Inspection on 23/08/05 for Elizabeth House Care Home

This inspection was carried out on 23rd August 2005.

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

The inspector 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 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 11/04/06

Elizabeth House Care Home 01/11/05

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 Woodhouse Mansfield, Nottinghamshire, NG19 9JT Lead Inspector Jayne Hilton Unannounced 23 August 2005 at 9:30 am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Elizabeth House Care Home C53 C03 S8668 Elizabeth House V245514 230805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Elizabeth House Care Home Address 2 Church Hill Avenue, Mansfield Woodhouse, Mansfield, Nottinghamshire, NG19 9JT Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01623 657368 01623 431 325 Mrs Vijay Ramnarain Mr Surenda Dev Lutchia Mr V Obheegadoo Mrs Vijay Ramnarain Care home only (PC) 16 Category(ies) of Old age, not falling within any other category registration, with number (OP) of places Elizabeth House Care Home C53 C03 S8668 Elizabeth House V245514 230805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 8/7/05 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 berooms, which are located on both floors and there is a passenger lift. There is 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. Elizabeth House Care Home C53 C03 S8668 Elizabeth House V245514 230805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced Inspection was carried out on 23rd August 2005, by Jayne Hilton and Lee West and commenced at 9.30am. The focus of the inspection was to investigate a number of concerns that had been made to The Commission For Social Care and via Social Services. The Inspection concluded at 3.30pm. Additional information was collected on 30th August 2005. The issues of concerns raised were assessed in relation to the national minimum standards and reported on in the relevant sections in the report. The methodology used for this inspection included the examination of sixteen service user plans, a tour of the building, examination of medication records, accident records, policies and procedures, staffing rosta’s, observation of staff practice, speaking with five staff, the manager, two service users and two relatives. Other documentation was examined throughout the course of the inspection. A detailed assessment was made on the Statement of Purpose What the service does well: What has improved since the last inspection? A requirement set at the previous inspection regarding risk assessments for safe working practices has been met. Elizabeth House Care Home C53 C03 S8668 Elizabeth House V245514 230805 Stage 4.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Elizabeth House Care Home C53 C03 S8668 Elizabeth House V245514 230805 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Elizabeth House Care Home C53 C03 S8668 Elizabeth House V245514 230805 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3, 4 A statement of purpose provided prospective service users with information about the home, however there are some details, which require amending or adding to this document to ensure it meets fully with the requirements of the regulation. Service users needs are assessed prior to being admitted to the home. The needs of service users are not being fully met, because the registered provider/manager has admitted service users that they are not registered to care for. EVIDENCE: The statement of purpose was assessed in detail and found to have some areas for amendment and addition to ensure it meets fully with the requirements of schedule 1 of the regulations. 1, The service user category of registration is not detailed-this must be included as per registration certificate e.g. The age range and sex of the service users for whom it is intended that accommodation should be provided. 2,the range of needs that the care home is intended to meet, 3, whether nursing is provided. 4, whether the home intends to take, emergency admissions and how the service users needs will be assessed under these circumstances, 5, change NCSC to CSCI on page 3, 6 and 15, 6, Include what arrangements are in place for dealing with reviews of Elizabeth House Care Home C53 C03 S8668 Elizabeth House V245514 230805 Stage 4.doc Version 1.40 Page 9 the service user plan, referred to in regulation 15 [1]. 7, Include a list of the room sizes, 8, Amend the registered managers details to ensure there is no confusion regarding nursing qualifications. Sixteen Care Plans were examined. Care plans included a pre-admission assessment record and a further assessment, which informed the care plan. Six service users who had moved to the home since the Care Standards Act 2000, were noted to have a clear primary diagnosis of dementia, one recently being a recent admission in April 2005, this person also had mental health needs identified. Another had a learning disability as well as dementia. One other service user had been admitted, on a private arrangement for respite and on an emergency basis, with very little medical history. An assessment had been, undertaken, by the manager and an identified need of confusion was documented. Because of the nature of the admission, little information had been obtained. On speaking with the service user the inspector felt that service user may be suffering from dementia, however there was not any medical diagnosis to support this, although a well person check had been obtained. The manager reported that previous inspectors had discussed the issue of the home not being legally registered to admit people with a primary need of dementia and that she had