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Inspection on 27/09/05 for Elizabeth Peters Residential Care Home

Also see our care home review for Elizabeth Peters Residential Care Home for more information

This inspection was carried out on 27th September 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Service users gave positive feedback about the home. Comments included, "Everything is good", "I like my room", "They treat you well", and "You couldn`t get any where better". The needs of service users are fully assessed before they are offered a place to ensure that they can be met. The home ensures that the physical and mental health needs of service users are monitored and addressed. The home`s medication system is safe though it is recommended that homely remedies be obtained in order that they can be quickly accessed for minor ailments. Service users confirmed that they exercise autonomy and choice and that their privacy and dignity are respected. Although service users are often reluctant to engage in structured activities staffing level are sufficient to allow staff to work with them on an individual basis to ensure that they are given opportunities for social and community contact. Service users are offered a choice of meals and records indicate a flexible approach to food in accordance with service users preferences. Service users had not made complaints but stated they would be happy to do so if necessary. The home offers a comfortable and homely environment for service users with sufficient personal and shared space.

What has improved since the last inspection?

The written information provided to service users had been greatly improved though needed a minor correction. The restraint policy had been reviewed to ensure that service users are protected from abuse. Refurbishment had continued and timescales provided for the outstanding completion of the kitchen. A routine maintenance programme is still required. Service users rooms are personalised and notes were available on the files of service users who had chosen not to have a key. The home is working towards ensuring that its training programme meets the needs of service users and had obtained information to ensure that it is in accordance with National Training Organisation specifications, though it is recommended a training plan be developed. The home has further improved its quality assurance system and included the results of service users surveys in its service user guide. An annual development plan has been produced that indicates the business is financially viable and details the plans for the coming year. The health, safety and welfare of service users are protected and previous requirements relating to the electrical installation of the building, fire brigade requirements, fire training, food hygiene certificates and first aid certificates have been met. A previous requirement relating to the notification of events to CSCI remains outstanding.

What the care home could do better:

Although one care plan indicated significant improvement from previous inspections the other two care plans had important areas missing. Previous requirements that care plans must cover all needs of the service user, indicate the service users involvement, the system was to be used correctly, and that a risk assessment was in place for each service user had not been met. Although it was reported that service users were managing with the homes environment, an occupational therapy assessment of the premises is still recommended in order to ensure that the future needs of service users can be met. The home is clean and pleasant though some environmental health requirements and recommendations were still to be met. These are the kitchen refurbishment, relocation of laundry facilities and food temperature testing in order to ensure that the home is hygienic. Although the provider is a competent manager for the home, she must submit her application to be registered as required by regulation.

CARE HOMES FOR OLDER PEOPLE Elizabeth Peters Residential Care Home 22 Newquay Road Catford London SE6 2NS Lead Inspector Kate Matson Unannounced 27 September 2005 th 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 Peters Residential Care Home G52-G02 S25593 ElizabethPetersResidential V245594 270905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Elizabeth Peters Residential Care Home Address 22 Newquay Road, Catford, London, SE6 2NS 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) 0208 244 0013 Elizabeth Peters Care Homes Limited CRH Care Home PC Care home only 3 Category(ies) of DE Dementia registration, with number MD Mental Disorder of places OP Old Age PD Physical Disability Elizabeth Peters Residential Care Home G52-G02 S25593 ElizabethPetersResidential V245594 270905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: This home is registered for 3 persons of whom up to 3 may be elderly, up to 3 may be elderly with dementia, up to 3 may be elderly with a learning disability, up to 3 persons may be elderly with a mental disorder and up to 1 may have a physical disability but be over 50 years of age. Date of last inspection 4th January 2005 Brief Description of the Service: Elizabeth Peters House is a small home for three older people who may have a mental health problem or dementia. The home is one of four owned and managed by a local provider, Elizabeth Peters Care Homes Ltd. The home is situated in a quiet residential street close to the centre of Catford. The home is well served by public transport facilities with bus and train services