Inspection on 30/08/05 for Elizabeth House

This inspection was carried out on 30th August 2005.

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 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 31/07/07

Elizabeth House 26/09/06

Elizabeth House 20/02/06

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 Solihull B90 3BX Lead Inspector Kulwant Ghuman Unannounced 30 August 2005 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 E54 S4507 Elizabeth House V247259 300805 Stage 2.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Elizabeth House Address Elizabeth Grove Union Road Shirley Solihull B90 3BX 0121 744 2753 0121 744 2753 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) Shirley Old Peoples Welfare Committee Ltd Mrs Ann Baker Care Home 19 Category(ies) of Older People registration, with number of places Elizabeth House E54 S4507 Elizabeth House V247259 300805 Stage 2.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 14 February 2005 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. Elizabeth House E54 S4507 Elizabeth House V247259 300805 Stage 2.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out on an unannounced basis by two inspectors on the 30th August 2005. A complaint had been made to the CSCI that needed to be investigated which was undertaken as part of the unannounced inspection of the home and the findings have been included in this report. This was the first of the statutory visits to the home for the April 2005/ 2006 year. During the inspection process the inspectors were able to tour the building, have lunch with the residents, speak with five residents and sample some documents including some care documents. All of the residents spoken with said they were happy with the care provided. The manager and a senior carer were spoken with. What the service does well: What has improved since the last inspection? What they could do better: The home must improve the management of records by ensuring that all the required documents are updated, stored securely and available in the home. Information for residents should be available in larger print. Elizabeth House E54 S4507 Elizabeth House V247259 300805 Stage 2.doc Version 1.40 Page 6 The home needs to look at ways in which the lunchtime choices are made known to residents. Staff supervision must be held more regularly. Some heath and safety issues including the testing of fire equipment and the management of medicines in the home needed to be improved. The home must introduce a system for monitoring the service provided by the home. 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 E54 S4507 Elizabeth House V247259 300805 Stage 2.doc Version 1.40 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 E54 S4507 Elizabeth House V247259 300805 Stage 2.doc Version 1.40 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, 2, 3, 4, 5 There was information available for prospective residents about the facilities and services in the home enabling an informed decision about admission to be made ,some amendments were needed to improve this information. Copies of the social worker’s assessments were not being obtained therefore staff did not know the needs of the residents at the pre-admission visit. EVIDENCE: There was a statement of purpose available for residents but it needed to be amended to include a complaints procedure indicating the procedure to be followed in the event of a complaint, timescales for responding to the complainant and details of how the CSCI could be contacted by the complainant. It was recommended that the where there are emergency placements a timescale is given within which all relevant information regarding the resident is provided to the home by the placing authority. The statement of purpose should also indicate that residents above the age of 65 years could be admitted to the home. It was also recommended that the statement of purpose was made available in a larger print size so that residents (and their representatives) with failing sight would find it easier to read. Elizabeth House E54 S4507 Elizabeth House V247259 300805 Stage 2.doc Version 1.40 Page 9 One of the residents’ files sampled did not have a completed terms and conditions of residence for the home in place. The blank copy available in the file did not have the correct address of the CSCI office covering the home. There was a care plan available from the placing social worker; however, this did not provide very much detail regarding the needs of the resident. There were some details available on the assessment carried out by the hospital. It was recommended that the home request a copy of the assessment of need completed by the authority responsible for the placement. Residents and their representatives were encouraged to visit the home prior to admission to the home. There was no recorded assessment carried out at the pre-admission visit to the home so it could not be determined that the home had assessed whether the home could meet the needs of the residents. Residents were admitted to the home on a trial basis and a 28-day review was carried out to determine whether the placement met the residents needs and if it was to become long term. Elizabeth House E54 S4507 Elizabeth House V247259 300805 Stage 2.doc Version 1.40 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 standard(s) 7, 8, 9, 10 The home had some good care plans in place but for new admissions to the home a care plan needed to be put in place as soon as possible after admission