intended to submit an application to vary the registration. There was a clear breach of legislation regarding the manager admitting service users outside of the registration categories. An immediate requirement was made that the registered provider must not admit service users who are assessed as having a primary need/diagnosis of dementia. The inspector advised the manager of what supporting information and evidence the CSCI would need with an application to consider approving any variation to the registration. There was evidence that service users needs were not being fully met and that the dependency levels of service users admitted were of a fairly high level and that service users who had been admitted with dementia in 2002 onwards were naturally changing. Two service users were also at risk of wandering. This clearly had an impact on the other service users and the number of staff provided on each shift. The inspector requested that the manager obtain social worker reviews for those identified to be at risk of wandering. Elizabeth House Care Home C53 C03 S8668 Elizabeth House V245514 230805 Stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, Service users health, personal and social care needs are set out in individuals care plans, however the health care needs of service users are not being fully met or fully documented, in relation to personal care, tissue viability, continence management, manual handling, mobility and risk of falls, and fluid intake. There are also a number of issues to address in relation to the systems in place for medicines management. EVIDENCE: Medical histories, health assessments and how and who were involved in meeting these needs appeared to be comprehensively recorded in each plan. The manager and staff on duty at the time of this inspection provided a clear and detailed insight into the medical and health needs of the residents. However a detailed examination of a care plan of a service user who was at risk of falls and wandering, had not had a review of the risk management chart for these since January 2005. The manager had identified the person as a high risk on initially completing the chart. The service user had suffered a number of falls and had also recently wandered out of the home, yet there was reference to the incident on the chart to relate to this incident and obviously no evaluation or subsequent review had been documented. The manager and staff reported that regular monitoring was taking place, however there was no Elizabeth House Care Home C53 C03 S8668 Elizabeth House V245514 230805 Stage 4.doc Version 1.40 Page 11 evidence of this in relation to the documentation and clearly staff could not monitor the two service users who wander, when needing to attend and hoist other service users. The design of the building is also not conducive with clear observation of service users in the communal areas. There was evidence that staff were not always following pressure relieving regimes and the District Nursing Team are involved in supporting the staff team in pressure sore care. The staff team need to be more proactive in the prevention of pressure sores. One service user was on bed rest during the inspection has quite marked pressure sores on her sacrum and hips. Although she was on bed rest there was no turning chart/care chart in place. She had no means of getting a drink there was no glass, jug, cup or anything to give her a drink. There was also evidence that staff were practicing poor manual handling techniques and staff reported that they had not undertaken training in manual handling for some time. A hoist is used for one service user and staff confirmed that two staff use this at all times. Service users and relatives speak very highly of the home they feel the care is adequate. One service user stated the care is wonderful. A service user reported that she prefers to have a bath on a daily basis, but can only have one or two a week. One service user who was admitted to hospital with a suspected stroke after a fall did not have the event of the fall documented in his care plan, although this was recorded in the accident records. It is recommended that a running record sheet is included in the care plans for incidence of falls and which can be used for the appropriate evaluation and review of mobility plans. There was a very strong smell of urine in the lounge the hairdresser was using and the cover on one of the armchairs was soaked in urine. This was removed, but the chair was not washed. Continence management was observed to be, not as it should be and possibly because of the dependency levels of service users and workload of staff rather than deliberate neglect. Staff reported that it now takes two staff to toilet quite a few of the residents. One service user who cannot be independent with using the toilet reported that sadly, the staff don’t come straight away when she rings and she has had one or two “accidents” but they don’t get angry. A complaint had been made that the manager had carried out minor medical procedures such as treatment for skin flaps. There was no evidence to substantiate this claim, however on speaking with staff and visitors there was some misapprehension that the manager was a qualified nurse. The manager confirmed with the inspectors that although she had worked as a nursing assistant for some time, she had no formal qualifications in nursing and confirmed that she would never attempt to carry out clinical procedures. Elizabeth House Care Home C53 C03 S8668 Elizabeth House V245514 230805 Stage 4.doc Version 1.40 Page 12 The accident records were examined and although some had not being cross referenced to in care plans, there did