Inspection on 09/06/08 for Elizabeth House

This inspection was carried out on 9th June 2008.

CSCI found this care home to be providing an Adequate service.

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

Other inspections for this house

Elizabeth House 21/04/09

Elizabeth House 12/01/09

Elizabeth House 20/11/06

Elizabeth House 25/10/05

Elizabeth House 25/05/05

Elizabeth House 15/03/05

Elizabeth House 31/08/04

Elizabeth House 12/02/04

Similar services:

Applegarth

Trevayler Residential Care Home

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Elizabeth House Perth Avenue New Parks Estate Leicester LE3 6QR Lead Inspector Linda Clarke Unannounced Inspection 9th June 2008 09:45 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 DS0000037621.V366042.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 DS0000037621.V366042.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elizabeth House Address Perth Avenue New Parks Estate Leicester LE3 6QR 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) 0116 2871031 0116 2871031 elizabeth-house@leicester.gov.uk socis209@leicester.gov.uk Leicester City Council Mr Philip John O`Dell Care Home 37 Category(ies) of Dementia - over 65 years of age (20), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (20), Old age, not falling within any other category (37), Physical disability over 65 years of age (8), Sensory Impairment over 65 years of age (10) Elizabeth House DS0000037621.V366042.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service User Numbers DE(E) & MD(E) No one falling within category DE(E) or MD(E) may be admitted into Elizabeth House when 20 persons who fall within categories/combined categories DE(E) or MD(E) are already accommodated within the home Service User Numbers PD(E) No one falling within category PD(E) may be admitted into Elizabeth House when there are 8 persons of category PD(E) already accommodated within the home Service User Numbers SI(E) No one falling within the category SI(E) may be admitted into Elizabeth House where there are 10 persons of category SI(E) already accommodated within the home 20th November 2006 2. 3. Date of last inspection Brief Description of the Service: Elizabeth House Residential Home provides accommodation for thirty-seven older people and is owned by the Adult and Community Services Department of Leicester City Council. The Home is located in a quiet residential area. Public transport services can be accessed near to the Home. The Home is ten minutes car ride from the city centre, Fosse Park and the M1 motorway. Elizabeth House is a large modern and purpose built property. Accommodation is offered on ground and first floor level, which can be accessed by a passenger lift. Bath/shower and toilet facilities are located throughout the Home. Car parking space is located to the front of the Home. There is a large patio area to the centre of the building. All areas of the Home are accessible to people using mobility support, aids and equipment. Information is located on site detailing the range of services offered, which includes the Statement of Purpose. Elizabeth House has copies of the Commission of Social Care Inspections (CSCI), Inspection Reports, are located in the foyer along with the displayed registration certificate. The maximum weekly fee is £394.00; an individual’s financial contribution to their care is dependent upon a financial assessment. There are additional individual expenditure such as hairdresser, chiropodist, newspapers, magazines and personal toiletries and the fee will depend on the services received. Inspection reports regarding the home are available and can be accessed via the CSCI website: www.csci.org.uk. Further information about the home is available from the Registered Manager. Elizabeth House DS0000037621.V366042.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. ‘We’ as it appears throughout the Inspection Report refers to ‘The Commission for Social Care Inspection.’ The inspection process consisted of pre-planning the inspection, which included reviewing the Annual Quality Assurance Assessment (AQAA), which is selfassessment tool completed by a representative of the service, reviewing previous Inspection Reports, and any information we have received. We sent surveys to nine people who use the service of which four were completed and returned, nine surveys were sent to families and friends of people using the service, of which four were completed and returned, five staff surveys were sent out of which four were returned, and five health care professional surveys were sent out of which all were returned. The unannounced site visit commenced on the 9th June 2008, and took place between 09:45 and 18:45 The focus of the inspection is based upon the outcomes for people who use the service. The method of inspection was ‘case tracking’. This involved identifying people with varying levels of care needs and looking at how these are being met by the staff at Elizabeth House. Four people accessing services were selected, of which one was accessing respite care. Discussions were held with three people whose records were viewed, and three other people who lived at the Home, and visiting relatives. What the service does well: Elizabeth House ensures that people accessing services have their needs comprehensively assessed prior to their moving in, to ensure that their needs can be met. We sent surveys to health care professionals, who indicated positive responses to questions with regards to the care of people, the promotion of privacy and