so that care staff could assist the resident as required. All risks identified for residents needed to have management strategies in place. The management of medicines in the home was good. EVIDENCE: One of the two residents files sampled did not have a care plan in place. For one resident this was due to the residents recent admission. The inspectors were told that the senior staff guided the care staff on how to meet the residents’ needs. The home must ensure that a care plan is drawn up as soon as possible after admission to the home to guide staff on individual care needs. . The other file had a care plan that contained some good information on how the needs of the resident were to be met. There were no tissue viability assessments in place and risk assessments needed to ensure that there were strategies available to staff for handling any identified risks. The health care needs of residents were adequately met with input from GP’s, district nurses, opticians, dentists and community psychiatric nurses. Elizabeth House E54 S4507 Elizabeth House V247259 300805 Stage 2.doc Version 1.40 Page 11 Weight records were maintained in the home but these were not always on a monthly basis due to residents not being able to stand on the scales. The home needed to look into the possibility of accessing a more appropriate weighing scale or looking into other ways in which residents’ weights could be monitored. The management of medicines in the home was generally good with only a few inconsistencies noted during an audit of medicines by the inspector. The audit indicated that a controlled medicines register was needed, balances of medicines not used up in one month were not carried forward on the MAR charts, and on occasions medicines were signed for but not given to the resident or the amounts left in the trolley did not correspond to what should be left according to the MAR charts. Movicol was being administered from a communal box which was not acceptable as it could not be determined that residents were receiving it through an audit trail. Each resident’s supply belongs them individually. Staff should not be using medicines from the homely remedies supply and there was no clear audit trail for these medicines. Where directions for the administration of medicines had been changed this needed to be recorded on the MAR chart and signed by two members of staff. Staff administering medication had undertaken accredited training. There were photographs of the residents kept with the MAR charts as well as copies of prescriptions. Residents were treated with respect and their right to privacy was upheld by the staff and the provision of appropriate privacy locks on bathroom and toilet doors, enabling residents to lock their bedrooms if they wished. Staff knocked on doors before entering. There was a telephone that could be used by residents in the quiet lounge in private. Elizabeth House E54 S4507 Elizabeth House V247259 300805 Stage 2.doc Version 1.40 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 standard(s) 12, 13, 15 Residents were able to live a lifestyle that was individualised and were encouraged to maintain contacts outside the home. Residents receive well prepared meals that they enjoy. EVIDENCE: The Friends of Elizabeth House were involved in organising several activities in the home. There was a programme of activities organised for each day and these included art classes, dominoes, quizzes and live entertainment in the home. Residents enjoyed sitting in the gardens and chatting in the lounges or spending time on their own bedrooms. The inspectors were informed that residents were also taken for walks and rides out on a small group basis. Some residents went out with their relatives. Representatives of local churches visited the home so that residents’ religious needs could be met if they wanted. There was a library service to the home that enabled the residents to have access to a selection of books. Residents were enabled to choose clothes they wanted to purchase by organising regular clothes shows in the home. Elizabeth House E54 S4507 Elizabeth House V247259 300805 Stage 2.doc Version 1.40 Page 13 There was nothing seen in the home that indicated that there were any restrictions on residents maintaining contact with family and friends. The inspectors were able to join the residents for lunch. The meal was well presented and the residents appeared to enjoy the meals. There were choices on offer for the pudding and there was evidence that there were choices available at teatime. The lunchtime menu was on display outside the dining room. It was recommended that this be displayed in a larger print so that it was easier for the residents to read. The residents told the inspectors that staff went around the evening before to ask what they wanted the following evening. It was recommended that the home look at possible ways of making it clearer that there was a choice of food available at lunchtime. Diabetic dietary needs were catered for. There were no residents who required culturally sensitive diets. Elizabeth House E54 S4507 Elizabeth House V247259 300805 Stage 2.doc Version 1.40 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 standard(s) 16, 18 The home did not receive many complaints but needed to ensure that complainants were reassured that their complaints were being taken seriously and records of the investigation held securely in the home. The home needed to ensure accurate recording of any potential adult protection issues, to