within a short walking distance of the home. There is a small parade of shops close by, with larger shops and facilities available in Catford town centre. There were no vacancies on the day of the inspection. Elizabeth Peters Residential Care Home G52-G02 S25593 ElizabethPetersResidential V245594 270905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This statutory announced inspection was carried out over nine hours. The inspection included discussion with two service users, the registered provider a senior staff member, a tour of the building and examination of care plans and other records. What the service does well: What has improved since the last inspection? The written information provided to service users had been greatly improved though needed a minor correction. The restraint policy had been reviewed to ensure that service users are protected from abuse. Refurbishment had continued and timescales provided for the outstanding completion of the kitchen. A routine maintenance programme is still required. Service users rooms are personalised and notes were available on the files of service users who had chosen not to have a key. The home is working towards ensuring that its training programme meets the needs of service users and had obtained information to ensure that it is in Elizabeth Peters Residential Care Home G52-G02 S25593 ElizabethPetersResidential V245594 270905 Stage 4.doc Version 1.40 Page 6 accordance with National Training Organisation specifications, though it is recommended a training plan be developed. The home has further improved its quality assurance system and included the results of service users surveys in its service user guide. An annual development plan has been produced that indicates the business is financially viable and details the plans for the coming year. The health, safety and welfare of service users are protected and previous requirements relating to the electrical installation of the building, fire brigade requirements, fire training, food hygiene certificates and first aid certificates have been met. A previous requirement relating to the notification of events to CSCI remains outstanding. 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 Peters Residential Care Home G52-G02 S25593 ElizabethPetersResidential V245594 270905 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 Peters Residential Care Home G52-G02 S25593 ElizabethPetersResidential V245594 270905 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 and 3 Although service users had been provided with information packs including required and other useful information, some of the information was incorrect. The needs of service users are fully assessed before being offered a place at the home. EVIDENCE: At previous inspections it was noted that the statement of purpose and service user guide were missing some required information. At this inspection it was pleasing to note that service users had been provided with an information pack to keep in their rooms. This included a statement of purpose, service users guide, complaints procedure, fire procedures specific to each service users and their room, and information about advocacy services. The statement of purpose and service user guide included all of the required information as well as some additional useful information. However the service user guide described a wider number of communal spaces than are available in the home. The document must be reviewed to ensure that the information supplied to service users is correct. All three of the service users had lived at the home for some time, however their personal files included evidence of the original assessment completed for Elizabeth Peters Residential Care Home G52-G02 S25593 ElizabethPetersResidential V245594 270905 Stage 4.doc Version 1.40 Page 9 the care management process and by the home to ensure that their needs could be met. Elizabeth Peters Residential Care Home G52-G02 S25593 ElizabethPetersResidential V245594 270905 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, 10 and 11 Although one care plan evidenced well, that all areas of the service users needs and risks were considered there was insufficient evidence available to support this for the other two service users. The physical and mental health care needs of service users are monitored and appropriately addressed. The homes medication policies and procedures protect service users though better access to homely remedies is recommended. Service users confirmed that their privacy and dignity were respected. The home ensures that the wishes of service users regarding illness or death are carried out as far as possible. EVIDENCE: The home uses a care planning system that facilitates a clear and comprehensive assessment of all aspects of service users needs. At previous inspections it was noted that care plans covered only a few specific areas, the format was not being used correctly and whilst care plans were regularly reviewed and there was evidence of service users signatures, it was not clear what service users had agreed to. Also risk assessments were not available for all service users. At this inspection all three of the current service users care plans were examined. One of the care plans revealed that one of the previous requirements had been implemented well as it was correctly completed, Elizabeth Peters Residential Care Home G52-G02 S25593 ElizabethPetersResidential V245594 270905 Stage 4.doc Version 1.40 Page 11 covered all aspects of the service users life, was regularly reviewed and evidenced the service user’s