dignity and the ability of staff to meet their needs. Additional comments were also included: • • I have been a GP in the area for 20 years and have had patients at Elizabeth House over these years; I have had no problems with the type of care they provide. Well done. Appear to provide the best possible care to residents; residents appear well cared for and happy. Elizabeth House DS0000037621.V366042.R01.S.doc Version 5.2 Page 6 People in residence at Elizabeth House benefit from a staff team who in many instances have worked at the Home for a number of years, this promotes continuity of care, whilst receiving care from experienced staff. Staff attend regular meetings and receive regular supervision, which ensures staff are aware of changes in practices and procedures in the Home. We sent surveys to people and asked them for their views about the service they receive or observe, surveys contained comments about what the service does well, which included: • • • I am very satisfied with the care provided at Elizabeth House and I have now been here over a year. They show a caring interest in varied needs of users and endeavour to meet as many personal wishes as reasonably possible. Provides a safe, friendly and caring environment – a tribute to the efforts of management and all staff. We sent surveys to staff all commented positively on the support they receive from the Management Team, and felt that the training they receive is relevant to their role. What has improved since the last inspection? What they could do better: People who are considering moving into or staying at Elizabeth House should be provided with information about the services offered at the Home, to enable them to make decisions about their care, and to be aware of their rights, the information needs to be in a format appropriate to the individual. People residing at Elizabeth should be involved in the development and review of their care plan; the care plan should support a holistic approach to care by including all aspects of their daily lives and care needs. To include a greater range of activities and recreational pursuits, which are appropriate to people with additional needs. The garden of the Home could be better presented so that people living at the Home have a pleasant view from their rooms and from the patio. Elizabeth House DS0000037621.V366042.R01.S.doc Version 5.2 Page 7 The dining experience and increased independence for people living at the Home could be achieved by the use of serving dishes being placed on dining tables, enabling people to serve themselves. People living at the Home, need to be provided with the information about what they should do if they are unhappy, or feel insecure or unsafe. The information should contain information about how to raise concerns, and other agencies that can be contacted. Staffing arrangements should be reviewed to ensure that there are sufficient staff on duty to meet the needs of people living at the Home, and that systems for responding to call bells are reviewed, to ensure that everyone at the Home is responded to in a timely and efficient manner. We sent surveys to health care professionals who made some comments where changes could be made to improve the service it delivers. • The care they are able to give is limited by resources especially staffing levels. People living at the Home need to be confident that the views they express in questionnaires or meetings are listened to and acted upon, and made available to all, and are able to see how there views are used to continually improve the services of Elizabeth House. We sent surveys to people and asked them for their views about the service they receive or observe, surveys contained comments about what the service could do better, which included: • • Garden could be more attractive and the outside entrance. With greater staff and financial resources a few more trips out would be nice and provide extra stimulation. We sent surveys to staff that identified two areas where they thought improvements could be made, the first being that additional staff would enable them to spend time with people living at the Home talking with them. The second was a need for an increase in activities both within and external to Elizabeth House. 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 DS0000037621.V366042.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 DS0000037621.V366042.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 and 3. Standard 6 is not applicable. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People moving into Elizabeth House are not informed of their rights and the services they may expect to receive as they are not provided with the Homes Service User Guide; their needs are assessed to ensure that the Home can provide the appropriate care. EVIDENCE: We spoke with six people who either live at Elizabeth House or are residing at the Home with a view to returning to their own home, or moving into alternative accommodation. In some instances people said that their Social Worker had given them verbal information about the Home, but all said that they had not received any written information about Elizabeth House, prior to or upon moving into the Home. Elizabeth House DS0000037621.V366042.R01.S.doc Version 5.2 Page 10 We were shown the Home’s Statement of Purpose and Service User Guide, which, provides information about the services offered by the Home and includes information on meals, activities, how to respond in an emergency and how to make a complaint and information about staff. Neither document was dated, but other records we read indicated that all documents were to be reviewed by Leicester City Council. People at Elizabeth House said that staff were very welcoming when they arrived at the Home, and that they were shown around parts of the Home. A number of people we spoke with had chosen to move into Elizabeth House as opposed to another Home, as they lived locally or had stayed at the Home previously, and had enjoyed their stay. We looked at the records of four people, and found that everyone had had their needs assessed by a Social Worker before moving into the Home; this ensures that the Home and its staff can meet the needs of the person. Elizabeth House does not provide intermediate care. Elizabeth House DS0000037621.V366042.