Inspection on 11/04/06 for Elizabeth House Care Home

This inspection was carried out on 11th April 2006.

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

The inspector 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 Care Home 02/07/09

Elizabeth House Care Home 22/04/09

Elizabeth House Care Home 08/04/08

Elizabeth House Care Home 11/04/07

Elizabeth House Care Home 01/11/05

Elizabeth House Care Home 23/08/05

Elizabeth House Care Home 08/07/05

Elizabeth House Care Home 03/11/04

Elizabeth House Care Home 20/04/04

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

CARE HOMES FOR OLDER PEOPLE Elizabeth House Care Home 2 Church Hill Avenue Mansfield Woodhouse Mansfield Nottinghamshire NG19 9JT Lead Inspector Rehana Rashid Unannounced Inspection 11th April 2006 11:20 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 Care Home DS0000008668.V288987.R01.S.doc Version 5.1 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 Care Home DS0000008668.V288987.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Elizabeth House Care Home Address 2 Church Hill Avenue Mansfield Woodhouse Mansfield Nottinghamshire NG19 9JT 01623 657368 01623 431325 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) RAMNARAIN9@aol.com Mrs Vijay Ramnarain Mr Surendra Dev Lutchia, Mr Vivek Obheegadoo Mrs Vijay Ramnarain Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Elizabeth House Care Home DS0000008668.V288987.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st November 2005 Brief Description of the Service: Elizabeth House is a care home providing personal care and accommodation for 16 older people. The home is located in Mansfield Woodhouse, in a quiet residential area and close to shops, pubs, the post office and other amenities. The home is an older style domestic property with a more recent two-floor extension. There are 14 single, and 1 double bedroom, which are located on both floors and there is a passenger lift. There are a variety of lounge areas. There is a garden that is easily accessible for service users. There is limited car parking available on the homes driveway and further parking is available on the street. The manager and at least two staff are on duty throughout the day and night care staff are available throughout the night. Range of monthly fees at the time of the inspection 11th April 2006 was from £275 to £327 this information was obtained from Debbie Ramnarain (Registered Manager). Elizabeth House Care Home DS0000008668.V288987.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was carried out on 11th April 2006 for duration of seven hours. The main method of inspection was case tracking, which involved randomly selecting two service users and examining the care records. Case tracking is used to establish if the needs of the residents are being appropriately assessed by the home and their needs are being catered for. Indirect and direct observation of practice and interaction between staff and residents was also carried out as part of the inspection methodology. The manager gave the inspector a partial tour of the building. Which included the communal areas, 2 bathrooms (ground floor and first floor) and three bedrooms. Residents were briefly observed during teatime. Other documentation including health and safety records were also examined. The management of medication was partly assessed for the two residents case tracked. During the course of the inspection the Inspectors spoke with two residents, the feedback was positive about the level of care received. These residents spoke positively about the care staff and about the service provided by the home. Three relatives were interviewed during the inspection that praised the home and the level of care provided by the staff. The Manager assisted in the inspection process. Two members of staff were spoken with due to the time taken for the other areas of inspection. Those service users spoken with and a relative praised the home and clearly outcomes for those residing in the home are good. There are however some outstanding requirements and good practice recommendations from the previous inspection. Two immediate requirements were issued which the registered Manager agreed to meet. What the service does well: Elizabeth House Care Home DS0000008668.V288987.R01.S.doc Version 5.1 Page 6 Elizabeth House offers a homely environment to its residents. Residents spoken with said they liked it at the home and were well cared for by the staff. They also stated that the home provided them with good meals. Residents were observed to be relaxed and appeared content. Staff were observed to speak to residents respectfully and provided reassurance appropriately and sensitively when needed. The rapport between the staff and residents was good. The residents and relative spoken with reported that they were happy with the services provided and that they felt their needs were met fully. Residents and relatives stated they are confident that in an event should they have a complaint the manager will listen and if necessary take appropriate action. Residents presented as being well groomed. The residents live in a clean environment. Both relatives and residents expressed they are treated with respect and dignity. During meals it was observed anyone requiring assistance to eat were helped in a sensitive manner. Care plans contain information on the residents health, social and personal care needs. Staff were helpful and pleasant to the inspector. Residents bedrooms viewed by the inspector were comfortable, clean and maintained well. The rooms were personalised. What has improved since the last inspection? What they could do better: Recruitment practices were assessed as continuing to having shortfalls and an immediate requirement was set in relation to this. There was no evidence of systems in place to prevent legionella. The Registered Person must seek advice from the Environmental Health officer regarding this. Since the last inspection keypads have been fitted to the front and rear exit door. The keypad on the rear door to be re-fitted securely and must be in working order. To ensure residents are maintained in a safe and secure environment, particularly those residents who have been identified as being at risk of wandering. Elizabeth House Care Home DS0000008668.V288987.R01.S.doc Version 5.1 Page 7 A State of Purpose is provided however there are some amendments needed following the last inspection, which remain outstanding. There is no formal system in place for staff supervision and the overall record keeping of staff personal records appears disorganised. The training folder is disorganised it is difficult to establish current training attended and completed by staff. 