involvement. However the other two care plans and risk assessments were missing and daily logs were not up to date. The member of staff on duty explained that she had taken the files home to update them following have an accident with some coffee. However unfortunately she was unable to provide the inspector with the evidence that the files were fully completed and the previous requirements are restated in this report. The care plan available and discussion with staff and service users indicated that the physical and mental health care needs of service users are monitored and addressed. One service user was now monitoring their blood sugar levels and receiving treatment for diabetes and seeing a dietician for advice. One service user was recovering from a relapse in their mental state and in close liaison with the psychiatrist and mental health team the home had helped the service user to remain at home. The homes medication system and records were examined. These were in order though it was noted that the home has no homely remedies at present. The manager stated that none of the current service users would take painkillers and they have other remedies for common ailments on prescription. However as the home is preparing to apply for registration for another two service users, it is recommended that homely remedies be obtained for the home with written approval from the GP stating to whom, and at what dose the remedy may be given. This ensures that service users have quick access to remedies for minor ailments. The statement of purpose and service user guide state that staff are trained to respect the privacy and dignity of service users, and service users confirmed that staff always ask permission before entering their rooms and one service user stated that their independence was always respected. The home operates a key worker system to ensure the continuity and consistency of care provided. The home has policies on illness and death to ensure that the privacy and dignity of service users who are dying are maintained at all times. The care plan available included details about the services users wishes in the event of their death, to ensure that these would be carried out. Elizabeth Peters Residential Care Home G52-G02 S25593 ElizabethPetersResidential V245594 270905 Stage 4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15 Service users are encouraged to take part in activities that suit their individual needs and preferences. Service users who so wish maintain contact with friends, family and the local community. Service users exercise choice and control over their lives. Service users are provided with a flexible choice of nutritious meals. EVIDENCE: Service users spoken to were not interested in any organised activities and preferred to organise their own time, reading and watching television. However staff demonstrated that an individual approach is taken to activities and two service users have made progress in the small number of activities they have been prepared to get involved in. One service user goes out once a week with a carer and another service user goes out once or twice every day with a carer. Service users had also been offered a holiday this summer though none of the current residents had wanted to go. Some service users have regular contact with their family and visitors are welcomed to the home in accordance with the wishes of service users. Service users use local shops and cafes and one attends a drop in coffee morning locally. The home had offered trips out in the past and the inspector was informed that a lunch out is being planned for service users. If this is successful it is recommended that this be offered at least monthly. Elizabeth Peters Residential Care Home G52-G02 S25593 ElizabethPetersResidential V245594 270905 Stage 4.doc Version 1.40 Page 13 Two of the service users need some support in managing their money however this comes from family members. The provider keeps records of money received from relatives in order to protect their interests. Information about advocacy is included in the information packs in each service users room. Service users rooms evidenced that they had brought personal possessions with them and continued to keep their rooms as they wished. Service users confirmed that they were able to get up, go to bed and go out as they wished. Service users gave positive feedback about the food. “The food is good” and confirmed that a choice is given on a daily basis, “You can change it if you don’t want it”. The menu is discussed every morning for that evening and the food record demonstrated that service users are offered a choice of food that is varied and nutritious and that they are frequently served different meals to each other indicating a flexible approach to meals. The meal served on the day of the inspection was well presented and appetising. Elizabeth Peters Residential Care Home G52-G02 S25593 ElizabethPetersResidential V245594 270905 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 and 18 Service users had not made complaints but confirmed they would be happy to if necessary. The home’s practices ensure service users are protected from abuse. EVIDENCE: Service users are provided with a complaints procedure in their information pack. Service users stated that they had not had any cause for complaint but confirmed that they would feel able to complain if necessary. The home has appropriate policies and procedures in place in order to protect service users from abuse. All staff had undergone training in adult abuse and staff stated how