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, 10 and 11. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at Elizabeth House are not in some instances involved in the development of their care plan, which impacts on the individualised and tailored care they may wish to receive. EVIDENCE: People in residence at Elizabeth House have a care plan, which provides basic information as to their personal and physical health care needs. Care plans in some instances are written from the perspective of the person receiving the care; information about a person’s expectation of care is included. Care plans provide information about a persons wishes in the event of their death, one person we spoke with said, “this was discussed very well, and we ended up having a laugh about it.” Elizabeth House DS0000037621.V366042.R01.S.doc Version 5.2 Page 12 Care plans provide minimal information about a person’s life prior to moving into the Home; information about a persons work, social and family history can provide information, which can be used to ensure that the care a person receives, is reflective of their lifestyle and choices. Care plans make reference to specific needs such as Dementia or memory loss, or hearing and sight loss, but they do not provide sufficient information to promote the well-being of the individual. Care plans are not person centred, in that they do not include choices individuals have made, or there preferred daily routine, such as what time they wish to get up, where they want to eat their meals, what activities they wish to participate in. Records about people’s daily lives are kept, but their content only reflects the personal and health care they receive. Care plans are regularly reviewed, but care plans are not in all instances signed by the person using the service or their representative. We spoke with several people living at Elizabeth House, some were aware of the contents of their care plan, whilst some were not. People we spoke with did not have a copy of their care plan. People we spoke with and our observations confirmed that people are given choices, as to whether they wish to stay in their personal room or sit in communal areas. Interactions between people living at the Home and staff were friendly; with many people living the Home stated that staff were very helpful and friendly. Surveys we sent to people living at the Home confirm that staff listen and act on what they say. We asked people living at the Home about the care they receive one person said, “staff don’t let me down, they’re very good, they are excellent and helpful”. Whilst some else said “nothing is too much trouble”. We looked at the records and medication of four people they were found to be in good order, one person was prescribed controlled drugs, and the records of these were viewed and were found to be in good order. Amendments to legislation require that Controlled Drugs stored in care homes are in a cupboard designed for the specific person, it is the responsibility of the Registered Manager to ensure that storage facilities comply. Staff dispensing medication have received training in ‘the safe handling of medicines’. Elizabeth House DS0000037621.V366042.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at Elizabeth House are encouraged to make choices and maintain contact with family and friends; the range of recreational pursuits and activities made available limits their lifestyle choices. EVIDENCE: People we spoke with gave mixed views as to the range and frequency of activities and recreational pursuits provided. Everyone said that they enjoyed trips out to a garden centre, where they stopped for a drink and cake, and all equally enjoyed trips on the river barge. One person said, “I would like to go to Bradgate Park”. We observed a small group of people going to the local shops supported by staff in the morning, and in the afternoon a game of bingo was held in the dining room. Other observations were that some people spent time in their own room, whilst others sat in one of the communal lounges, where the television was on, however few people appeared to me watching the programme. Elizabeth House DS0000037621.V366042.R01.S.doc Version 5.2 Page 14 Elizabeth House does not employ an activities organiser, but the Registered Manager said that additional funds had been made available to enable staff to organise and facilitate activities. Care plans of people living at the Home contain minimal information about people’s hobbies and interests. Care plans need to be improved to promote an holistic approach to care to ensure that everyone has the opportunity to engage in activities and recreational pursuits which are individual and support their chosen lifestyle. We spoke with staff who had mixed views about the range of activities available, some