Inspection on 14/07/06 for Ellerslie

This inspection was carried out on 14th July 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Ellerslie 29/09/09

Ellerslie 11/12/08

Ellerslie 16/06/08

Ellerslie 19/06/07

Ellerslie 21/11/05

Ellerslie 24/06/05

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Ellerslie 108 Albert Road Pittville Cheltenham Glos GL52 3JB Lead Inspector Mrs Eleanor Fox Key Unannounced Inspection 14th July 2006 09:30 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 Ellerslie DS0000064584.V299380.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ellerslie DS0000064584.V299380.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ellerslie Address 108 Albert Road Pittville Cheltenham Glos GL52 3JB 01242 514384 01242 255804 manager.ellerslie@osjct.co.uk 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) The Orders of St John Care Trust Mrs Susan Rose Alakija Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Ellerslie DS0000064584.V299380.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st November 2005 Brief Description of the Service: Ellerslie is a large three-storey building, which has been converted and extended to provide accommodation for up to 31 residents who require nursing and personal care. It is situated close to Cheltenham town centre, a short walk from Pittville Pump Rooms and the racecourse. The Care Home is equipped with shaft lifts to assist those unable to manage the stairs. In addition, a variety of aids and adaptations have been provided throughout the property to help the residents. With the exception of two spacious double rooms, all the bedrooms are for single occupation. Only two rooms have en suite facilities but assisted bathrooms and toilets have been installed throughout the majority of the property, the exception being the top floor of the Home. There has still been no progress in providing suitable facilities for the residents accommodated in this part of the building. The comfortable communal facilities consist of three well-appointed lounges and a dining room. A Day Centre has been developed within the property; this is in use 4 days a week but may also be used by residents at weekends. The attractive private gardens are easily accessible and may be enjoyed by the residents in warm weather; they are well protected from the busy main road by tall mature trees. Adequate parking is provided for staff and visitors. The provider supplies information about the home, including the most recent CSCI report in a file at the entrance of Ellerslie. Current fees range from £352.70 to £693. Hairdressing, chiropody and any personal items are charged extra. Ellerslie DS0000064584.V299380.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. One inspector undertook this unannounced inspection of the home over two days in July. During the visit, she chose four of the residents for close scrutiny. She spoke to each of these people, read their care records, visited their bedrooms and observed their interaction with members of staff. One person had been admitted to the home very recently and was able to provide comment about her initial impressions of Ellerslie. The inspector read selected personnel and recruitment records, walked around the property and observed the service of the mid-day meal. She also spoke with the majority of the staff who were on duty on these two days. Finally, she talked with the Manager, and to the administrator, particularly in relation to general management issues. Both were open and most cooperative in providing information as requested. CSCI surveys were distributed to residents, relatives and members of staff working at the home. Eighteen were returned from residents, all of whom had required assistance from a named member of staff to complete the forms. Ten surveys were received from staff in the home and twelve comment cards were received from relatives. Many of their comments and opinions are reflected in the content of this report. What the service does well: This home continues to work hard to ensure that residents are served a good standard and variety of food in relaxed surroundings. People completing the questionnaires confirmed their general satisfaction with the food provided although a minority had reservations about specific items, such as cooked vegetables. One person spoke most enthusiastically about “the wonderful food here.” Each person continues to be subject to a thorough assessment before they are admitted to this home to ensure that the staff are able to meet their care needs. Ellerslie DS0000064584.V299380.R01.S.doc Version 5.2 Page 6 Members of staff are encouraged to undertake the wide variety of appropriate training, which is offered in this home. All administrative records are kept methodically and are stored securely. Members of staff appear to be friendly in their approach, establishing good working relationships with the residents. Many of those questioned spoke very fondly of the staff caring for them. They also confirmed their satisfaction of the care provided in their completed questionnaires. What has improved since the last inspection? What they could do better: As identified on three previous visits, there continue to be a number of maintenance and decorative issues that are still awaiting action. Despite assurances to the contrary, there has still been no progress in providing residents accommodated on the top floor with adequate bathing and toilet facilities. This issue must be addressed urgently. There is a good focus on quality improvement processes but the provision of an annual improvement report has not yet been addressed. The management of recruitment processes also requires urgent improvement. Ellerslie DS0000064584.V299380.R01.S.doc Version 5.2 Page 7 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. Ellerslie DS0000064584.V299380.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ellerslie DS0000064584.V299380.