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 Care Home DS0000008668.V288987.R01.S.doc Version 5.1 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 Care Home DS0000008668.V288987.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 Quality in this outcome area is adequate this judgement has been made using available evidence including a visit to this service. Needs of new residents are assessed prior to admission. EVIDENCE: Two residents admissions records seen indicated that the terms and conditions of the residency have been by signed by the resident’s representatives and the manager. Preadmission assessment had been completed prior to the commencement of the placement. One resident’s relative who was present at the time of the inspection stated she had the opportunity to visit the home. Elizabeth House Care Home DS0000008668.V288987.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s health, personal and social care needs are set out in and individual plan of care, there are some areas, which require further improvement. This is to ensure that the resident’s needs are fully met. Medicine management is improving. Residents are treated with respect and their right to privacy is upheld. EVIDENCE: Two residents care plans were viewed during this inspection, which were randomly selected. Care plans were generally clear describing the resident’s needs and the action staff needed to take to meet the needs. Some areas require further improvement. One residents care plan reflected that due to pressure care issues she needs to be turned regularly. The manager stated this information was in the resident’s room to ensure staff are completing the chart. However a member of staff was unable to locate the turning chart to show the inspector. There was no evidence on the file that the care plan had Elizabeth House Care Home DS0000008668.V288987.R01.S.doc Version 5.1 Page 11 been updated due to the change in the residents needs relating to pressure care. Review dates were recorded in the two care plans sampled but there was no evidence of review outcomes. It is recommended that outcomes following reviews be clearly documented. This information should be reflected in care plans or risk assessments in situation were resident needs have changed ensuring the home are continuing to meet residents changing needs. Both files contained photographs on the front of the file and were organised. Resident’s daily communication sheets reflected significant events, which are signed and dated by the author. The files indicated that the residents health needs are addressed and when appropriate or necessary the home seek input from local health care professionals such as the General Practitioner or District Nurse. Visits by health professionals including Chiropodist, GP and District Nurse are recorded on the communication sheets and kept in the residents care plan file. Medication was observed to be stored securely and locked in a trolley. When the inspector examined the medication for three service users, two medication records had attached to them photographs of the service users. The manager was aware some off the photographs had come away from the medication records; the inspector was shown double-sided adhesive stickers, which were to be used to ensure photographs are securely attached. Towards the end of the inspection the manager was seen by the inspector attaching the photographs onto the medical records. Medication checked on the day of the inspection for three residents was correct against the prescription. On one chart examined there was a written entry, which was signed by the GP due to an adjustment in the dosage. Residents relative were pleased with the health care and support provided by the home. A relative commented that the home are proactive in keeping her informed with regards to the health needs of her relative. Another residents relatives stated the home manage his relatives incontinence is well managed. It was reported by the manager that there are no service users currently selfadministering medication. During the inspection staff were observed to preserve the privacy and dignity of residents. When the Manager was showing the inspector around the home, she knocked on the service users bedroom doors and bathrooms prior to entering and proceeded to enter after knocking. Residents stated staff are respectful and polite towards them. They stated staff are welcoming towards their visitors. Throughout the inspection visitors were observed to come and go. One resident’s relative arrived whilst the inspector was in the communal Elizabeth House Care Home DS0000008668.V288987.R01.S.doc Version 5.1 Page 12 area and for privacy they want to the resident’s room. A member of staff stated the resident prefers to go to her room when she has visitors. Relatives spoken with at the inspection stated there are no restrictions as to when they visit and staff are very welcoming towards them. The relatives also spoke very highly of the staff. Residents do not have access to a pay phone. One resident stated she has not had the need to use the phone and should she need to make a call she is confident that she can use the homes telephone. During the inspection it was evident that staff have a good rapport with the residents. The inspector observed conversation between staff and residents. The Manager confirmed she has a cordless phone in one the communal areas, so if there is a call for a resident the phone can be taken to the resident or to their bedroom. The cordless telephone is located in the communal area, which was seen by the inspector. Elizabeth House Care Home DS0000008668.V288987.