valuable they had found this. The home’s policy on restraint had been reviewed following a requirement from a previous inspection. As already stated service users are supported to manage their own money as far as possible and the provider ensures that service users get the money they are entitled to from their relatives where they are assisting in this area. Elizabeth Peters Residential Care Home G52-G02 S25593 ElizabethPetersResidential V245594 270905 Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 22, 23, 24, 25 and 26. The home is largely well maintained though the kitchen still requires refurbishment. There is adequate shared space for service users. An occupational therapy assessment of the premises is still recommended although it is reported that service users are currently managing with the homes environment. Service users reported that they were happy with their rooms and they were seen to reflect their personalities. The heating and lighting meet the needs of service users. The home is clean and pleasant though some environmental health requirements and recommendations were still to be met. EVIDENCE: Elizabeth Peters House is a small home situated in a quiet residential street close to the centre of Catford. It is a converted property and blends in well with the surrounding buildings and is well served by public transport facilities with bus and train service within walking distance of the home. There is a small parade of shops close by, with larger shops and facilities available in Catford town centre. At previous inspections requirements were made to Elizabeth Peters Residential Care Home G52-G02 S25593 ElizabethPetersResidential V245594 270905 Stage 4.doc Version 1.40 Page 16 instigate a significant amount of refurbishment, maintenance and re-decoration work to ensure that the home remains suitable for its purpose, and to develop a programme of routine maintenance and renewal. At this inspection, it was found that the home was largely well maintained. The bathroom had been refurbished and there was evidence of regular redecoration of the home. However the kitchen still required refurbishment and the environmental health officer had also required this to be done. Also a routine maintenance programme was still unavailable. The provider however stated her intention to refurbish the kitchen but was currently waiting for quotes for a new boiler as she wished to replace this as part of the refurbishment. Following the inspection the inspector received a business plan for the home that included timescales for outstanding work and the previous requirement is considered met. However the other requirement is restated in this report though it has been partially met. The home has a lounge leading through to a conservatory at the rear with a dining area. There is a garden at the rear of the property with a patio. All communal areas were decorated and furnished in a comfortable and homely way. There is a call system in the home with an alarm facility in every room. There is some equipment available in the home such as handrails on the stairs and a grab rail in the bathroom. At a previous inspection it was noted that although the service users were ambulant, one of the service users had dementia and was likely to become frailer with age. The registered provider was reminded that an assessment of the premises and facilities should be made by suitably qualified persons including an occupational therapist with specialist knowledge of the client groups catered for to ensure that disability equipment provided and environmental adaptations made meet the needs of service users where issues such as physical frailty or dementia are identified. It was recommended that such an assessment take place. At this inspection the registered provider stated that she had consulted with the GP who had said that this was not necessary. Also staff confirmed that currently the service users are coping with the environment as it is and all were able to get out of the bath without assistance. However as service users are becoming frailer and the provider is planning to apply for registration for another two service users the recommendation is restated in this report. Two of the rooms are above 10 m2 as required. The third one is just smaller than that though all room sizes are noted in the statement of purpose as required. All service users confirmed that they were happy with their rooms. All three of the service users rooms were seen and they included all of the required items and reflected the personalities of service users. Keys had been provided or where service users did not wish to have them this was noted in their files as required by a previous inspection. All three bedrooms were well lit and individually and naturally ventilated. Rooms were centrally heated with guarded radiators that can be individually controlled in service users bedrooms. However it was required at the last inspection that the radiator in the bathroom radiator in the bathroom is guarded, or of a low temperature surface, in order to protect service users. It Elizabeth Peters Residential Care Home G52-G02 S25593 ElizabethPetersResidential V245594 270905 Stage 4.doc Version 1.40 Page 17 was noted at this inspection that a cover had been fitted. Taps are fitted with regulators to ensure water is delivered close to 43 °C. On the day of the inspection the home was clean and tidy and free from offensive odours. The laundry floor and walls were seen to have impermeable finishes. The washing machine had suitable programmes for disinfection of soiled