felt that opportunities for people to be involved in activities had increased, but that activities for people who had specific needs such as Dementia or memory loss or a sensory impairment were not sufficient. A member of staff we spoke with said that some of the gentlemen who lived at the Home had been involved in planting flowers and plants in containers for the patio. People living at the Home said that their visitors are made welcome, and that they are always offered a drink. One person said, “I have my own telephone, so I can ring my friends and family at any time.” An alcove located near the entrance to the Home has a payphone for those who do not have their own telephone. We sent surveys to people who live at Elizabeth House and asked them if they participate in activities arranged by the Home. All indicated that they participate to some extent one survey included additional information • The home tries to provide as many activities as possible but many of the residents are severely disabled mentally and physically so it is not easy. We have barge trips in the summer, cinema shows and entertainers, and there is bingo every Thursday. People living at the Home are welcomed to attend the meetings in the Home, where they can express their views, we looked at the minutes of the meetings held in February and May 2008 issues discussed included meals, activities, staffing arrangements and laundry. We asked people living in the Home if they were given a copy of the minutes of meetings they said that they didn’t. We spoke with a number of people to ascertain their views about the food, all made positive comments, and said that choices were always available; we observed that people were given a choice, but were not asked in advance but at the time of the meal. The menu is not displayed in the Home, and therefore no one is aware as to what will be served at the next meal. We spent time in the main dining room at teatime; all the tables were set with a tablecloth, napkin, condiments and drinks. Additional independence could be provided to people, by food being placed in serving dishes on dining tables, enabling people to serve themselves. Elizabeth House DS0000037621.V366042.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. 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 residing at Elizabeth House are confident in raising concerns with staff, and are supported by staff that are confident in their role in relation to reporting concerns regarding the welfare of individuals. EVIDENCE: We spoke with people living at Elizabeth House, all said that they knew how to raise a concern or make a complaint, in that they would speak with the Manager or a member of their family, people were not aware of advocacy services and no one was aware of the Homes complaint procedure, nor did they have a copy. The Registered Manager said that the complaints procedure is displayed close to the payphone, but acknowledged that the Home was awaiting a delivery of leaflets about how to make a complaint. Information provided by the Registered Manager as part of the inspection process, detailed that the Home has received one complaint in the last twelve months, which was not upheld. We have not received any complaints or concerns with regards to Elizabeth House. Staff we spoke with, and records viewed confirmed that a majority of staff have received training on ‘safeguarding’, which provides staff with information on the forms in which abuse may occur, and the possible signs individuals may Elizabeth House DS0000037621.V366042.R01.S.doc Version 5.2 Page 16 display if they are suffering abuse. All staff were able to confirm their role in reporting any suspicions or allegations of abuse. We observed that there is a positive and open rapport between people living at the Home and the staff, and people we spoke with were positive about the care they receive and the attitude of staff. The surveys we received from people living at the Home indicated that staff listen and act on what they say. Elizabeth House DS0000037621.V366042.R01.S.doc Version 5.2 Page 17 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, 20, 21, 22, 23, 25 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People in residence at Elizabeth House stay in a homely and well-maintained environment, which is suitable to their individual and collective needs. EVIDENCE: Elizabeth House provides communal and dining areas on the ground and first floor, the larger lounge and separate dining room being on the ground floor. All communal rooms were decorated to a reasonable standard, and were clean and tidy. The number of lounges enables people living at the Home to access different rooms in which to relax. Bedrooms are located on the ground and first floor, as are bathing, shower and toilet facilities, bathing and shower facilities are accessible to all people living at the Home, and have specialist equipment to assist people with their Elizabeth House DS0000037621.V366042.R01.S.doc Version 5.2 Page 18 personal care. Access to the first floor is via a stairwell or passenger lift. We spoke with people who were sitting in their own rooms, and found that staff ensured that the ‘call bell’ was within their reach, which enables people to request assistance if required. We spoke with people who live at the Home, along with visiting relatives, all were satisfied with the décor, and said it was always clean and tidy. Staff receive training in infection control, and precautions are taken with all aspects of running the Home to ensure that people are not put at