seemed to be good practice of recording accidents whether service users had slipped from chairs or had suffered actual falls. There was a large number of accidents recorded for a small home, several were for one particular service user in relation to the number of falls. As stated earlier, improved documentation in relation to the evaluation of falls. The medication administration and storage systems were examined in detail. Medication – The entries for 8.00am 12 noon medications on the 15th and 16th August 2005 had not been completed for all service users and one service users night medication had not been signed for on 8th and 9th August 2005. The manager had been signing the MAR sheets in block after the medicines have been given out. The Inspector advised the manager this was not acceptable practice. The Medication fridge was iced-up and contained 2 bottles of opened eye drops, which were dated with date of opening. The medicine round was observed and the medication was given in accordance with the regulations, except that the tablets were given from the blister packs and then the MAR sheet was turned to and checked. Improved practice is required in this area. On examination of the medicine cupboard it was found that there was a huge overstocking of medications. One service user had 6 GNT sprays with one just in date, which was prescribed in 2003. There were medications in individual “tupperwear” containers, which were too big for the two boxes, but other medication was scattered in 3 large baskets. There was medication in the baskets from residents who had died and also had left the home. Oromorph which was prescribed for one service users on 20th June 05 was never given to her and there was no evidence to track of when it came into the home. These extra medications must be sorted and sent back to the pharmacist as quickly as possible. The controlled drugs register whilst being signed is not auditing the number of tablets. It is recommended that the provision of a drugs trolley would be more suitable. Elizabeth House Care Home C53 C03 S8668 Elizabeth House V245514 230805 Stage 4.doc Version 1.40 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 standard(s) 15 Service users receive a generally wholesome appealing balanced diet in pleasing surroundings and enjoy their food. EVIDENCE: Service users and relatives commented that the meals are good and one service user reported that she had put weight on since moving to the home. The cook confirmed that she has an Intermediate food hygiene certificate and has undertaken other relative training. The cook was observed preparing sandwiches for tea during the inspection and these were observed to be properly prepared, covered and put into fridge for storage. Two different selections are on offer daily. Menus are rotated and the cook is aware of the service users likes and dislikes. They home, has monthly meat deliveries and fresh vegetables delivered weekly. The food storage was clean and there was not a lot of stock as the cook reports, this makes things easier to rotate. The food observed was all within a reasonable standard. Fridge and freezer temps taken and recorded daily. The working area was clean and tidy and the dishes are washed using the double sink method. The cook stated that if service user’s try to get into the kitchen they close the middle “stable” door although she needs access to the fridges in the dining room/office. A snack machine was observed in the small lounge. The meal served on the day of the inspection appeared appetising and nutritious. Supplies of biscuits and fresh fruit were observed in the home. Elizabeth House Care Home C53 C03 S8668 Elizabeth House V245514 230805 Stage 4.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 18 A complaint investigation was the main focus of the inspection. A complaints procedure was displayed in the home and a copy provided in the statement of purpose. The complaints records were not examined at this inspection. Policies and procedures are in place to protect service users who are vulnerable, however good practice recommendations have been made to further improve this and in light of the service users that have been admitted outside of the registration category. EVIDENCE: A number of concerns have been raised with the commission about the home and these were investigated at this inspection. Many of the concerns raised were not upheld. Some were partly upheld and some were upheld. A full investigation record has been completed and the outcome details, of the investigation, has been forwarded to the registered provider and the complainants. There was a policy in place for the use of restraint and risk assessments were noted to be in place, where service users may have equipment that could be viewed as restraint, such as special reclining chairs, bedrails, locks on doors etc. The inspector assessed that there was no evidence of inappropriate restraint being used in the home. All service users bedrooms had approved safety locks fitted, which can be locked from the inside and outside but service users cannot be locked in One service user’s bedroom, did have a type fitted that could be more complicated to use and it is recommended that this be changed for one of the other types. Staff reported that service users can have Elizabeth House Care Home C53 C03 S8668 Elizabeth House V245514 230805 Stage 4.doc Version 1.40 Page 15 the keys to their rooms if they wish and many choose to hang them outside of their room on a hook. There were no restricting locks on the small dining room doors, but a safety gate [stable type door] is used to prevent service users wandering into the kitchen. A number of incidents were