Inspection on 31/07/07 for Elizabeth House

This inspection was carried out on 31st July 2007.

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

The inspector 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 26/09/06

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 Deborah Shelton Unannounced Inspection 31st July 2007 10:40 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.V347353.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.V347353.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.V347353.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th September 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. The current range of fees at the home is £425 to £450 per week. Additional charges are made for chiropody, hairdressing, toiletries and newspapers/magazines Elizabeth House DS0000004507.V347353.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The following are the findings of an unannounced inspection visit that took place on Tuesday 31 July 2007 between the hours of 10:40am and 7.45pm. The Home manager was on duty along with a team leader and three care assistants, the cook and two domestics. Nineteen people were living at Elizabeth House at the time of the visit. Three residents were ‘case tracked’, this involves finding out about the individual’s experience of living in the care home by meeting with them, talking to them and their families (where possible) about their experiences. Looking at their care files, looking at their environment, and discussions with staff on duty. Reviewing staff training records to ensure training is provided to meet resident’s needs. The inspection process consisted of a review of policies and procedures, discussions with the manager, staff and residents. Other records examined during this inspection included, complaints, care, staff recruitment, social activity records, staff duty rotas, health, safety and medication records. Notification of incidents received by us from the Home and any other information received were also examined. The inspection process enabled the inspector to see residents in their usual surroundings and see the interaction between staff and residents. The inspector was introduced to a majority of the people that live at Elizabeth House and conversations were held with seven people. Further information to identify the outcomes for residents’ was also gained through observation of residents and staff and discussion with staff. The inspector wishes to thank the manager and her staff for the hospitality on the day of inspection. What the service does well: The atmosphere at Elizabeth House was relaxed and friendly, residents were at ease in their surroundings and in the company of staff. Fixtures and fittings are reasonably well maintained and furnishings give a homely feeling. Residents stated that they are happy at the Home and gave positive feedback as follows: “I am totally happy here” “you can come and go as you like but it is courteous to tell them where you are going” Elizabeth House DS0000004507.V347353.R01.S.doc Version 5.2 Page 6 “I live like I would in my own home, like a hotel but better” “there is something going on every afternoon, you join in if you want to” “I was depressed and lonely when I lived at home but I feel safe here and can chat to others or have time alone” “it is a home with a small h. It is better than a hotel I couldn’t ask for better. Everything and everyone is perfect. The food is cooked to perfection, you couldn’t ask for better” “it’s first class here you couldn’t ask for more” “this is a first class place” “the management is fantastic, they do anything for you” “you come to realise that at the end of your life there has to be changes. You have to leave your home which is sad but I couldn’t expect anything better than this, its first class” Some residents who spoke to the inspector offered their assistance with answering any questions about the Home. These residents said that they were perfectly happy at Elizabeth House. Staff commented that they work well as a team, have the equipment needed to be able to do their job and have regular training updates. What has improved since the last inspection? The manager and staff have worked hard to improve care plans and risk assessments. At previous inspections it was noted that care plans were not available for some residents and risk assessments were not linked to those care plans available. This requirement was considered to be met at this inspection. Care plans contained comprehensive information to guide staff regarding the health, personal and social care needs of residents. A majority of daily entries gave a detailed account of residents’ health and wellbeing on a daily basis. Systems regarding medicine management have improved. Staff now keep copies of original prescriptions and check the details against MAR and medication received. Medicines to be returned to the pharmacy were stored appropriately on the day of inspection. Documentation was seen to demonstrate that eight carpets have been ordered and are due to be laid in bedrooms in September. Elizabeth House DS0000004507.V347353.R01.S.doc Version 5.2 Page 7 The manager confirmed that staff do not work at the Home before a satisfactory Protection of Vulnerable Adults (POVA) and Criminal Records Bureau (CRB) check are received. This was evidenced in the staff files reviewed. This requirement made at the last inspection is now met. A majority of issues identified at previous inspections have now been addressed and the manager is aware of the action to take to address outstanding issues. 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. The summary of this inspection report can be made available in other formats on request. Elizabeth House DS0000004507.V347353.R01.S.doc Version 5.2 Page 8 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.V347353.