unnecessary risk, from the spread of infection. Elizabeth House is built around a central garden and patio area; the Home is built on a slope, which prevents access to the garden. A patio area looks over the garden, which is overgrown and would benefit from being maintained. The patio area provides tables and chairs and has plants and flowers in containers, during the visit we noted people living at the Home and staff using the space to sit and relax in the sun. Elizabeth House DS0000037621.V366042.R01.S.doc Version 5.2 Page 19 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 adequate. This judgement has been made using available evidence including a visit to this service. People living at Elizabeth House are supported by staff who have the training and the skill mix to support them, the deployment of staff and staffing levels results in people not receiving timely and prompt care. EVIDENCE: Systems in the Home enable the Management team to ascertain how long it takes for staff to respond to calls bells activated by people living at the Home. During the site visit the call bell system was tested which was responded to promptly, however three members of staff responded to the same call, which is not an effective use of staff resources and has the potential to affect the response other people living in the Home receive. We spoke with people living at the Home and asked them about the staffs ability to respond to call bells, some people stated that they only use the call bell when they have to as they are aware of how busy the staff are, and that the needs of some people living at the Home are greater than there own. People said sometimes staff answer their call bell, to advise them that they are with another person and give a time when they will be available, which satisfied the people we spoke with, but all said this sometimes doesn’t happen. Elizabeth House DS0000037621.V366042.R01.S.doc Version 5.2 Page 20 Staff we spoke with gave mixed views about staffing levels, with a majority of staff stating that there are not enough staff on duty to meet the needs of people living at the Home. We sent out surveys to people using the service and asked they if they received the care and support they need and whether staff are available when they need them. The following comments were made: • • • • So many residents who need such a lot of care, I try to help myself where I can, but carers do come if I can’t. Sometimes there is a wait in periods of high demand when few staff are available. Carers do their best, but are so short staffed; they work very hard and do their best to help the residents. The staff at Elizabeth House are always friendly and helpful. Agency staff are employed at the Home, where staffing levels are below the required number, the Home endeavours to use to the same agency staff to promote consistency of care for people living at the Home. Information supplied by the Registered Manager prior to the site visit, states that 90 of care staff have attained a National Vocational Qualification (NVQ) in Care, with the remaining 10 working towards the qualification, care staff are supported by staff that are responsible for the maintenance and cleanliness of the Home, and by catering staff that prepare and cook the meals and number of which have a NVQ in their field of work. A significant number of staff have worked at Elizabeth House for many years, this enables people living at the Home to be cared for in a consistent manner and by staff with significant experience. The Human Resource Team of Leicester City Council oversees the recruitment of staff at Elizabeth House. All records with regards to staff recruitment including application forms, references and Criminal Record Bureau (CRB) disclosures are stored centrally; therefore we could not view these. Information supplied by the Registered Manager as part of the inspection process states that there is a rigorous recruitment procedure and that all staff have a satisfactory CRB. Newly recruited staff undertake a probationary and induction period, where they undergo training relevant to their role. We spoke with staff who provided information about the training they receive, training is related to the safety and welfare of people using the service, along with training which is specific to their health and care needs. The training staff receive enables them to provide appropriate care, and in supportive and sensitive manner. Elizabeth House DS0000037621.V366042.R01.S.doc Version 5.2 Page 21 We sent surveys to staff all commented positively on the support they receive from the Management Team, and felt that the training they received was relevant to their role. Staff identified that an area for improvement was to increase the staffing levels to enable them to spend time speaking with people who live at the Home. Elizabeth House DS0000037621.V366042.R01.S.doc Version 5.2 Page 22 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, 32, 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. People living and working at Elizabeth House are provided with opportunities to influence the day-to-day running of the Home, communication systems amongst people living and working at the Home are not always robust. EVIDENCE: The Registered Manager, Mr Phillip O’Dell has been the Registered Manager of the Home for seventeen years, and has attained the Registered Managers Award, and holds a CQSW (Certification of Qualification in Social Work). We spoke with staff who said that the Management Team were supportive, but staff did raise issues about communication