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents find the lifestyle experienced in the home matches their expectations and preferences. The home arranges social activities for the residents. They maintain contact with family, friends and exercise control over their lives. Residents receive a balanced diet. EVIDENCE: The staff at the home stated social activities are organised for the service users and the service users are given the choice as to whether or not they wish to participate. This was substantiated by speaking with the residents, one resident stated there are social activities at the home i.e. bingo and keep fit. She stated they are given the choice to participate. The same resident stated in the evening she prefers to get changed into her nightwear and returns to the lounge to watch television and the staff assist her to bed when she wants to go to sleep. Two residents spoken with indicated that they maintain contact with relatives and friends. During the inspection the inspector observed relatives/ friends coming and going to the home as they wished. Elizabeth House Care Home DS0000008668.V288987.R01.S.doc Version 5.1 Page 14 Resident spoken with indicated that meals are varied and wholesome and that daily choice is given. The residents commented ‘Meals are very good’. The home has a four weekly menu which the inspector examined and it indicated a wholesome diet. One resident’s relative stated as their relative has difficulties with chewing, the staff cut the food into small manageable pieces. The manager stated residents who require assistance with eating are supervised and assisted by staff. This practice was observed by the inspector, during teatime it was observed anyone requiring assistance to eat were helped in a sensitive manner. The food storage was clean and there was a selection of foods. Elizabeth House Care Home DS0000008668.V288987.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users complaints are taken seriously. Staff members spoken to during the inspection were aware of the issues of protection of service users from abuse. EVIDENCE: Complaints procedures were displayed in the reception area of the home and in the resident’s bedrooms. Residents spoken with stated they are aware of the complaints process and would speak to the manager if they had any concerns. Relatives confirmed they are very confident that should they have a compliant the manager would take it very seriously and deal with it appropriately. The home have a complaints book, the manager stated this is used to record complaints made directly to the home. The two staff members spoken with stated they are aware of the Protection of Vulnerable Adults procedures. One staff member stated she is currently doing NVQ 2 and believes the next module is on adult protection. During the previous inspection the inspector made a good practice recommendation that the missing persons policy is amended to include notification to CSCI. However during the inspection the missing persons policy was viewed and this information has not been amended. This was discussed was the manager who stated she will amend this immediately. Elizabeth House Care Home DS0000008668.V288987.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,24 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a wellmaintained environment, which is clean, pleasant and hygienic. The home was clean and smelled fresh throughout. Bedrooms are well equipped and personalised according to personal choice with their own possessions around them. EVIDENCE: During a partial tour of the building it was observed that the keypad on the rear door was missing. An immediate requirement was set and this was discussed with the manager. The keypad to re-fitted securely and must be in working order. To ensure residents are maintained in a safe and secure environment, particularly those residents who have been identified as being at risk of wandering. Elizabeth House Care Home DS0000008668.V288987.R01.S.doc Version 5.1 Page 17 Elizabeth House offers its residents a clean and homely environment. The residents spoken with at the time of the inspection stated they are able to sit where they wish in any of the communal areas within the home. The bedrooms are located on the ground and first floor. A passenger lift and stairs provide access to the first floor. Two single and one double bedroom were viewed at the time of the inspection, windows were fitted with restrictors. The standard of cleanliness in these rooms was good. All three bedrooms were individually personalised containing personal possessions belonging to the service users including photographs. During the partial tour of the home it was observed the home is clean, pleasant and hygienic. On the day of the inspection the home was free from offensive odours. However the shower room in the extension part of the home was being used as storage. There is limited car parking available on the homes driveway and further parking is available on the street. There were paper towels noted in the bathrooms, toilets and the kitchenette/dining area. There was sudocreme with the prescription label removed in the ground floor bathroom, the manager checked the container was empty and disposed of it. There was also Emolliient Cream in the same bathroom with a prescription label on it. The manager is aware that this was set as a requirement at the last inspection. This was discussed with her she stated she has told staff that once they have used the prescription creams to return them to the resident’s rooms. This requirement is outstanding from the last inspection. Furthermore there was a stool on the floor with a lid, which contained toiletries in it. The lid was very unsightly with stains on it. The manager stated she would replace this. Elizabeth House Care Home DS0000008668.V288987.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is adequate this judgement has been made using available evidence including a visit to this service. Staff numbers meet the current number of residents. Residents are in safe hands. The home’s recruitment practices continue to require improvements. EVIDENCE: The staffing rota was seen; there are two staff plus the manager on duty during the day. In addition to this there is a cook and a domestic. During the night there are two staff members on duty. Staff spoken with stated at the moment there are 11 residents so the current staffing levels are sufficient however if the number of residents increases this staffing level may not be sufficient depending on residents varying dependency levels. Three staff files were viewed; the files were disorganised and difficult to find information. Two files contained no photographic evidence and failed to show proof of identification. Schedule 2 of the Care Home Regulations lists the requirements for documentation to be held in staff personal files. Whilst examining the files it was evident the homes policies and procedures for