Inspection on 25/05/05 for Elizabeth House

This inspection was carried out on 25th May 2005.

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

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

Other inspections for this house

Elizabeth House 21/04/09

Elizabeth House 12/01/09

Elizabeth House 09/06/08

Elizabeth House 20/11/06

Elizabeth House 25/10/05

Elizabeth House 15/03/05

Elizabeth House 31/08/04

Elizabeth House 12/02/04

Similar services:

Applegarth

Trevayler Residential Care Home

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

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

CARE HOMES FOR OLDER PEOPLE Elizabeth House Perth Avenue New Parks Estate Leicester Leicestershire LE3 6QR Lead Inspector Rajshree Mistry Unannounced 25 May 2005 at 12noon 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 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 C51 S37621 Elizabeth House V37621 250505.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Elizabeth House Address Perth Avenue New Parks Estate Leiceste LE3 6QR 0116 2871031 0116 2871031 None Leicester City Council Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Phillip ODell Care Home 37 Category(ies) of MD(E) Mental disorder over 65 - 20 registration, with number DE(E) Dementia over 65 - 20 of places PD(E) Physical disability over 65 - 8 OP - Old Age - 37 SI(E) Sensory Impairment over 65 - 10 Elizabeth House C51 S37621 Elizabeth House V37621 250505.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: No person falling within category Dementia, DE(E) or Mental Disorder, MD(E) may be admitted to the home when 20 persons who fall within category DE(E) or MD(E) are already accommodated within the home. No person falling within category, Physical Disability, PD(E) may be admitted to the home when 8 persons who fall within category PD(E) are already accommodated within the home. No person falling within category Sensory Impairment, SI(E) may be admitted to the home when 10 persons who fall within category SI(E) are already accommodated within the home. Date of last inspection 15th March 2005 Brief Description of the Service: Elizabeth House Residential Home provides accommodation for thirty seven older people and is owned by the Leicester City Council. The home is located in a quiet residential area. Public transport service can be accessed near to the home. The home is ten minutes car ride from the city centre, Fosse Park and the M1 motorway. Elizabeth House is a large modern and purpose built property. Accommodation is offered on ground and first floor level, which can be accessed by a passenger lift. Bath/shower and toilet facilities are located throughout the home. Car parking space is located to the front of the home. There is a large patio area to the centre of the building. All areas of the home are accessible to people using mobility support, aids and equipment. Elizabeth House C51 S37621 Elizabeth House V37621 250505.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place from 12noon on 25th May 2005 and lasted for over 5 hours. The method of inspection consisted of examining the information received in the pre-inspection questionnaire prior to the inspection. On the day of the inspection the method used consisted of a tour of the premises, examination of the health and safety records for the home, four service users were spoken with and observed, specifically to look at their lifestyle at the home and how their care needs were met. Individual plans of care and relevant care records were examined. Key workers for service users’ talked about care provisions, how the identified needs were met and their training and management support. Service users visiting relatives shared their views about the home, which were very positive and complimentary about the care provided by the home for the service users. Towards the latter part of the inspection visit, time was spent with the home’s manager discussing some of the findings, information received and observations made. What the service does well: Elizabeth House has a stable staff team, with clear roles and responsibilities. The management team operates a named key working system, whereby each service user has at least two named carers. Service users are consulted and encouraged to express their views, raise issues and exercise choice. There is a distinct focus on the needs of the service user and promoting independence. The home’s management team strive to look to continuously improve the standard of the home by listening and receiving good practice information and sharing of good practices. Staff receive good induction training and access a scheduled programme of training. The décor in the home creates a warm atmosphere. Service users move around the home freely. A range of specialist equipment is available in the home. Service users can have their own keys to their bedrooms. A good choice of meals is prepared on the premises, these are nutritionally balanced and meet dietary needs. Management of medication is good with systems in place to monitor. Records relating to service users and health and safety are accessible, in good order and stored in line with data protection. Elizabeth House C51 S37621 Elizabeth House V37621 250505.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Elizabeth House C51 S37621 Elizabeth House V37621 250505.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Elizabeth House C51 S37621 Elizabeth House V37621 250505.doc Version 1.30 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 standard(s) 1, 3, 5, Information about the home and the facilities is made available at the earliest opportunity. The whole admission process is well managed and service users are given clear and detailed information about the provision of care. The robust assessment process ensures that care needs are met and individually tailored. EVIDENCE: There is a comprehensive Statement of Purpose and Service User Guide for all service users accessing long and short term care. The information is clear and made available to the prospective service user and their family at the first meeting or opportunity. The admission procedure is good in that the assessments of individuals are carried out by the health and/or social care professionals, as part of the referral process. Specific risk assessments are carried out by the qualified home’s manager or the deputy managers. Four service users files examined contained information detailing the service users’ choice of lifestyle and how to maintain and promote independence. The management team encourages service users’ and their relatives to visit. A trial period of stay is offered to all prospective service users and to discuss how individual care needs can be met. One service user said he had visited first