Inspection on 26/09/06 for Elizabeth House

This inspection was carried out on 26th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Elizabeth House 31/07/07

Elizabeth House 20/02/06

Elizabeth House 30/08/05

Elizabeth House 14/02/05

Elizabeth House 09/08/04

Elizabeth House 10/02/04

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

CARE HOMES FOR OLDER PEOPLE Elizabeth House Elizabeth Grove Union Road Shirley Solihull B90 3BX Lead Inspector Kulwant Ghuman Unannounced Inspection 26th September 2006 09:35 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 DS0000004507.V310667.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Elizabeth House DS0000004507.V310667.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elizabeth House Address Elizabeth Grove Union Road Shirley Solihull B90 3BX 0121 744 2753 F/P 0121 744 2753 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) Shirley Old People`s Welfare Committee Mrs Ann Baker Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places Elizabeth House DS0000004507.V310667.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th February 2006 Brief Description of the Service: Elizabeth House is a registered care home catering for 19 older men and women aged 65 and over. A committee of a voluntary organisation is responsible for the home. The main criterion for admission is that the prospective resident should be able to walk with or without a walking aid but without the need for physical assistance from another person. The home has three lounges, a dining room and gardens at the front and rear of the building. Bedrooms are located on the ground and first floors. The kitchen, laundry and office are located on the ground floor. It is located in a pleasant cul-de-sac in Shirley, Solihull, which is conveniently close to the main Shirley shopping centre, with amenities such as places of worship, places for socialising and public transport. Fees at the home range from £400 to £450 per week. Elizabeth House DS0000004507.V310667.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this key inspection over one day in September 2006. During the inspection a tour of the building was carried out, lunch was taken with the residents, four residents files and two staff files were sampled as well as other care and health and safety documents. Eight of the residents were spoken with as well as the manager, deputy and one member of staff. Prior to the inspection a completed pre-inspection questionnaire had been forwarded to the CSCI, which gave some information about the home. The inspector also received completed questionnaires from seventeen residents, eight relatives and five visiting professionals to the home. Without exception all the comments were positive and included: “My father receives great care and all his needs are met. Help is always offered. All my suggestions have been acted on and any concerns addressed. I am happy he is in the house. They have not let us down yet.” “Cannot speak highly enough of all the staff. Emotional support is excellent too.” “I think the home is perfectly run.” “Elizabeth House is a home from home. The staff are loving, caring and capable.” What the service does well: The home provides a well-maintained, safe, comfortable and homely environment for the residents to live in. Residents can meet with their friends and relatives at all reasonable times and they are able to choose whether or not to see visitors. The health care needs of the residents are identified and referred to the appropriate professionals for their attention. Residents are enabled to remain as independent as possible and are able to take reasonable risks that would otherwise take away their independence. The residents said that the food was good and well presented. The inspector observed this at lunchtime and appropriate support was given to residents requiring it in a comfortable environment. Elizabeth House DS0000004507.V310667.R01.S.doc Version 5.2 Page 6 The home had a stable staff team providing good continuity of care for the residents. The home is well supported by the management committed and the Friends of Elizabeth House. 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 DS0000004507.V310667.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Elizabeth House DS0000004507.V310667.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,4 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The admission process was well managed ensuring that the staff knew the residents’ needs and ensuring that the home could meet their needs. EVIDENCE: The files of two residents recently admitted to the home were sampled. The files evidenced that where possible the resident and their representatives were invited to the home during which time an assessment was carried out. The assessment documentation was clear and simple and identified the areas where care plans were needed to enable the care staff to meet the resident’s needs. The assessment documentation covered areas including physical health care, mental health care, mood assessment, behaviour assessment, social care needs, participation in activities, personal hygiene care, eating, continence, religion/culture and bereavement. Elizabeth House DS0000004507.V310667.R01.S.doc Version 5.2 Page 9 The home had accessed information about the residents from social workers or hospital discharge notes. One of the files included the terms and conditions of residence in the home that had been signed by the resident, the inspector was informed that the other resident had received a copy but had not yet signed it as they kept forgetting what was included in it. It was advised that in such situations the relative or other responsible individual should be asked to sign the contract. There was no evidence on the files that a 28-day review had been carried out to ensure that the home was suitable for the resident and that their needs could be met on a long-term basis. Elizabeth House DS0000004507.V310667.