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People receive a full assessment identifying their needs and abilities. This ensures that the Home can meet their needs and care can be planned before the resident moves in to Elizabeth House. Residents receive sufficient information to enable them to make an informed choice about moving into the Home. EVIDENCE: A copy of the Service User’s Guide is given to all residents upon admission to the Home. This document is available in large print and contains information about the service people can expect to receive at Elizabeth House. A requirement was made at the last inspection to ensure that each resident is issued a contract and signs this document to confirm that they agree with the terms and conditions of occupancy. The manager confirmed that this has been Elizabeth House DS0000004507.V347353.R01.S.doc Version 5.2 Page 10 achieved and the three care files seen contained signed and dated contracts. There was therefore documentary evidence to demonstrate that these resident’s have agreed to the terms and conditions of occupancy at this Home. A discussion was held with the manager regarding the pre-admission process. A majority of pre-admission assessments are undertaken whilst the potential resident visits the Home to have a look around and chat to other residents. The manager or deputy undertake pre-admission assessments and find out as much information as possible from the potential resident or their relative. The manager confirmed that they would visit the person in hospital to undertake the assessment if this was necessary, however they encourage everyone to have a look around the Home before they agree to move in. Information about the Home is discussed and questions are asked about the resident’s health and well being. All three care files seen, including that of the most recently admitted resident contained pre-admission assessment documentation which demonstrated that sufficient information is gathered about the resident to ensure that the Home would be able to meet their needs. One resident confirmed that she had visited the Home twice with a friend and had all of the information she needed before any decision was made about moving in. Elizabeth House DS0000004507.V347353.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents have a plan of care, which describes what staff have to do to meet the identified needs of people living in the home. Medication administration practices are good and protect residents from harm. Residents are treated with respect at all times. EVIDENCE: Three people were identified for case tracking. Their care files and associated documentation was reviewed and conversations where held with these residents where possible. A requirement was made at the last inspection as the care files viewed did not have care plans. Each person now has a care plan and monitoring records. Standardised documentation is used during the care planning process. Care plans contained information enabling staff to meet the needs of those under their care. They were appropriate, current and available for every Elizabeth House DS0000004507.V347353.R01.S.doc Version 5.2 Page 12 identified need. For those residents who are mainly self-caring care plans were in place regarding any risk identified. Care plans mention privacy, dignity and the type and level of assistance needed, and details of any equipment needed to assist with daily living. Instructions regarding how staff are to assist resident’s with bathing to avoid any cross infection were recorded in files seen. One of the care plans required review and updating as the last review was over two months ago. Reviews were not taking place on a monthly basis as this resident is mainly self caring and has a low level of unchanging needs. Care plans and risk assessments were in the process of being developed for the most recently admitted resident who had moved into Elizabeth House one week ago. Care plans contained brief information obtained from the preadmission assessment. The manager confirmed that these are updated with further information within the first few weeks of admission. Records of discussions between key workers and residents are available, some of these are signed by residents. Documentary evidence was available to demonstrate that the Deputy manager had audited one of the files and recorded that staff must ensure that care plans are signed by residents. There was no documentary evidence to demonstrate that this had been done. Key worker records were completed in one file up to April 2007. This resident’s health had deteriorated and the resident is no longer able to participate in social activities due to ill health and prolonged periods of bed rest. Staff must ensure that they record times when they have one to one time with this resident, chatting, completing manicures etc as records should be kept of social stimulation for residents who are not able to leave their beds for any period of time due to ill health. Daily records for this resident were very detailed and recorded changes in general condition and health care needs. There was no documentary evidence to demonstrate that all residents are being weighed on a regular basis. The manager confirmed that there had been difficulties weighing those residents who are unable to stand unaided. Scales have recently been purchased so that those residents who use wheelchairs can be weighed in their chairs. The manager confirmed that regular weights will be recorded as soon as these scales are received. Until the weight of residents is recorded and monitored this issue will remain outstanding. It was identified at the last inspection that risk assessments are not crossreferenced to care plans. From review of documentation at this inspection it was noted that this issue has been addressed. Any risk identified now generates a care plan that describes the action that staff are to take to reduce Elizabeth House DS0000004507.V347353.R01.S.doc Version 5.2 Page 13 the identified risk. Details of specialist equipment required was recorded in risk assessments and in care plans. Risk assessments were available regarding the risk of developing