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. A thorough assessment process plus the provision of literature about the home, although now requiring some revision, enables prospective residents to make an informed decision regarding their admission and gives them assurance that their needs will be met. EVIDENCE: Each prospective resident is provided with comprehensive information about the home. However this has still not been fully reviewed and updated following the change of ownership in early 2005. It is anticipated that the new documentation will be available in the near future. A contract outlining the terms and conditions for admission to the home, had been provided to each of the residents who were selected as part of a case Ellerslie DS0000064584.V299380.R01.S.doc Version 5.2 Page 10 tracking exercise during the inspection of the home. Signed copies of the completed documentation were seen in their personal files. Thorough assessments are undertaken of each prospective resident prior to their admission to Ellerslie. The completed records are stored in each person’s care file and are then used to assist with the admission processes. Copies of Social Services assessments and any other relevant documentation are also filed so that they may be used for reference purposes. Intermediate care is not provided at this home. Ellerslie DS0000064584.V299380.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected 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 good. This judgement has been made using available evidence including a visit to the service. The care planning systems in place now provide the staff with the guidance they require to care for all the residents’ needs. Some minor improvements in the medication administration systems are required to ensure that residents are not put at any risk of potential errors. Residents are treated with courtesy and respect. EVIDENCE: Written care plans are developed for each resident based on a full assessment of care needs. In each example seen on this occasion, clear and appropriate guidance had been recorded for the members of staff providing care. Where there had been any changes in condition, these had been identified at the monthly reviews and documented. One lady who spoke to the inspector confirmed that she had been given the opportunity to be involved in the planning of her care. This person had a skin Ellerslie DS0000064584.V299380.R01.S.doc Version 5.2 Page 12 disorder, which had been addressed by the staff and which was now improving. Discussion with the residents and observation of the care documentation shows that the residents are receiving care from external medical personnel when required. The tissue viability nurse had recently provided advice on the care of one person. The Continence care nurse had also just seen one lady and an Optician had recently examined another resident. Regular monitoring of residents’ weights is conducted, particularly if there is any deterioration in the resident’s physical condition. Nutritional supplements are provided when required. One person had been discharged from hospital in ‘an emaciated condition’ but had since improved, gaining weight in recent months. The risk of possible vulnerability to developing pressure sores is also assessed and pressure relief equipment provided if required. One gentleman showed the inspector his ‘special cushion’. Medications are ordered and stored correctly. Guidance was provided in the care records to instruct staff when to administer ‘as required’ medication. Photographs of each resident are provided to aid identification. However, it was identified in one resident’s care records that this person was allergic to Penicillin and Lignocaine but no mention of this was made on his medication administration sheet. Although there is a reminder on the front of the medication administration file, handwritten medications relating to two of the selected residents had not been signed and countersigned. One of the selected residents had chosen to self medicate some of her drugs. Risk assessments had been undertaken and the appropriate documentation completed. Members of staff were observed speaking to residents in a polite but friendly manner. Interaction between the staffing team and the residents was particularly positive during the service of the lunchtime meal; there appeared to be a very good rapport between all those present. On the whole, comments in the questionnaires were very complimentary about the staff employed at the home, some of which commented on significant improvements in recent months. Ellerslie DS0000064584.V299380.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected 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 the service. Residents are facilitated to maintain any links they wish with family, friends and the local community, thus adding interest to their lives through social contact. The meals are nutritious and balanced, offering both choice and variety to the residents. EVIDENCE: Discussions with residents and observation of the records show that a good variety of activities are arranged in the home, based on residents’ particular interests. Detailed personal profiles had been provided for each of the residents chosen as part of the case tracking exercise and one person, who had always enjoyed being out in the open air, appreciated being able to take walks with a member of staff in the large garden. However, three people did say they would like to see the activities increased. A summer garden fete was being arranged later in the month. The Home continues to have the benefit of a fully equipped sensory room, which some of the residents do find beneficial. Ellerslie DS0000064584.V299380.R01.S.doc Version 5.2 Page 14 Residents are free to receive visitors when and where they wish. One person did say that they would like to have the use of