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 and 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The needs of the residents appeared to be met however the care planning documentation was not completed and it could not be fully determined to what level the needs were being met. Staff did not have the documentation available to them to guide them on how to meet the residents’ needs. The health care needs of the residents were being met. EVIDENCE: The care plans for four residents were sampled. Two were for residents recently admitted to the home and two were for residents who had been at the home for some time. There were no completed care plans available for three of the residents sampled. One of the files had some care plans available but not all the areas identified in the assessment process as requiring a care plan had the corresponding care plan in place. Elizabeth House DS0000004507.V310667.R01.S.doc Version 5.2 Page 11 The inspector was informed that the care plans were being put in place however, it was not acceptable that residents who had been in the home for over 3 months did not have a care plan in place. Also, where residents had had care plans in place previously, these must remain accessible to the care staff until the new care plans are available. There were nutritional and pressure area assessments in place for the residents. There were personal risk assessments in place for one of the residents however, the daily records indicated that the resident was at risk of leaving the building unknown to the staff or may refuse to return to the home whilst out with a member of staff and systems needed to be put in place for staff to manage these situations. Where the documentation had been completed there was evidence of some good practice. For example, the night care plans included information regarding times of rising and going to bed, how often night checks were to be undertaken and so on. The care plans that had been completed for one resident included a good level of detail informing the care staff exactly how to assist the resident with personal care. Also there was information about what tasks the resident could do independently. Care plans and risk assessment needed to be discussed with residents and their representatives and evidenced that this has taken place. Care plans needed to be reviewed on a monthly basis. The risk assessments included information on where there was a risk, for example of not undertaking hygiene tasks fully by the resident, but how a level of risk was acceptable to enable some independence and that the staff were to observe levels of hygiene. There was evidence that the health care needs of the residents were being met by referral to the GP, district nurses, chiropodist, dentist, optician and hospital appointments attended. The management of medicines was generally acceptable. The home continued to use the monthly monitored dosage system. The majority of medicines had been checked against the prescriptions and recorded on the MAR chart however, there were some medicines that had not been recorded appropriately. There were some suppositories in the home but there was no record of their existence as they had been prescribed several months earlier but had been kept in the home to be used by the district nurses as required. The manager needed to ensure that there was an audit trail for all medicines coming into and leaving the home. Elizabeth House DS0000004507.V310667.R01.S.doc Version 5.2 Page 12 There were some Docusate capsules that were with the PRN (as and when required medicines) however the inspector was informed that these had been recently stopped by the GP and were to be returned to the chemist at the end of the medicine period. The manager needed to ensure that the there was a protocol in place for staff who were to administer medicines when required so that there was consistency in when the medicines were given. The storage and recording of controlled medicines was acceptable. There was nothing seen or heard during the inspection to indicate that the residents’ dignity and privacy were not respected. The home was making efforts to record residents’ requirements in respect of culture and religion and their wishes following death. Elizabeth House DS0000004507.V310667.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents were enabled to live a flexible lifestyle, allowing them opportunities for activities if they wanted to join in. There was continued contact with the local community, friends and relatives leading to a sense of belonging for the residents. Residents were happy with the standard of food provided. EVIDENCE: The home recorded the residents’ hobbies and life history prior to moving into the home. There was flexibility in the home regarding the time of rising and going to bed. Whether a cup of tea was required before breakfast and the amount of assistance given to the residents. There was evidence in the residents’ files seen of activities being undertaken including bingo, dominoes, exercises, holy communion, art classes, trips to local gardens and walks out with the staff. There were some entertainers who came into the home. Elizabeth House DS0000004507.V310667.R01.S.doc Version 5.2 Page 14 There was contact with relatives and friends who visited the home. During the inspection it was observed that a resident decided not to see a visitor as it was lunchtime and asked them to return at a later time. The home had access to large cards, jigsaws and dominoes to assist those residents with limited sight. One of the residents told the inspector that they preferred to sit in the quiet lounge and listen to the radio. Residents could choose where to sit in the home and some preferred to stay in their bedrooms during the day and go to the dining room for meals. The menus seen appeared to be varied and