a pressure area, falls, nutrition, restraint, mobility and risk assessments specific to individual residents i.e. going to the shops alone etc. Fluid and food intake charts are available for any resident identified at high risk on the nutritional risk assessment. These were seen in the bedroom of one resident being case tracked. Each care file contained a brief life history. Some daily records contained insufficient information for example, “fine” or “slept well” was recorded on occasion. This does not give any description of the resident’s health and wellbeing or how they have spent their time. A majority of daily records contained detailed information about the resident’s health and personal care tasks undertaken. Entries in care files and comments by residents confirmed that relevant health professionals such as the GP, district nurse, optician, dentist and chiropodist are accessed as necessary and are involved in meeting the health care needs of those that live at Elizabeth House. Information regarding any accidents or incidents are kept in care files, staff are therefore easily able to monitor ongoing accidents and take appropriate action and data protection standards are met. Specialist equipment required as detailed in pre-admission assessments and care plans was available in resident’s rooms or communal areas as appropriate. All residents spoken to were positive about the care they receive in the home. The management of medicines was examined. The home has a medication trolley, which is securely stored when not in use. The medication administration records for the three residents reviewed through the case tracking process were seen. Each medication administration record (MAR) was completed in a satisfactory manner and medications available were in line with those recorded on MAR charts. Storage of medication was appropriate on the day of inspection, controlled drugs storage facilities were available. Keys to medication cabinets were not appropriately stored. The manager was advised to ensure that medication cupboard keys are securely locked away when not in use. Staff on duty should have access to the keys at all times. Following the visit confirmation was received that medication cabinet keys are held by staff on duty who sign a sheet at the end of each shift to record who the key has been handed to. Documentation to demonstrate this was forwarded. Elizabeth House DS0000004507.V347353.R01.S.doc Version 5.2 Page 14 Photographs of residents are available on MAR charts to assist staff with identification. A list of sample signatures of staff is also available for ease of identification of staff that have administered medication this therefore provides an audit trail. The manager confirmed that once per month an audit is undertaken. Medication is counted at the start of the day and then again at the end of the day to ensure that stock levels are correct. A record sheet is kept to demonstrate that these audits take place. Returned medications are collected on a regular basis. A returned medication book is available which is signed by the pharmacist to confirm that medications have been taken by them. Returned medications were stored appropriately. Staff have undertaken training regarding the medication system in place at the Home plus all staff who administer medication have undertaken a distance learning course in the safe handling of medication. All medications are now checked against prescriptions and medication administration records detail the amounts received. This was a requirement made at the last inspection, which is now met. Medication policies were in place and had been reviewed on a six monthly basis. A homely remedies policy is available which has been agreed by GPs. None of the residents at this Home currently self-administer their medication but a policy is in place should any resident be capable of doing so. Throughout the inspection staff were observed to respect privacy and dignity and be caring and supportive towards residents. Those living at Elizabeth House looked well cared for, their hair had been combed and nails were trimmed and clean. They were well presented and wore suitable clothes for the time of year. Residents’ personal care needs were met in their own bedroom or in one of the communal bathrooms and doors were closed demonstrating that staff respect resident’s privacy and dignity. Elizabeth House DS0000004507.V347353.R01.S.doc Version 5.2 Page 15 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. 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 this service. The lifestyle experience in terms of meals, social and leisure activities meets the needs of the residents at Elizabeth House. Resident’s are able to exercise choice and control over their day-to-day life in the home. EVIDENCE: Care files record details of activities, social and leisure pursuits that residents have been involved in. Documentary evidence was available in one file seen to demonstrate that a resident had been involved in activities approximately every other day. An activity programme is in place and copies of documentation regarding entertainment provided by external companies are available. On the day of inspection two residents were sitting in the small lounge listening to classical music. During the afternoon seven residents were playing dominoes all appeared to enjoy the experience and were laughing and chatting amongst each other. Elizabeth House DS0000004507.V347353.R01.S.doc Version 5.2 Page 16 Comments made by residents regarding activities are as follows: “there is something to do every afternoon, you can come and go as you please, we like to sit in this lounge and listen to classical music” “you can do pretty much as you please. I like to spend some time in my room, some in the lounge and the garden if the weather is good” “I like to spend my time writing letters to friends” “There is plenty to do if you want, there is a really nice atmosphere, everyone gets on well” “its dominoes this afternoon, singing on