an alternative small private area other than their bedroom to talk to relatives; the dining room is usually made available for this purpose if it is not being used. An informative and entertaining newsletter is now prepared for Ellerslie keeping residents and their families and friends aware of events and issues in the home and in Cheltenham. Members of staff were observed and overheard offering residents choices on how they spent their day. Some people preferred to remain in the privacy of their bedroom; their wishes were respected. The service of the mid day meal was observed. Because of the size of the dining room, this meal is served in ‘two sittings’. However, residents are given plenty of time to eat their meals in a relaxed manner and in congenial surroundings. A good choice of food is offered. Some people were pleased to accept additional helpings when these were offered to them. Those people requiring assistance were observed being helped in a gentle but encouraging fashion. One gentleman described the full cooked breakfast he had eaten that day as – “the best meal of the day”. Ellerslie DS0000064584.V299380.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be 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 good. This judgement has been made using available evidence including a visit to the service. The full implementation of the home’s policies and procedures gives residents the reassurance that they may expect to live in a safe environment and that any concerns they raise will be addressed in a timely manner. EVIDENCE: Over the last seven months there have been four formal complaints about the home, mainly relating to staffing and care issues. These have been fully investigated and where applicable, appropriate action taken. Only one of these is not yet resolved as further investigations are being carried out. Although seven relatives commented that they were unaware of how to make a complaint about Ellerslie, the processes are clearly available in the front hall; they were seen on this visit. The training manager is about to conduct a series of training sessions for staff, which will relate to abuse issues. However, the majority of the carers have a good understanding of the subject, having already undertaken training on these issues. The home has detailed abuse policies, including information about whistle blowing. These are readily available to staff employed at the home. Ellerslie DS0000064584.V299380.R01.S.doc Version 5.2 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, 21, 23, 25 and 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. Further urgent investment is required to create a comfortable and homely environment and to meet all the needs of the residents living in the home. EVIDENCE: Although the majority of the home was visited, the bedrooms of each of the residents selected for case tracking were particularly scrutinised on this occasion. The home was reasonably clean and, on this occasion only mildly offensive odours were evident in a few areas. Upgraded bathing facilities have been installed on the first floor; the fire alarm system has also been replaced. However, despite some remedial paintwork, much of the home still looks ‘tired and shabby’; it requires decorative and maintenance attention. There are also Ellerslie DS0000064584.V299380.R01.S.doc Version 5.2 Page 17 still a number of windows, which require repair. Where work has been completed, it was observed that some damaged areas have merely been covered with a coat of paint without addressing the initial appropriate repair first. One person did comment that the clock in the lounge has not worked throughout the period her relative has lived at Ellerslie. On this occasion, the stair carpet on the upper floor of the building had been temporarily removed. It was reported that the peripatetic maintenance team have been booked to undertake some of the outstanding work at the end of July. Despite assurances that a shower room and toilet would be installed on the top floor of the building by March 2006, the work has still not been completed. The current bathroom is inaccessible to the majority of residents accommodated in that area. Currently there are inadequate bathing and toilet facilities in the home to meet the needs of the residents. It was identified to the manager that the carpet required stretching in three of the bedrooms as the uneven surfaces currently pose a health and safety risk. An additional calorifier was installed in March to rectify ongoing deficiencies in the heating and hot water systems. Laundry facilities are provided in the basement area. On this occasion, these processes appeared to be being managed correctly with clean and soiled laundry fully segregated. Ellerslie DS0000064584.V299380.R01.S.doc Version 5.2 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 the service. Residents now receive care from a more stable competent workforce but improvements in recruitment practice are necessary to ensure that residents are fully protected. EVIDENCE: On this visit, there were twenty-six residents living in the Home. In the morning, the Manager, a trained nurse and 5 carers were on duty to look after the people living there; a nurse and four carers were due to be on duty in the evening; with a nurse and two carers working at Ellerslie overnight. Following successful recruitment, the home now has a reasonably stable care team with agency staff employed as infrequently as possible. There are, however, occasional problems at weekends due to staff sickness; the nursing staff are permitted to arrange additional cover if required. Of the twenty-two carers employed at Ellerslie, eight are already qualified to the National Vocational Qualification in Care, Level 2 and a further five carers are now undergoing the training. One person has achieved a Level 3 qualification. The domestic members of staff employed in the