ensure residents are protected by action and protection. EVIDENCE: There was a very brief complaints procedure available in the home that did not include any timescales for responding to the complaint and needed the contact details of the Birmingham and Solihull office of the CSCI included in it. The complaints log was examined and it contained details of two complaints made to the home during July 2005 by the same resident. A complaint had been received by the CSCI, which was being investigated as part of the unannounced inspection regarding the attitude of a carer towards a resident. Discussions with staff and examination of the records did not uphold the complaint. There was no evidence available to determine that the resident had been subjected to persistent harassment/verbal abuse/bullying by a carer. The complainant was also concerned that the home had not taken their concerns seriously. There were no records of the issues raised by the complainant, the actions taken by the home in response to the issues raised and no copies of letters sent to the complainant in response. Elizabeth House E54 S4507 Elizabeth House V247259 300805 Stage 2.doc Version 1.40 Page 15 The complainant said that there had been several telephone conversations and face-to-face meeting but there was no evidence of the issues discussed or the outcomes. The inspectors were told that some documents regarding the complaint investigation had gone missing. The home must ensure that a record of all complaints made to the home must be logged in the complaints log and that the responses to the complaints must be held securely in the home. The home had a suitable abuse policy in place. During the inspection, and complaint investigation, an issue was identified that could have been seen as an issue of adult protection. The home must ensure that any resident who is the subject of any behaviour that could be identified as raising adult protection issues is referred to the social worker or social work team if unallocated for consideration of the adult protection issues. The home must ensure that there is accurate recording of these incidents. Elizabeth House E54 S4507 Elizabeth House V247259 300805 Stage 2.doc Version 1.40 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 standard(s) 19, 20, 21,2 2, 23, 24, 25, 26 The premises were clean and well well-maintained ,providing very comfortable communal and private accommodation for the residents which was suited th their needs. Bathing and toilet facilities with specialist equipment is provided suited to meet the needs of the residents. EVIDENCE: The premises were well maintained with an ongoing programme for refurbishment of bedrooms. The lounges, dining room and garden were pleasantly furnished and comfortable for the residents. The garden area was not totally secure but the area was overlooked by the supported living accommodation in the area and staff supervised the residents when they were in the garden. The staff and manager needed to be mindful of residents with dementia and the possibility of someone walking away unnoticed. There was ramped access into the home. Bedrooms were located on the first and ground floor and there were adequate bathing facilities on both floors. On the first floor there were two bathrooms of Elizabeth House E54 S4507 Elizabeth House V247259 300805 Stage 2.doc Version 1.40 Page 17 which one was assisted. The residents on the first floor needed to be able to walk up and down at least 3 steps to access the assisted bath. On the ground floor the walk-in shower room was in the process of being redecorated. There was an additional assisted bath available to the residents providing them with a choice of shower or bath. There were appropriate privacy locks in place on bathrooms and toilets. There was a shaft lift enabling those residents with additional mobility needs to access the first floor. There was an emergency call system in place covering all areas of the home. The inspectors tested one of the call points which was cancelled prior to the member of staff reaching the bedroom, however, the inspectors were informed that unless the call was cancelled from the bedroom the alarm would start ringing again within a short period of time. This facility reduced the risk of residents being left unattended. There were hand and grab rails in all suitable places. The bedrooms which varied in size were individualised to meet the residents’ requirements. All the residents seen were happy with their bedrooms. All bedrooms were appropriately furnished and decorated as required with the agreement of the resident. One bedroom was in need of redecoration but the resident did not want it decorated at the present time. A couple of bedrooms on the ground floor needed to have the carpets replaced. The home was centrally heated with radiator guards in place that allowed the residents to control the temperatures. Hot water was available throughout the home. One of the water outlets in the bathroom in the assisted bathroom on the first floor delivered water that was too hot. Regular checks of the water temperatures were made by the home but this indicated that the water regulator needed to be adjusted. The extractor fan in the walk in shower on the ground floor was not in working order. There was a laundry at the home that was very well organised and kept clean and tidy. Elizabeth House E54 S4507 Elizabeth House V247259 300805 Stage 2.doc Version 1.40 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 