laundry, although this was not an issue at the home. However the laundry is sited adjacent to the kitchen and can only be accessed through the kitchen meaning that dirty laundry has to be carried through a food preparation area. The provider had been given contradictory advice by the environmental health department and at the last inspection the registered provider was required to request an inspection report from the environmental health department and forward a copy of the most recent report to CSCI Southwark office. At this inspection it was found that a report from November 2004 was available though this had not been sent to CSCI as requested. This report required the refurbishment of the kitchen, the replacement of the kitchen ceiling, which had been done and recommended the relocation of the laundry facilities, and food temperature testing. The provider had already stated that the kitchen refurbishment was planned but was to be completed at the same time as the fitting of a new boiler for which she was awaiting quotes. She was exploring options for the relocation of the laundry facilities. She stated that the food testing had been taking place but there were no records available to support this. The registered provider must ensure that requirements and recommendations of the environmental health department are met and implemented. Elizabeth Peters Residential Care Home G52-G02 S25593 ElizabethPetersResidential V245594 270905 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 and 30 The staffing level ensures that the needs of service users are met. The home is working towards ensuring that its training programme meets the needs of service users. EVIDENCE: The staff rota indicated that there are two staff on duty throughout the day and one staff member sleeping in at night. Service users confirmed that they there were sufficient staff to meet their needs. As already stated one service user goes out twice a day with staff members. It was noted that as well as the staff sleeping on duty there was also a staff member who had recently retired continuing to live at the home and the provider’s grandson who has special needs living at the home. The inspector was concerned about any impact this may have on the residents, however the ex-staff member had lived at the home since it opened and service users knew him well. The provider’s grandson had also lived at the home since 2000 but was due to move out in November 2005. Previous inspections had required that the registered provider must ensure that the homes training and development programme meets the NTO workforce training targets. At this inspection it was noted that information from Skills for Care (the national training organisation) had been obtained and also staff members had been sent on external courses. It is recommended that in order to demonstrate a proactive approach to training to ensure that the needs of staff and service users are fully met, a training plan is developed based on mandatory requirements, the assessed needs of staff and the needs of service users. Elizabeth Peters Residential Care Home G52-G02 S25593 ElizabethPetersResidential V245594 270905 Stage 4.doc Version 1.40 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 34 and 38. Although the manager is competent she has yet to submit her application for registration as required by regulation. The home has effective quality assurance systems in place to ensure it is run in the best interests of service users. The accounting and financial procedures of the home protect service users. The health, safety and welfare of service users are promoted and protected though written notifications of incidents are still not being made to CSCI as required by regulation. EVIDENCE: Previous inspections had raised concerns about the management arrangements at the home as the previous manager was not working full time hours and then was absent from the home due to a bereavement. The registered provider had taken over as manager of the home earlier in 2005 though CSCI had not been notified formally of this as required by regulation. Although the provider was registered manager of another home in the group she was informed at the last Elizabeth Peters Residential Care Home G52-G02 S25593 ElizabethPetersResidential V245594 270905 Stage 4.doc Version 1.40 Page 20 inspection that she would need to submit a new application to be registered manager of Elizabeth Peters House. Although the provider has confirmed her intention to do this the requirement is restated in this report. Previous inspections had noted that the home had developed an effective quality assurance system that included satisfaction questionnaires given to service users, visitors and staff, although it was required that the results of surveys are published in the service user guide. At this inspection it was noted that results of service user surveys had been included in the service user guide and this made the document a much more personal account of life in the home. It is recommended that the results of surveys of relatives, visiting professionals and staff surveys are also included in the document to give an even fuller picture of the home. It was also recommended at a previous inspection that policies and procedures are indexed in order to make them more easily accessible to staff and service users. At this inspection it was pleasing to see a senior staff member was working on the indexing and had organised the documents into the same groups as National Minimum Standards. It was noted at previous inspections that an accountant is employed