home have also completed or are undertaking NVQ training. Ellerslie DS0000064584.V299380.R01.S.doc Version 5.2 Page 19 Personnel files relating to all the staff employed since the last inspection were read in detail. Each person had completed an application form providing a full employment history. Records had been maintained of the interview processes and correct POVA (Protection of Vulnerable Adults) and CRB (Criminal Record Bureau) screening had been completed. However, of the ten people employed, two had only one written reference on file and two had commenced duties with no written references. The Manager has been requested to source the missing documentation as a matter of urgency and to inform the Commission for Social Care Inspection when these processes have been completed. Discussion with the person responsible for arranging training and observation of the records showed that all mandatory training continues to be addressed in a timely manner. In addition, staff have received recent instruction in customer care, care planning, care of ageing skin, continence and bowel management and diabetic care. The care leaders have also had training on all aspects of their role. Ellerslie DS0000064584.V299380.R01.S.doc Version 5.2 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 good. This judgement has been made using available evidence including a visit to the service. The effective implementation of the majority of the Company’s policies and procedures ensures that the home is well managed and the residents’ rights upheld. EVIDENCE: The experienced nurse manager of this home now has the support of a conscientious deputy and efficient administrator to assist her in the effective management of the home. The home continues to undertake a number of auditing processes. Residents’ satisfaction with meals provided, complaints, accidents and general quality of the provision of care continues to be monitored monthly. The Company’s Ellerslie DS0000064584.V299380.R01.S.doc Version 5.2 Page 21 Quality Manager has just conducted a medication audit; the home’s processes were considered satisfactory. The results of the resident quality survey have now been produced. Although these show a general satisfaction with the home, a number of specific issues have been identified. The manager is now preparing a quality improvement report, a copy of which will be provided to the Commission for Social Care Inspection. The Administrator continues to take responsibility for the personal monies for the majority of the residents; the records relating to the four residents selected for case tracking were checked on this occasion. It was observed that correct records are maintained and that individual secure storage is provided. Details about residents’ status in relation to ‘Power of Attorney’ are also maintained on file. Health and safety issues are generally addressed well at this Home. However, it was observed that, although there was a notice on the door of one bedroom to warn people that Oxygen therapy was being provided, there was no advice of the precautions to take in the vicinity of this area; for example not to smoke or to strike a match. This is now being provided. All necessary maintenance of equipment is undertaken in a timely fashion; records were provided for inspection. The requirements issued by the Fire Officer in the latter half of 2005 have now been addressed. Issues identified by the Environmental Health Officer following a visit on 18/05/06 are currently being rectified. Ellerslie DS0000064584.V299380.R01.S.doc Version 5.2 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 2 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 1 x 1 x 2 x 3 3 STAFFING Standard No Score 27 3 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 2 x 3 x x 2 Ellerslie DS0000064584.V299380.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 6 (a & b) Requirement The Statement of Purpose and Service User’s Guide must be fully reviewed and updated. Once completed, copies must be made available to current and prospective residents. A copy must also be provided to the Commission for Social Care Inspection. The person making the record in the drug administration documentation must sign any handwritten amendments. (This requirement has been repeated from the last two inspections.) It must be clearly recorded when residents are identified as suffering an allergy to specific medications. Decorative and maintenance requirements identified under Standard 19 must be addressed (This requirement has been repeated from the last three inspections.) An assisted bathroom or shower DS0000064584.V299380.R01.S.doc Timescale for action 30/09/06 2 OP9 13(2) 01/08/06 3. OP9 13(2) 01/08/06 4 OP19 23(2b) 30/09/06 5 Ellerslie OP21 23(2j) 30/09/06 Page 24 Version 5.2 facility, and accessible toilet must be provided on the upper floor of the building (This requirement has been repeated from the last four inspections.) 6 7. OP23 OP29 16 (2c) 15 (4) Sched. 2 Carpets in residents’ bedrooms must be made safe to prevent the risk of injury. Two written references must be obtained for each prospective staff applicant (This requirement has been repeated from the last inspection.) A quality improvement report must be provided for the home (This requirement has been repeated from the last inspection.) Adequate warning instructions must be clearly displayed when oxygen is being administered to a resident 31/08/06 31/08/06 8. OP33 24(2) 31/08/06 9 OP38 13(4) & 23(4) 31/08/06 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 Refer to Standard OP28 Good Practice Recommendations At least 50 of the care staff should be trained to National Vocational Qualification, Level 2 or equivalent. Ellerslie DS0000064584.V299380.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Ellerslie DS0000064584.V299380.R01.S.doc Version 5.2 Page 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!