nutritious. The meals were home cooked. The inspector was able to take lunch with the residents. The meal consisted of chicken and mushroom pie, roast potatoes, carrots and cabbage. There were boiled potatoes available for some residents. One resident had their meal chopped up and was assisted with eating. Another resident was encouraged to eat. There was a choice of puddings available. Residents were offered seconds and some did take advantage of this. The inspector was informed that residents were asked the previous day if they wanted the meal on offer and could state if they wanted an alternative. There were choices available at breakfast and teatime including a cooked breakfast. All the residents spoken to said they enjoyed the meals. The mealtime was unhurried and provided in a comfortable environment. The inspector discussed with the managers in the home ways in which the meals could be served to ensure that some residents did not have to wait a long time for their meals and how those able to serve themselves could be enabled to do so. Elizabeth House DS0000004507.V310667.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. There are policies and procedure in place to safeguard the residents. EVIDENCE: There had been no complaints registered with the CSCI regarding the home and no official complaints had been received directly by the home. There was a complaints procedure on display in the home and residents were confident that they could raise issues and they would be looked into. There was a grumbles book in the home and there had been two entries made in it. One had been addressed but there was no evidence that the other had been followed through. There was an adult protection procedure in the home but this was not examined during this inspection. Examination of the incident record indicated that there had been an incident where a resident had made an allegation that they had been roughly handled. The GP was called to examine the resident and it was felt that there was nothing to be pursued. The manager must ensure that any allegation is reported to the social work team so that they can make a decision as to whether to invoke procedures or not as the lead agency and decide on how the issue is to be investigated. Elizabeth House DS0000004507.V310667.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,222,24,25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The environment was well maintained and provided a comfortable and homely setting for the residents. Bathing and toilet facilities with specialist equipment were provided suited to meet the needs of the residents. EVIDENCE: The premises had not changed since the last inspection and continued to be suitable for the residents in the home. There was suitable and adequate communal space available for the residents in the dining room, garden and lounges. The inspector was able to enter the home unnoticed by staff in the morning as the door had been left open. Staff needed to be mindful that residents could also have left the building unbeknown to them. Elizabeth House DS0000004507.V310667.R01.S.doc Version 5.2 Page 17 There were assisted bathing facilities on both floors of the home and there were toilets available at appropriate places. Commodes were available in bedrooms for residents requiring them. The home had ramps into the home, a passenger lift connected the two floors of the home and there were adaptations available such as emergency call system, raised toilet seats and grab rails. There were pressure mattresses and cushions available. Hospital type beds had been obtained for residents requiring them. One of the beds seen had raised bedsides but there were no bumpers in place. The inspector was informed that these were available. There was a potential risk that the resident’s limbs could get caught between the wooden sides and therefore a risk assessment needed to be put in place. Bedrooms appeared to be personalised and residents stated they were happy with their rooms. Several bedroom carpets on the ground floor were dirty and needed to be cleaned or replaced as required. The home was centrally heated throughout and radiators had been guarded. The home was found to be clean throughout, apart from the carpets in the ground floor bedrooms. There were no odours in the home. The kitchen was clean and well maintained. The staff needed to ensure that fridge and freezer temperatures were recorded on a regular basis. There were no other concerns regarding the management of infection control. Staff were observed to wear the appropriate protective clothing. Elizabeth House DS0000004507.V310667.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. There were adequate numbers of staff on duty on a daily basis to meet the residents’ needs. The recruitment procedure was robust and staff were competent to do their jobs. EVIDENCE: There were 3 care assistants on duty during the day in addition to the manager and ancillary staff. There were two staff on duty during the night. There was a core team of staff who had been at the home for a number of years. The home had used some agency staff to cover some shifts as there had been some staff on sick leave and one senior members of staff had left. One of the senior members of staff had left the home some time ago and the post had not been filled. The knock on effect of this had meant that the completion of the new care planning documents had taken a lower priority and time was being spent with residents whose care needs had increased with time. There were more than 50 of the care staff who had completed their NVQ Level 2 training. There was an ongoing programme of staff training. Some staff had not undertaken food hygiene training and some staff needed to refresh their first aid training. Fire training had not been undertaken twice a Elizabeth House DS0000004507.V310667.R01.S.doc Version 5.2 Page 19 year. An in-house induction was carried out by the home however the full induction (in line with the Skills for Care induction requirements) needed to be completed within 12 weeks of commencing employment. The recruitment of staff in the home was generally much improved. There was evidence that suggested that one member of staff had been employed and was undergoing induction training prior to the CRB having been received by the home. The manager informed the inspector that the home had not been able to access the POVA first checks due to the payment method used by the home for CRB’s. In this situation the home needed to have received a satisfactory CRB certificate before the individual was employed. All other documentation was available in the home. Elizabeth House DS0000004507.V310667.