and then “signed up for life at this home – you can’t get better”. Elizabeth House C51 S37621 Elizabeth House V37621 250505.doc Version 1.30 Page 9 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 standard(s) 7, 9, 10 Service users are well looked after having their health and social care needs met. Care provided is holistic and personalised. Management of medication in the home is good. Service users receive their medication in a timely manner. Recording is accurate and clear. Service users’ privacy is upheld and they are treated with respect. EVIDENCE: Care files were examined for four service users, which contained a plan of care tailored to meet the individual care needs, instructing staff how to deliver the care. Risks identified through specific assessments were managed to promote and maintain the individual independence without compromise. Care plans are reviewed by the Assistant Managers in consultation with the service user and the named key worker. Service users spoken with indicated that they were involved in drawing up their plan of care. Medication is stored in a locked Treatment Room, with medication procedures and is used by the visiting GP or District Nurse. Staff that are trained administers medication. Receipt, storage, administration of medication, returns and recording was seen and is considered to be safe. Medication for service users in hospital or that have recently died is stored in a separate Elizabeth House C51 S37621 Elizabeth House V37621 250505.doc Version 1.30 Page 10 section of the cabinet and clearly labelled. There is a robust system in place for auditing medication regularly. Management of controlled medication is robust. Service users spoken with said that they receive their medication on time and in the privacy of their own rooms. One service user was observed to asked the Assistant Manager for medication that is required as and when, which was recorded when taken on the medication administration records. An Assistant Manager has delegated responsibility to ensure the management of medication is remains robust. Service users and visiting relative spoken with said they were treated with care and the privacy and dignity was respected in the way the care was provided. Observations were made of carers responding to service users requests in that they were attentive, friendly, clearly spoken and were kept informed. Service users have the option of having keys to their own rooms. Elizabeth House C51 S37621 Elizabeth House V37621 250505.doc Version 1.30 Page 11 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 standard(s) 12, 13, 14, 15 Service users have a varied life at the home. There is a range of social and recreational events and activities accessible to all service users, which meets their needs. Service users are supported well in exercising choice and control in their lives. There are good choices of meals that are nutritionally balanced, good quality and meet special dietary needs. EVIDENCE: The service users’ lifestyle within the home is tailored to meet the cultural, social and recreational expectations. Planned events and activities at the home are displayed on the notice boards at the entrance of the home and in a number of communal areas. Service users are supported to practice their faith. Service users can chose to attend the Residents Meetings held regularly and recorded. The Assistant Manager has surveyed service users and staff to revise and improve the programme for social and leisure activities. A small greenhouse has been purchased for service users to be involved in planting activities in the garden. Service users that spoke with the Inspecting Officer indicated that there are planned events on a weekly basis such are Bingo, watching a movie/film. The Registered Manager indicated that there would be a planned barge trip for some service users who have expressed an interest. Service users were seen moving freely around the home, choosing to sit in quieter lounges or going out in the local community. Staff that spoke to the Inspecting Officer indicated that service user are encouraged and supported to Elizabeth House C51 S37621 Elizabeth House V37621 250505.doc Version 1.30 Page 12 make choices and decisions daily such as what to wear to having their hair done. One service user said “make life enjoyable, go out to the OAP centres, St Matthews Church and walks” and was reflected in his plan of care. Some service users were seen relaxing in the privacy of their own rooms watching television or reading a book. Visitors are welcome at any time. One service user receiving a visitor spoke to the Inspecting Officer and said they were satisfied with the provisions and staff respected the choice of lifestyle. This service user having an interest for sewing and staff were aware of this. The menu on the day of inspection was viewed and showed a choice of nutritionally balanced meals accommodating special dietary requirements. The Cook told the Inspecting Officer what dietary requirements existed for some service users and meals are made accordingly. Meals are served in the large dining room, although service users can choose to have meals in their own rooms. Several service users were seen having their lunchtime meals in their own rooms. Service users confirmed that they were offered a good choice of meals at all times. One service user who did not want the roast chicken was offered an alternative. Staff were seen serving drinks and biscuits to service users and their relatives during the inspection visit. Elizabeth House C51 S37621 Elizabeth House V37621 250505.doc Version 1.30 Page 13 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 standard(s) 16, 18 The complaints system is robust, clear and accessible to all. Adult protection procedures are in place and staff in general are aware of the procedures to respond to any suspicion or allegation of abuse. EVIDENCE: There is a robust complaints procedure that is displayed at the entrance of the home and communal areas. Service users are given the home’s complaints procedure at the point of admission and contained in the service user guide. Service users and relatives spoken with indicated that concerns and complaints are acted promptly. A service user who spoke to the Inspecting Officer raised concerns relating to service users wandering at nights. On the concerns being raised with the home’s Assistant Manager and Registered Manager, it was confirmed that arrangements’ would be made to contact the service users’ social worker. Service users spoken with felt they were safe and protected. The new adult protection procedure has been introduced. Two staff spoken with had a good understanding the procedure to follow in accordance with adult protection issues and whistle blowing. Elizabeth House