recruitment are not adequate. One member of staff had been employed without a Criminal Records Bureau check or evidence of Protection of Elizabeth House Care Home DS0000008668.V288987.R01.S.doc Version 5.1 Page 19 Vulnerable Adults First check. An immediate requirement has been set for this, which has, at the time of writing this report, been addressed with appropriate checks evidenced. The homes recruitment process should ensure staff and volunteers do not commence employment without a POVA first check and a satisfactory CRB disclosure. These checks need to have been applied for and obtained before staff commence employment (Regulation 19). Residents and relatives spoken with during the inspection stated they felt staff at the home are competent in their jobs. Staff training records were viewed on the day of the inspection, it was difficult to locate information on courses attended by staff as the file was disorganised. The manager confirmed a number of staff have been on a manual handling course, she agreed to fax details to CSCI. Two out of the three staff files showed evidence of level 2-dementia awareness undertaken by staff, Continence promotion. One staff file contained a certificate on medication training; these training sessions were undertaken during the last six-month. Training in first aid, food hygiene and health and safety was evident. Evidence was seen that some staff had received fire training during March 2006. Elizabeth House Care Home DS0000008668.V288987.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager is registered with CSCI. The home is run in the best interest of the residents. Resident’s financial interests are safeguarded. The health, safety and welfare of residents is generally promoted and protected. EVIDENCE: The manager is registered with CSCI. Due to the amount of time spent in other areas the homes quality monitoring systems was not fully inspected. The manager stated she talks with residents and relatives on a regular basis to ensure the service provided is satisfactory. Provided evidence of a service users questionnaire that is to be carried out. Elizabeth House Care Home DS0000008668.V288987.R01.S.doc Version 5.1 Page 21 Two residents financial records were examined and found to be satisfactory. Resident’s expenses money is managed by the home and placed in secure facilities for safekeeping. The expenses money is mainly used for the hairdresser and chiropodist receipting for this practice was included with records. A selection of staff files were viewed and seen to contain no evidence of formal supervision sessions. Formal supervision is not in place and this needs to be implemented which is specified in Standard 36.1 to 36.5 and Regulation 18. This is an outstanding requirement from the last inspection. The inspector viewed a range of records relating to health and safety. During the inspection the Employers Liability Insurance Certificate was displayed in the reception. PAT testing has taken place on electrical items. The electrical system has been tested. The hoist and passenger lift have been serviced. The gas certificate was not seen, the manager agreed to fax to CSCI. Fire test records were adequate, door closure tests take place monthly but April door testing is outstanding. The manager agreed to do this immediately. Evidence was seen which confirmed the Fire Officer visited the home to carry out a fire risk assessment on 31st March 2006, however the manager stated she is still waiting to receive a copy of the fire risk assessment. On the same date fire some staff undertook training. One member of staff stated she was unable to attend due to sickness. There was no evidence of systems in place to prevent legionella. The manager has agreed to contact the Environmental Health officer to seek information regarding legionella control measures Elizabeth House Care Home DS0000008668.V288987.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 2 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 2 X X X 3 2 3 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 2 3 1 2 2 Elizabeth House Care Home DS0000008668.V288987.R01.S.doc Version 5.1 Page 23 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 Requirement Timescale for action 11/05/06 2. OP22 13 Ensure that the Statement of Purpose is amended as specified within the inspection report dated 01/11/05. (This requirement remains outstanding from the last inspection). The keypad on the rear door to 11/04/06 be re-fitted securely and must be in working order. To ensure residents are maintained in a safe and secure environment, particularly those residents who have been identified as being at risk of wandering. Ensure the personal creams and any prescribed medications/shampoo of service users is not left in bathrooms or used for anyone other than for the person it is prescribed for. ((This requirement remains outstanding from the last inspection). Ensure that staff and volunteers do not commence work in the home until all the DS0000008668.V288987.R01.S.doc 3. OP26 12, 13, 14, 16 11/05/06 4. OP29 19 11/04/06 Elizabeth House Care Home Version 5.1 Page 24 necessary recruitment checks have been carried out which include POVA first check and a satisfactory CRB disclosure. These checks need to have been applied for and obtained before staff commence employment. IMMEDIATE 5. OP29 18 Ensure all staff files contain the documentation required by schedule 2 of the regulations. (This requirement remains outstanding from the last inspection). Ensure all staff undertake manual handling training updates and pressure relief training Ensure staff have formal supervision re-instated. (This requirement remains outstanding from the last inspection). 11/06/06 6. OP30 19 11/06/06 7. OP36 18 11/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP19 OP18 Good Practice Recommendations Seek advice from the Health and Safety Executive regarding Legionella prevention measures Amend the missing persons policy to include notification to CSCI under regulation 37 3. OP26 Review the arrangements for storage of toiletries in DS0000008668.V288987.R01.S.doc Version 5.1 Page 25 Elizabeth House Care Home bathrooms 4. OP27 Provide an extra staff member on each day shift Elizabeth House Care Home DS0000008668.V288987.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Care Home DS0000008668.V288987.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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