recorded in the accident book of a service user being found on the kitchen floor, which was evidence that the gate is not consistently used, as it would be unlikely that service users would be able, to open the bolt system. Although the home is not intended to be a ‘secure unit’ measures have been taken to minimise the risk of wandering of the service users. A safety gate and fencing is sited at the exterior of the home, to prevent service users from wandering out of the rear door. Other fire doors are alarmed. The front door is kept locked and visitors have to knock or ring the bell to gain entry. There was evidence that the front door had been found unlocked on occasions by staff coming on shift, however steps have been taken to be vigilant regarding this. The manager was advised to look at simple alarm methods. Visitors are also reminded to ensure that staff, are aware they are leaving and to secure the door. The small conservatory area at the rear of the home leads to the laundry and other access door for the kitchen and the laundry door was found to be open and posed a risk to service users who may wander in there. Also a bunch of keys was found in the exterior door of the conservatory, which staff admitted they had forgotten to remove. The inspector advised that the fire officer be consulted regarding, fitting a keypad or similar to the interior door to the conservatory area to prevent access to the utility area by vulnerable service users. A missing persons policy was in place and appeared appropriate, however it is recommended that the document, states that, all events of service users going missing must be reported to CSCI as required by regulation 37. Elizabeth House Care Home C53 C03 S8668 Elizabeth House V245514 230805 Stage 4.doc Version 1.40 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20,23, 24,25,26 Service users rooms are safe and comfortable. The home is generally clean and well maintained but there are some issues to address regarding security, infection control, minor repairs and the evidence of smoking in the toilet. EVIDENCE: Several bedrooms were examined in relation to door locks and the rooms were all observed to be, personalised, clean and adequately furnished and equipped. In the Toilet/bathroom on the first floor at the top of the stairs, it was observed that the toilet handle is broken and there is no mans of drying hands at all. Visitors to the home reported that paper towels were very often not available, however most locations apart from the toilet mentioned and the dining area/kitchenette did have these present. Someone had been smoking in the bathroom, as there was ash around the toilet seat, otherwise it was found to be clean. The manager needs to address this as staff reported that there, were no service users who smoke, residing in the home. Elizabeth House Care Home C53 C03 S8668 Elizabeth House V245514 230805 Stage 4.doc Version 1.40 Page 17 There was a bath seat provided in the bath. A hoist is provided and other manual handling equipment was provided in the home. The infection control policy was examined and found to contain incorrect information, which was believed to be a print error. A new policy should be provided that is appropriate. Gloves were present in the home on the day of the inspection and staff reported that these were always available. The security of the building is discussed in standard 18. The registered provider should carry out a risk assessment for the security of the building. Elizabeth House Care Home C53 C03 S8668 Elizabeth House V245514 230805 Stage 4.doc Version 1.40 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 30 Staffing levels meet the minimum standards for the registration purposes of the home however, the dependency levels of the service users admitted is high and therefore it is strongly recommended that an extra staff member is employed to account for this. Staff training needs updating regarding manual handling practices, tissue viability and dementia care. EVIDENCE: The rota was examined and staff confirmed the hours being worked were as recorded. Staff work appropriately, allocated shifts and two staff are covered on each shift. Domestic and catering staff, are employed in addition to this. The manager reported she works as an extra staff member between 10am and 6.30pm weekdays. However on the day of the inspection the manager was observed to be in demand from telephone calls, management duties, relatives, GP visits/hospital appointments, assisting the inspectors and was very much needed to assist staff with attending service users needs. Staff reported that they feel that there are a lot of service users with dementia now and it is causing a lot of work for them – only two on duty and often have to ask the cook to keep an eye on things and staff state they are going home exhausted. A number of service users were observed to need assistance with feeding. In light of the dependency levels of the current service users it is recommended that an extra member of the care staff, is employed to ensure that all the needs of service users is met. The manager should be super numery for at least 90 of her working time to ensure the legislative requirements and responsibilities of the home are maintained and met. Elizabeth House Care Home C53 C03 S8668 Elizabeth House V245514 230805 Stage 4.doc Version 1.40 Page 19 One staff member reported that she has done quite a bit of training outside the home but had one session of in-house training, which she felt was not of an appropriate standard. No moving and handling training has been given for quite a while. Staff must undertake training in dementia care and for pressure sore prevention. Training