by the home. It was required at previous inspections that the registered provider supplies a business and financial plan to CSCI demonstrating that the home is financially viable. At this inspection a financial forecast demonstrated this and an annual development plan was sent to the inspector following the inspection that detailed the plans for the coming year including timescales for refurbishment. The requirement is considered met however it is recommended that a training plan as discussed under Standard 30 be included in the annual development plan. Recent previous inspections had required that electrical installation certificate be sent to CSCI, the requirements of the fire brigade be complied with as soon as possible, persons working at the home receive training in fire prevention, staff involved in food preparation have food hygiene certificates, there is a qualified first aider on duty at all times and that the registered provider must give notice to CSCI of death, illness and other events as required by regulation without delay. At this inspection it was found that all of the requirements had been met apart from written notification of a notifiable incident had not been made although the senior member of staff stated she had telephoned the office. This requirement is restated in the report. Other records were examined and indicated that the fire procedures, were in order and fire equipment, electrical appliances, and gas system were appropriately inspected and serviced. Elizabeth Peters Residential Care Home G52-G02 S25593 ElizabethPetersResidential V245594 270905 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 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 1 3 x 2 3 3 3 2 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 1 x 3 3 x x x 2 Elizabeth Peters Residential Care Home G52-G02 S25593 ElizabethPetersResidential V245594 270905 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. Standard 1 Regulation 4 and 5 Requirement Timescale for action 31/12/05 2. 7 15 3. 7 15 4. 19 23 (2) (d) The registered manager must ensure that the service users guide contains correct information. The registered provider must 31/12/05 ensure that care plans cover all relevant aspects of service users lives, and that the chosen care planning system is appropriately used (previous timescales of 30/11/04 and 30/04/05 not met though one care plan indicated the requirement was met) The registered provider must 31/12/05 ensure that all service users care plans contain a risk assessment and evidence of the service users involvement in the care plan (previous timescale of 30/04/05 not met though one care plan indicated the requirement was met) The Registered Person must 31/01/06 instigate a significant amount of refurbishment, maintenance and re-decoration work to ensure that the home remains suitable for its purpose, and must develop a programme of routine maintenance and renewal (this has been partially met, kitchen Version 1.40 Elizabeth Peters Residential Care Home G52-G02 S25593 ElizabethPetersResidential V245594 270905 Stage 4.doc Page 23 5. 26 13 (3) and 16 (2) (j) 6. 31 8 (1) 7. 38 37 refurbishment and routine maintenance plan outstanding, previous timescales of 01/08/04, and 30/06/05 not met) The registered provider must 31/01/06 ensure that requirements and recommendations of the environmental health department are met and implemented. The Registered Person must 31/01/06 ensure that there is a full-time or full-time equivalent Registered Manager/s in post (although the provider is managing the home an application for registration has not been received. previous timescales of 01/0704 and 30/04/05 not met) The registered provider must 30/11/05 give notice to CSCI of death, illness and other events listed under Regulation 37 of the Care Homes Regulations without delay (previous timescales of 30/09/04 and 31/03/05 not met) 8. 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. Refer to Standard 9 12 22 Good Practice Recommendations It is recommended that homely remedies be obtained for the home with written approval from the GP stating to whom, and at what dose the remedy may be given. It is recommended that if the planned lunch out is successful, this be offered on a monthly basis. It is recommended that an assessment of the premises and facilities be made, by suitably qualified persons including an occupational therapist with specialist knowledge of the client groups catered for, to ensure that disability equipment is provided and environmental G52-G02 S25593 ElizabethPetersResidential V245594 270905 Stage 4.doc Version 1.40 Page 24 Elizabeth Peters Residential Care Home 4. 30 5. 6. 33 33 adaptations are made to meet the needs of service users. It is recommended that in order to demonstrate a proactive approach to training to ensure that the needs of staff and service users are fully met, a training plan is developed based on mandatory requirements, the assessed needs of staff and the needs of service users. It is recommended that the results of surveys of relatives, visiting professionals and staff surveys are also included in the document to give an even fuller picture of the home It is recommended that a training plan as discussed under Standard 30 be included in the annual development plan. Elizabeth Peters Residential Care Home G52-G02 S25593 ElizabethPetersResidential V245594 270905 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Ground Floor 46 Loman Street Southwark SE1 0EH 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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