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, 29, 30 Staffing levels and competencies were such that the needs of the residents could be safely met. The recruitment procedures needed to be improved to ensure that CRB checks were received prior to the employment of staff. EVIDENCE: There were 3 care assistants on duty throughout the day in addition to the manager or assistant manager. There were additional staff on duty to undertake the cleaning and cooking duties. During the night there were two members of staff on duty. There was one vacancy in the home for a senior care assistant. There was no evidence to suggest that there was a large turnover of staff at the home, however as part of the complaint being investigated a letter was received by the CSCI raising issues about the reasons for some staff leaving the home and the management style of the manager. These issues could not be taken any further as they were not specific. One staff file was sampled. The file evidenced that a CRB check had been undertaken however it was not received until several months after the individual had taken up employment. There was no evidence that a POVA first check had been undertaken. There was a record of induction but it was not dated or signed. Theses records This did not evidence that all the required checks were taken to ensure that only individuals suitable to work with vulnerable adults were employed in the home. Elizabeth House E54 S4507 Elizabeth House V247259 300805 Stage 2.doc Version 1.40 Page 19 Discussions with the manager and staff at the home indicated that the home would benefit from training in the care of residents with dementia and other mental health needs, and, some team building. Elizabeth House E54 S4507 Elizabeth House V247259 300805 Stage 2.doc Version 1.40 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 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) 31, 32, 36, 37, 38 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 with some further improvements required. Residents are consulted and involved in issues relating to activities, menu selection and events within the home, enabling them to exercise choice and independence. EVIDENCE: The manager had worked in the home for about 10years. The home was managed well and the manager was currently undertaking the Registered Managers Award. The manager attempted to ensure that the home was managed so that it benefited the residents. The home was not registered for residents with dementia or specific mental health needs but there were residents in the home Elizabeth House E54 S4507 Elizabeth House V247259 300805 Stage 2.doc Version 1.40 Page 21 that were developing these needs and with an ageing population it was likely to occur more often. Staff needed to be equipped in recognising when these needs were developing and ways in which they could manage these needs. Discussions during the investigation of the complaint indicated that there had been some problems within the staff group and between some staff and the complainants. The manager needed to undertake some team building within the staff group and discuss the lessons that could be learnt from the complaint. The inspector was told that there were regular residents’ meetings and the statement of purpose indicated that they should be held four times a year. There were minutes of two residents’ meeting available for inspection that showed that residents were consulted on the menus and activities in the home. The staff file sampled showed that there had been only one supervision session within a period of 8 months. The home needed to ensure that all accidents where an injury had occurred to a resident or where a third party, for example district nurse, had been involved are notified to the CSCI through the reporting system. Any incident that affects the well-being of a resident must also be notified to the CSCI. Accident records needed to be numbered and stored appropriately so that the requirements of the Data Protection Act were adhered to. The missing persons policy needed to be amended to include the details of the CSCI and ensure that checks are made regarding the well being of the resident on their return to the home. Health and safety were generally very well managed in the home and issues raised by staff were quickly addressed. The fire alarms were not being tested on a weekly basis and must be done so to assure the continued safe working of the system. The fire risk assessment needed to be updated and the home must ensure that it meets the requirements of the fire service. Staff training in the actions to be taken in the event of a fire needed updating. One of the fire exit doors was locked with a key and this could cause a problem if there was a fire and the key could not be found. The manager needed to liaise with the fire service regarding the use of keys on fire exit doors. The monthly testing of the emergency lighting was out of date and although the gas equipment had been serviced no certificate had been left at the home. Elizabeth House E54 S4507 Elizabeth House V247259 300805 Stage 2.