Wednesday, there is something going on every afternoon and you join in if you want to”. “there are things going on in the day. I have sat outside yesterday and this morning” From discussions with residents and records seen it was noted that the social care needs of those who live at Elizabeth House are met. The home has an open visiting policy. People are encouraged to maintain links with their family, friends and local community. Visitors were seen in the Home and were made welcome. During discussions with staff it was noted that residents are encouraged to remain as independent as possible and throughout the inspection staff were seen to maintain independence, dignity and privacy. One resident said that she is able to maintain her independence. She confirmed that if she needs to “see a GP or dentist I go, I just tell them what I am doing”. The resident’s preferred times for rising and retiring are recorded in care files. Staff confirmed that these are flexible, however residents are encouraged to get up for breakfast at 8.30am. Residents are given a choice at breakfast. A menu board records the meal for the day and residents are able to have an alternative if they prefer. There is a choice of deserts and a choice of a cold or hot evening meal each day. A drink plus snack is offered at 7pm and a warm milky drink is offered later in the evening. Some of the residents spoken to were unaware that there is a choice of meal available at lunchtime. The inspector did not dine with residents but observed the lunchtime meal being served. Residents appeared to enjoy their meals. Menus and records of food provided show that choice is available. The kitchen was seen to be clean, organised and well managed. Elizabeth House DS0000004507.V347353.R01.S.doc Version 5.2 Page 17 Comments received by residents regarding food were positive, some of these comments are recorded below: “the food is cooked to perfection” “the food is good” “the food is acceptable, there is always enough of it” “the food is good, you don’t have a choice, you eat off the menu but it is always nice” Residents were aware what they were having for the lunchtime meal and two spoken to said that they were looking forward to it. Elizabeth House DS0000004507.V347353.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People living in the home can be confident that their concerns will be listened to and acted upon. Further work is required to bring the adult protection procedure to a required standard. However staff awareness of adult protection procedures reduces the risk of abuse. EVIDENCE: No complaints or allegations of abuse have been received since the last inspection of the Home. A copy of the complaint procedure is on display on the wall, this policy is therefore accessible to residents, staff and visitors to the Home. Residents were confident that any complaints or concerns raised would be handled appropriated and acted upon by the manager. One resident said that if she had any concerns she would “tell someone with authority, and if they didn’t sort it out it means they are not doing their job, but I am sure that they are here”. The Home’s abuse policy was reviewed, this policy contained basic information and was not sufficiently detailed regarding the action that would be taken if abuse were suspected. The policy does not mention that the manager or person in charge should report the suspected abuse to the social services department. The policy does not record that staff would be suspended if they were suspected of committing abuse and dismissed if abuse substantiated. Elizabeth House DS0000004507.V347353.R01.S.doc Version 5.2 Page 19 The manager was unable to find a copy of the local social services authority adult protection procedures and “no secrets guidance”. These documents should be available on the premises and cross-referenced to the Home’s adult protection policy. Staff have recently undertaken training regarding adult protection issues. Staff spoken to were aware of the abuse policy and the action to take if they witnessed an act of abuse. New lifting equipment has been purchased to assist a resident with moving from bed to chair etc following a previous adult protection investigation relating to moving and handling issues. A whistle blowing procedure was available, however this document does not explain in plain English what staff should do if they have concerns, who they should contact and in what circumstances. Contact details are not available. The manager confirmed that she would review this policy and try to make it easier for staff to understand. Following the inspection a revised whistle blowing policy was received which refers to the policy for reporting incidents or concerns. Contact details for us and the Shirley Old People’s Welfare Committee are clearly recorded. Elizabeth House DS0000004507.V347353.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Elizabeth House provides, comfortable surroundings that are reasonably maintained and clean. This should increase the experience of quality of life for residents. EVIDENCE: Bedrooms seen had been personalised with pictures and ornaments. All rooms were clean and free of offensive odours. Fixtures and fittings were well maintained and rooms were clean and bright. Call systems are available in each bedroom and those seen were accessible to residents whilst in bed. Records are available to demonstrate that call systems are checked on an annual basis to ensure that they are in good working order. Elizabeth House DS0000004507.V347353.R01.S.doc Version 5.2 Page 21 Communal areas were comfortably furnished and residents appeared at ease in their surroundings. A lockable facility is provided in all rooms, bedroom doors can be locked and risk assessments are in place to identify those who are able and who wish to have a key to their bedroom. Residents said that the Home is always clean and well maintained. The comments received about the facilities were positive, some of these comments are detailed below: “there are a