C51 S37621 Elizabeth House V37621 250505.doc Version 1.30 Page 14 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 standard(s) 19, 21, 22, 23, 24 A comfortable, well maintained, personalised and a good standard of accommodation is provided collectively and suited to individual service users needs. The atmosphere in the home is warm and welcoming. Specialist equipment is available to promote service users’ independence. EVIDENCE: Access to the home is wheelchair friendly. The home is in good standard of décor, bright with ample natural light. The home has a handy person who is responsible to repair minor faults, such as the peeling wallpaper near the window in the large bedroom, identified by the visiting relative. On the day of the inspection the handy person was wallpapering a wall in the upstairs lounge, watched by service users. Service users have access to several lounges on the ground and first floor, which is accessed by the stairs or the passenger lift. Bedrooms are also located on the ground and first floor. Staff accommodation is on the lower floor that is not accessed by the service users. Elizabeth House C51 S37621 Elizabeth House V37621 250505.doc Version 1.30 Page 15 All communal areas and hallways were observed to be in a good, clean condition. Grab rails are fixed along the corridor walls. Bath/shower and toilet facilities are close bedrooms and lounges throughout the home. The home has specialist equipment in place to safely hoist and transfer service users. There is a designated wheelchair storage area. One service user that spoke to the Inspecting Officer indicated that there was an occasion when a service user wondered into her room looking for something at night and staff were not immediately aware. Discussion with the Assistant Manager confirmed that this related to a service user with dementia and staff would respond during the nightly checks. The four bedrooms viewed were individually decorated, with personal possessions such as photographs and small items of furniture. The bedrooms were spacious and were provided with lockable storage. One service user occupies a large room to accommodate the wheelchair and hoist. Elizabeth House C51 S37621 Elizabeth House V37621 250505.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 30 Service users’ needs are well met by the number and skill mix of staff. Staff at the home are trained, supported, and employed in sufficient numbers to meet the resident needs. EVIDENCE: The staff rota for the day was examined and reflected the staff on duty, including some agency staff. Observations made during the inspection indicated that the staff were responding to service users needs promptly. The senior management at the home consists of the Registered Manager, two Assistant Managers, senior carers, carers and domestic staff. The Assistant Managers are completing National Vocational Qualification (NVQ) level 4 and projects include revising and improving the social and leisure activities programme and improving the risk assessments. Over seventy per cent of staff have completed NVQ level 2, 3 or 4 with a further group of staff commencing NVQ level 2. All agency staff completed an induction programme covering health and safety and other key policies and procedures. The Local Authority has in place a departmental training plan, the document details general areas of training and training specific to needs of the service users. Two staff files examined contained training undertaken covering health and safety, adult protection, care practice and specialist training such as working with people with sensory impairment, challenging behaviour and mental health needs. The staff-training matrix is used to match key workers for new service users. The management team is in the process of recruiting new staff and systems are in place to ensure that all the appropriate checks Elizabeth House C51 S37621 Elizabeth House V37621 250505.doc Version 1.30 Page 17 have been carried out. The current occupancy in the home includes six service users with dementia care needs. The staff-training matrix viewed showed that not all staff received training in dementia awareness. The service users and relatives that spoke with the Inspecting Officer indicated that staff responded to needs timely and were aware of what they were doing. Staff were observed responding to the nurse call bell system promptly and assisting service users with mobility. Elizabeth House C51 S37621 Elizabeth House V37621 250505.doc Version 1.30 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34, 35, 37, 38 Service users are consulted about living in the home. All service users finances are safeguarded with a robust system. Service users and staff’s health, safety and welfare are being promoted and protected through the home’s policies and procedures. EVIDENCE: Records of service users valuables and cash are accurately detailed and up to date. Service users’ money is safeguard and accessible by the robust procedure. All service users have access to lockable cabinet and a key to their own rooms. The care plans and care records are in good order, and the key working system works well to provide service users with continuity of care. ‘Residents Meetings’ are held regularly and recorded. Service users can chose to attend or speak to the staff. Elizabeth House C51 S37621 Elizabeth House V37621 250505.doc Version 1.30 Page 19 During the tour of the home fire exits were clearly marked and were not obstructed. There is a programme of maintenance and checks in place. A random sample records checked were up to date including tests to fire safety equipment, fire drills, water temperatures and health and safety. The Fire Officer inspected the home on 28/04/05 and found risk assessments in place. Individual risk assessments are in place and reflected in the individual service users plans of care. The handy person is responsible for minor repairs and checks. Elizabeth House C51 S37621 Elizabeth House V37621 250505.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 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 3 x 3 3 3 3 x x STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x 3 3 x 3 3 Elizabeth House C51 S37621 Elizabeth House V37621 250505.doc Version 1.30 Page 21 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. 1. 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. 1. Refer to Standard OP22 Good Practice Recommendations It was strongly recommended that the Registered Manager look to source specialist equipment to alert staff when service users with dementia start to wander at night but without restraint. It was strongly recommended that staff receive specialist training in relation to caring for service users with dementia. 2. 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