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The manager ensured the smooth running of the home in a competent manner. The health and safety of the residents and staff was generally well managed. EVIDENCE: The manager had worked at the home for several years and showed a good knowledge of the residents in her care and the issues regarding the management of the home. The care of the residents was given priority in the home. Elizabeth House DS0000004507.V310667.R01.S.doc Version 5.2 Page 21 The home was working towards gathering information to assess the quality of their service. The home needed to ensure that the views of the residents were sought and a development report for the home was drawn up taking into account the residents’ views about the quality of the service provided. The home was looking after some monies left in safekeeping on behalf of the residents. There were adequate records maintained of the monies spent on behalf of residents and receipts were available. Health and safety were well managed in the home with servicing of equipment carried out on a regular basis. Fire checks were being carried out however, the home had failed to evidence that weekly fire alarm checks had been carried out since 12th September and the monthly emergency lighting had not been tested since 21st July 2006. Fire training was last carried out in October 2005 and the manager was advised that training was required every 6 months. Elizabeth House DS0000004507.V310667.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 2 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Elizabeth House DS0000004507.V310667.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 OP4 Regulation 14(2) Requirement The home must ensure that a 28 day review is carried to ensure that the home can meet the resident’s needs and that the resident and their representative is happy about the service. The manager must ensure that care plans are in place to meet all the identified needs of the residents. Care plans must be put in place in a timely manner following admission to the home. All existing care plans must be replaced with the new documents. Care plans must be crossreferenced to the risk assessments and all identified risks must have a strategy in place to manage the risk. Care plans must be reviewed on a monthly basis. 2. OP9 13(2) The manager must ensure that DS0000004507.V310667.R01.S.doc Timescale for action 01/11/06 2. OP7 15(1) 01/02/07 01/11/06 Page 24 Elizabeth House Version 5.2 there are instructions for staff detailing when PRN medicines are to be given. (Previous timescale of 15/03/06 not met.) The manager must ensure that all medicines are booked into the home and there is an audit trail for all medicines received into the home. Medicines to be returned to the pharmacist must be kept separate to the PRN medicines. 3. OP18 13(6) The manager must ensure that any suspicions or allegation of abuse are reported to the social work office. The bedroom carpets on the ground floor must be cleaned or replaced as required. The manager must ensure that residents are not put at risk by leaving doors open and unattended. There must be risk assessments in place for the use of bed rails for each resident requiring them. Fridge and freezer temperatures must be recorded on a regular basis. The manager must receive a satisfactory CRB or POVA first check before employment of staff commences. Staff must undertake food hygiene and first aid training where required. Skills for Care inductions must be completed within 12 weeks of starting employment. The manager must ensure that they achieve the Registered Managers Award. DS0000004507.V310667.R01.S.doc 01/11/06 4. 5. OP19 OP19 16(2)(c) 13(4) 01/04/07 01/11/06 6. 7. OP26 OP29 13(3) 19Sch 2 01/11/06 01/11/06 8. OP30 18(1)(a) 01/04/07 9. OP31 18(1)(a) 01/04/07 Elizabeth House Version 5.2 Page 25 (Not checked for compliance at this inspection and requirement carried forward.) 10. OP33 35(a, b) The manager must ensure that a report is prepared on the quality of the service provided based on the views of the residents. Staff must receive a minimum of 6 supervision sessions a year. (Compliance not assessed during this inspection and requirement carried forward. Fire alarms must be tested on a weekly basis and records kept. Previous timescale of 31/08/05 and 21/02/06 not met. The emergency lighting test must be carried out on a monthly basis. Fire training must be provided for staff on a six monthly basis. 01/04/07 11. OP36 18(2) 01/04/07 12. OP38 23(4)(c) 14/10/06 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. 2. Refer to Standard OP2 OP15 Good Practice Recommendations The resident’s representative should be asked to read and sign the terms and conditions on behalf of the resident where the resident is unable to do so. The home should consider ways in which residents could be given more independence at mealtimes. Elizabeth House DS0000004507.V310667.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 DS0000004507.V310667.R01.S.doc Version 5.2 Page 27 - 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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