few steps to a few rooms but its all easy to get to” “there are really nice gardens you can use if you want to” “there are some lovely gardens with seats. There is a kitchen garden and a nice balcony area to sit on”. There are three baths, two of which are assisted, there is also a shower. These are easily accessible to residents and were clean and hygienic. The contents of commodes are emptied down the toilet and commode pans are then placed in a sterilising machine. Staff were seen wearing disposable gloves and aprons in an appropriate manner throughout the inspection. The laundry was clean and hygienic and there was no backlog of items waiting to be laundered. There was no infection control policy on display that related to procedures in the laundry. A copy of a policy has been forwarded since this inspection. The Deputy Manager confirmed that this policy is now on display in the laundry and staff work to it. Elizabeth House DS0000004507.V347353.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There are sufficient numbers of staff on duty to meet the needs of people living in the home. Recruitment procedures support the protection of residents from the risk of harm EVIDENCE: The manager confirmed that the usual staffing complement for the home is: Manager or Deputy Team Leader 3 Care Staff Team Leader 3 Care Staff 2 Care staff (who are awake throughout the night) 8.00am – 2.00pm 2.00pm – 8.00pm 8.00pm – 8.00am Duty rotas seen confirmed this and the number of staff on duty on the day of inspection was in accordance with duty rotas. Elizabeth House DS0000004507.V347353.R01.S.doc Version 5.2 Page 23 Staff appeared to have an excellent relationship with those in their care. Residents praised the attitude of staff and the speed in which they assist when needed. Some of the comments made are detailed below: “They arrange things for you, they are very good but I do as I please. Out of courtesy I tell them what I am doing, its your own home, you do as you please”. “staff are all friendly and kind, I settled in better than I expected” “staff always knock on doors before they come into your room. They help you if you need it and leave you alone if you want that” “staff are lovely, the Home is well managed” “staff are polite, friendly, helpful and kind, they respect your privacy and dignity” “you are encouraged to be independent. Staff are like old friends not staff” “staff mother you and look after you but don’t do things for you which is good” “When you have lived somewhere for so long they know you, you know them. You all fit in together and adapt to each other’s routines, its all good” It was noted that agency staff are only used in an emergency. Existing staff are usually willing to work extra shifts to cover sickness or training etc. A total of eighteen care staff are employed, excluding the manager and deputy. Fourteen of these staff have achieved a National Vocational Qualification at level two in care, a further two staff are undertaking this qualification currently and two are training for the level three qualification. This means that all of the care staff employed either have achieved or are training to have the National Vocational Qualification in social care. This goes some way to ensure that care staff have the training needed to meet the care needs of residents. Three staff personnel files were reviewed. Each file contained documentation to demonstrate that the Home operate robust recruitment practices. Documentation such as application forms, references, criminal records bureau checks and details of training courses undertaken were available amongst other things. Elizabeth House DS0000004507.V347353.R01.S.doc Version 5.2 Page 24 Some staff have undertaken training since the last inspection, which includes conflict management, medication administration and bereavement. A training matrix records the training courses undertaken by all staff. This document records that a majority of staff have undertaken fire safety and first aid training. Two staff are undertaking moving and handling training and once completed all staff will have undertaken this training recently. Documentation was forwarded following the inspection which recorded details of training recently undertaken, ongoing and booked for the next two months. Varied training is being undertaken by the care staff including the manager and deputy. This includes both mandatory training such as food hygiene and infection control but also resident focussed training such as dementia, health and safety and nutrition. The manager must ensure that all staff receive fire training on at least an annual basis. Induction training records were reviewed. Documentation is given to staff and they are asked to answer questions on topics in line with the “Skills for Care” induction standards. The Deputy manager goes through all induction-training topics with staff. A team leader completes practical work demonstrations and then observes the new staff member and signs the induction documentation when it is considered that they are competent to undertake a task. A copy of all policies and procedures are available in the staff room and before staff complete induction training they would be expected to read these. Some of the induction records seen for one member of staff were completed in the Deputy Manager’s handwriting and some in the staff member’s handwriting. The manager confirmed that the Deputy sits with the staff member and asks questions and the responses are recorded. However, if the Deputy manager is documenting responses it is difficult to identify that the staff member undertaking the induction training has an understanding of the topics. A telephone discussion was held with the Deputy following the inspection and it was noted that she sat with the staff member and recorded her answers to questions. The Deputy said that she was confident that the member of staff had a full understanding of the induction standards. The Deputy agreed to ensure that staff complete induction documentation in future. Elizabeth House DS0000004507.V347353.R01.S.doc Version 5.2 Page 25 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. 