their families are regularly consulted about the way that the service is run so that both improvements can be made and problems can be dealt with. The registered person must 31/05/06 ensure that hot water temperatures for the home’s two baths are checked weekly with a record kept. Requirement 2 OP27 18 3 OP29 19 4 OP33 24 5 OP38 13 Elizabeth House DS0000008401.V286342.R01.S.doc Version 5.1 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP18 Good Practice Recommendations The registered person should obtain a full copy of the Bury Social Services Adult Protection Policy so that local guidance is followed should an abuse situation arise. Elizabeth House DS0000008401.V286342.R01.S.doc Version 5.1 Page 24 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.V286342.R01.S.doc Version 5.1 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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