must be provided for staff in manual handling practices. It is recommended that the training is provided by an accredited trainer to ensure staff are updated with current practice. Elizabeth House Care Home C53 C03 S8668 Elizabeth House V245514 230805 Stage 4.doc Version 1.40 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 These standards were not assessed. A Requirement set at the last inspection was, found, to be met. EVIDENCE: The requirement set at the previous inspection regarding risk assessments for safe working practices was found to be met but would be improved by further development. Elizabeth House Care Home C53 C03 S8668 Elizabeth House V245514 230805 Stage 4.doc Version 1.40 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 2 1 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION x 2 x x 3 3 3 2 STAFFING Standard No Score 27 2 28 x 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x x x x x x 3 Elizabeth House Care Home C53 C03 S8668 Elizabeth House V245514 230805 Stage 4.doc Version 1.40 Page 22 Yes 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. 2. Standard OP1 OP3 Regulation 4 14 Requirement Ensure that the Statement of Purpose is amended as specified within the report Ensure a full and detailed assessement is undertaken for service users who are admitted on an emergency basis and that they fit within the criteria of the registartion category Ensure all service users admitted to the home meet the regsitration category criteria [Service users diagnosed with a primary need of dementia must not be admitted to the homefailure to comply with this immediate requirement will result in enforcement action being taken] Ensure care plans are appropriatley evaluated and reviewed regularly. Ensure care plans address the identified needs of service users as specified, in relation to personal care. Ensure staff follow strategies for the prevention and healing of pressure sores Timescale for action 15th October 2005 15th September 2005 3. OP4 14 CSA 23rd August 2005 3.20pm 4. 5. OP7 OP7 15 15 15th October 2005 15th October 2005 15th October 2005 6. OP8 12, 13 Elizabeth House Care Home C53 C03 S8668 Elizabeth House V245514 230805 Stage 4.doc Version 1.40 Page 23 7. OP8 8. 9. 10. OP8 OP9 OP9 11. 12. 13. OP9 OP9 OP9 14. 15. 16. 17. OP9 OP18 OP20 OP20 Ensure service users who are frail or confined to bed have their care plan reviewed frequently and that care charts are used to monitor their care, nutrition, fluid intake and turns. 12, 13, 17 Ensure accident records cross reference with details within care plans and running records Medicines Ensure that the MAR [medication Act, 12, administration record] is 13, 16 completed at all times Medicines Ensure that the MAR is signed Act, 12, after visually observing each 13, 16 individual service users medication being taken.[they must not be signed en block] Medicines Defrost the medicines fridge Act, 12, 13, 16 Medicines The excess stock of medication Act, 12, must be returned to the 13, 16 pharmacy Medicines Ensure medicines are dispensed Act, 12, in accordance with the Medicines 13, 16 Act, regarding checking the prescribed dose prior to dispensing Medicines Ensure that the controlled drugs Act, 12, register is completed fully. 13, 16 12, 13, 16 Ensure keys to the home are kept secure and not left in doors 16, 23 12, 13, 16, 23 Repair the broken toilet handle 12, 13 15th September 2005 15TH October 2005 15th September 2005 15th September 2005 15th September 2005 15th September 2005 15th September 2005 15th September 2005 15TH October 2005 15TH October 2005 15TH October 2005 15TH October 2005 18. OP26 Investigate who had been smoking in the upstairs toilet on the day of the inspection and report the outcome to the inspector 12, 13, 16 Ensure paper towels are provided in the dining/kitchenette, bathrooms and toilets Elizabeth House Care Home C53 C03 S8668 Elizabeth House V245514 230805 Stage 4.doc Version 1.40 Page 24 19. 20. OP30 OP30 18 18 Ensure all staff undertake manual handling training updates Ensure all staff undertake training in Dementia 15th September 2005 15TH October 2005 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. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. Refer to Standard OP4 OP7 OP7 OP8 OP8 OP9 OP18 OP18 OP18 OP18 OP20 OP26 OP27 OP30 OP38 Good Practice Recommendations Obtain service users reviews with social services regarding their placement at the home. Ensure care plans contain a running record of events of falls with the service users mobility plan and risk assessment. Keep a record of observation checks for those service users at risk of wandering. Improve the standard of continence management and toileting regimes Improve manual handling practices Use a drugs trolley for storing and administering medication. Change the bedroom door lock on the identified service users bedroom door Look at providing simple door alarm gadgets where doors are not electronically alarmed Seek advice from the fire officer regarding the safety and security of the utility area in the conservatory. Amend the missing persons policy to include notification to CSCI under regualtion 37 Undertake and document a security risk assessment of the home Rewrite the infection control policy Provide an extra staff member on each day shift Provide training in pressure sore prevention Further develop the risk assessments for all safe working practices Elizabeth House Care Home C53 C03 S8668 Elizabeth House V245514 230805 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Edgeley House Riversider Business Park Tottle Road Nottingham NG1 2RT 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. 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