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 this 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 has worked at this Home for approximately twelve years and has a vast amount of qualifications and experience. The manager demonstrated an in-depth knowledge of the needs of those under her care. Lines of accountability are clear. The duty rota details on call arrangements, which are divided between the manager, deputy and team leaders. Staff on duty are therefore aware of who to contact in an emergency if they require advice or Elizabeth House DS0000004507.V347353.R01.S.doc Version 5.2 Page 26 assistance. The manager and her staff have worked hard to address some of the issues raised at previous inspections and is aware of the action to take to address any outstanding issues. The has recently completed the Registered Managers Award and is awaiting her Certificate of Achievement. The Home have started to implement quality assurance systems, however further work is required to ensure that the quality of service provided meets the needs and expectations of those that live at Elizabeth House. During discussion with the manager it was noted that a Committee Member visits the Home once per week/fortnight, chats to residents and staff, and reviews the fixtures and fittings but no regulation 26 report is completed. The manager was advised that regulation 26 reports should be completed and made available to inspectors upon request. The manager stated that she has an open door policy, staff, residents and visitors are able to talk to her at any time. A suggestions box is available and the manager discussed some suggestions made which have been acted upon. Separate relatives meetings are not held. Residents and relatives meetings are arranged on an ad-hoc basis, the next meeting has been arranged for 17 August 2007. The manager was unable to find any minutes of meetings since 2005 although she confirmed that meetings have taken place. A satisfaction survey was sent to residents and relatives to find out their views on the quality of the service provided at Elizabeth House. However there have been no surveys recently. The manager was aware of the need to undertake satisfaction surveys on a regular basis and provide evidence that issues identified have been acted upon. Satisfaction surveys have not been sent to staff. Staff meetings are held twice per year. The manager stated that working practice is audited on a daily basis by herself and the deputy manager. Resident’s spending money records were not reviewed in detail at this inspection. There have been no changes to the systems for managing resident’s finances. Appropriate records are available for review. Resident’s funds are safely stored and records show that two signatures are recorded for any receipt or withdrawal of funds. Staff supervision records were not reviewed on this occasion. The manager stated that further work is required to ensure that supervision is completed at the required frequency. Records were available regarding portable appliance testing, fire alarm tests, hot water temperature records and safety certificates for hoists. Thermostatic mixing valves are in place on hot water outlets. An external company completes quarterly checks of hot water temperatures and undertakes all legionella testing. The total fire system was checked in May 2007 and the fire risk assessment updated recently. Records were available to Elizabeth House DS0000004507.V347353.R01.S.doc Version 5.2 Page 27 demonstrate that fire drills take place with staff a few times per year. Fire alarms are tested on a weekly basis and an external company undertake tests of emergency lighting on a regular basis. All information was up to date and in good order. Elizabeth House DS0000004507.V347353.R01.S.doc Version 5.2 Page 28 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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 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 Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Elizabeth House DS0000004507.V347353.R01.S.doc Version 5.2 Page 29 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 OP7 Regulation 15(1) Requirement Evidence is required to demonstrate that care plans are drawn up with the involvement of the service user and/or their representative Timescale for action 05/10/07 2 OP18 13(6) The Adult Protection Policy must 05/10/07 be updated to include details of who should be contacted if abuse is suspected i.e. social services, commission for social care inspection etc and some mention of whether disciplinary action will be taken if abuse is substantiated. There must be a system in place that alerts staff of those entering the presmises to ensure that residents are not put at risk. (Outstanding since September 2006) 05/10/07 3 OP19 13(4) 4 OP33 35(a, b) A report must be prepared on the quality of the service provided based on the views of the residents. 05/10/07 Elizabeth House DS0000004507.V347353.R01.S.doc Version 5.2 Page 30 (Outstanding since September 2006) 5 OP38 23(4)(c) Fire training must be provided for all staff on at least an annual basis. (Outstanding since September 2006) 26/09/07 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 OP7 OP7 Good Practice Recommendations Care plans should be reviewed on a monthly basis. Daily entries should record details of any personal care given, health and well being information. This should include entries recorded by night staff. Details should be recorded of one to one time and any social stimulation undertaken with those residents in bed for prolonged periods due to ill health. 3 OP12 Elizabeth House DS0000004507.V347353.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Elizabeth House DS0000004507.V347353.R01.S.doc Version 5.2 Page 32 - 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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