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 2 2 2 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 2 3 x x x 1 2 2 Elizabeth House E54 S4507 Elizabeth House V247259 300805 Stage 2.doc Version 1.40 Page 23 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 OP1 Regulation 4(1) Requirement The statement of purpose must be amended to include the details discussed during the inspection. All residents must be provided with a terms and conditions of residence at the point of admission to the home. A copy of the assessment carried out by the placing authority must be obtained by the home prior to admission of a resident to the home. A care plan must be written up for residents as soon as possible after admission to the home. A tissue viability assessment must be in place for all residents. There must be a management strategy in place for all risks identified for residents. Arrangements must be made to enable the weights of residents to be monitored regularly. A controlled medicines register must be in place. Balances of unused medicines must be carried forward on the MAR charts.There must be a clear audit trail for all medicines received into the home(including Timescale for action 28.10.05 2. OP2 5(1) 15.10.05 3. OP3 14(1)(b) 15.10.05 4. 5. OP7 OP7 15(1) 13(4)(c) 15.10.05 28.10.05 6. 7. OP8 OP9 12(1)(a) 13(2) 1.11.05 15.10.05 Elizabeth House E54 S4507 Elizabeth House V247259 300805 Stage 2.doc Version 1.40 Page 24 8. OP16 22(1) 9. OP16 17(2) Sch 4(11) 10. OP18 17(1)(a) Sch 3(j) 11. 12. OP24 OP25 16(2)(c) 13(4)(c) 13. 14. 15. OP25 OP29 OP30 23(2)(c) 19 Sch 2 18(1)(a) homely remedies) and medicines in the home must tally with those recorded on the MAR charts. Any changes to the prescribing directions for medicines must be recorded on the MAR chart and signed by two staff. Communal supplies of medicines should not be used in the home. The complaints procedure available in the home must include timescales for response, the procedure to be followed by the complainant and the details of how the CSCI can be contacted by the complainant. A record of all complaints made by service users or their representatives or people working at the home, and actions taken in response to any complaint must be kept securely in the home. An accurate record must be maintained of any incident in the care home that is detrimental to the health or welfare of any resident and ensure it is dealt with according to the adult protection procedures. The bedroom carpets identified as being in need of replacement must be replaced. The hot water temperature in the bathroom on the first floor must be maintained at 43 degrees centigrade to prevent scolding. The extractor fan in the shower room must be repaired. All recruitment checks must be in place before employees take up employment. Induction records must be dated and signed and completed within 6 weeks of employment. 28.10.05 15.10.05 15.10.05 1.4.06 1.10.05 15.10.05 1.10.05 1.10.05 Elizabeth House E54 S4507 Elizabeth House V247259 300805 Stage 2.doc Version 1.40 Page 25 16. OP30 18(1)(c) (i) 12(5) 17. OP32 18. OP33 35(a-b) 19. 20. OP36 OP37 18(2) 17(1) 21. OP37 37 22. OP38 23(4)(c) (v) 13(4)(c) 23(2)(c) 16(2)(j) 16(2)(j) 23. 24. 25. 26. OP38 OP38 OP38 OP38 Staff must undertake training in the care of residents with dementia and mental health diseases. Staff must be encouraged and assisted to maintain good personal and professional relationships between each other and with residents and their representatives. The Registered Manager must ensure an effective quality assurance and quality monitoring system is implemented within the home to measure the aims, objectives and statement of purpose of home. (Not assessed for compliance at this inspection and carried forward . Previous timescale given 4.4.05) Staff must receive a minimum of 6 supervision sessions a year. The missing persons policy must be amended and the accident records stored according to the Data Protection Act. Nofications as required by regulation 37 of the care homes regulations must be forwarded to the CSCI as soon as possible after the event. The emergency lighting must be tested on a monthly basis . Fire alarms must be tested on a weekly basis. Fire training for staff must be updated. A copy of the gas certificate must be forwarded to the CSCI. Fire alarms must be tested on a weekly basis and records kept. The registered manager must ensure that kitchen staff label and date all decanted food packets stored in the pantry or freezer (Not accessed for compliance at this inspection and carried forward . Previous time. 1.1.06 15.11.05 1.1.06 1.4.06 1.10.05 31.8.05 31.8.05 14.9.05 15.10.05 31.8.05 1.10.05 Elizabeth House E54 S4507 Elizabeth House V247259 300805 Stage 2.doc Version 1.40 Page 26 27. OP38 16(2)(j) The registered manager must ensure an improved system of managing condiments : these must be rotated to avoid items being out of date. (Not assessed at compliance at this inspection. Previous timescale given 16.03.05) 1.10.05 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 OP1 Good Practice Recommendations A timescale should be included in documentation in which the placing authority must provide the home with all the relevant information for residents placed in emergency at the home. The statement of purpose should be available to residents and their relatives in large print. A record should be made of the assessment carried out by the home at the pre-admission visit. The home should look into possible ways of making choices at lunch time clearer to residents. 2. 3. 4. OP1 OP3 OP15 Elizabeth House E54 S4507 Elizabeth House V247259 300805 Stage 2.doc Version 1.40 Page 27 Commission for Social Care Inspection Birmingham & Solihull Local 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 E54 S4507 Elizabeth House V247259 300805 Stage 2.doc Version 1.40 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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