amongst staff within the Home, Elizabeth House DS0000037621.V366042.R01.S.doc Version 5.2 Page 23 staff said that ‘staff handovers’ were sometimes insufficient in that when they arrived on duty, the ‘handover’ was brief, and did not provide enough information about any changes or issues with regards to people living in the Home, since they were last at work. Staff meetings are held on a regular basis, with minutes being available, meetings provide an opportunity to discuss issues of concern, and provide up to date information from the Registered Manager about day-to-day issues. Elizabeth House holds regular ‘resident’ meetings, which provides an opportunity for people living at the Home to express their views and opinions, the minutes of recent meetings were viewed, we spoke with people living at the Home, and asked if they attended the ‘resident’ meetings, those that said they did not were asked if they had a copy of the minutes of the meetings, all said they did not receive a copy. We asked about quality assurance, and the Registered Manager advised that all those who come to the home for respite care are given a questionnaire to record their views about their stay, the questionnaire is also given to a number of people who live at the Home each month. We looked at questionnaires that were completed, a number of which were not dated. We asked how information in questionnaires would be used, the Registered Manager advised this would be collated and any issues noted would be addressed. It was suggested to the Registered Manager that once the information is collated a report is produced detailing the outcome of the quality assurance process, and include information on what action the Home is going to take to improve the service is provides. We spoke with staff that said they receive regular supervisions, which are conducted by their line Manager and are recorded. Supervisions are used to discuss the individual care of people living at the Home where the staff member is their keyworker, and to identify training needs, and discuss their care practices. Information provided by the Registered Manager states that systems within the Home including central heating, fire systems and electrical systems are regularly maintained. Elizabeth House DS0000037621.V366042.R01.S.doc Version 5.2 Page 24 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 2 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 3 3 3 3 3 X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 X 3 3 X 3 Elizabeth House DS0000037621.V366042.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? N/A 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 5(2) Requirement People accessing services at Elizabeth House to be provided with a Service User Guide, which is up to date and is in an appropriate format for the individual. People accessing services at Elizabeth House, where practicable should be involved in the preparation and writing of their care plan, which should reflect all aspects of their daily lives, including the choices and decisions they have made. The Registered Manager to establish whether the cabinet which stores Controlled Drugs at Elizabeth House complies with the Misuse of Drugs (Safe Custody) Regulations 1973. If it is found current storage facilities do not meet the regulations then a storage system, which does comply with the Misuse of Drugs (Safe Custody) Regulation 1973 is to be purchased and installed. Timescale for action 09/09/08 2 OP7 15(2) 09/09/08 2 OP9 13(2) 09/09/08 Elizabeth House DS0000037621.V366042.R01.S.doc Version 5.2 Page 26 3 OP16 22(6) 4 OP27 18(1) All those who access services at Elizabeth House, to be provided with a copy of the Homes complaints procedure in a format that is appropriate to their needs. Staffing arrangements need to ensure that there is sufficient staff on duty to meet the needs of people and that systems for responding to call bells are well thought out to ensure responses are both timely and efficient. 09/09/08 09/09/08 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 OP12 Good Practice Recommendations People living at the Home would benefit from care plans that have a holistic approach to care and reflect all aspects of their daily lives, including their preferred daily routine. People living at the Home regardless of their personal needs and circumstances should have access to recreational pursuits and activities of their choosing, which are recorded on their care plan. People living at the Home to be given further choice and promotion of independence by considering the use of serving dishes, that are placed on dining tables so that people can serve themselves. People living at the Home, along with their relatives and friends to be provided with information on agencies and professionals who they can contact if they wish to raise a concern or feel frightened or unsafe, including advocacy services. People living at the Home, should have the option of viewing a garden which is well-maintained and attractive. People accessing services to receive a report, which is in a format appropriate to their needs, which provides the DS0000037621.V366042.R01.S.doc Version 5.2 Page 27 2 OP15 3 OP16 3 5 OP19 OP33 Elizabeth House outcome of their involvement in the quality assurance process, and details the aims of the service to address issues raised and improve the quality of care. Elizabeth House DS0000037621.V366042.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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. 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