Inspection on 19/06/07 for Ellerslie

This inspection was carried out on 19th June 2007.

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 14/07/06

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 19th June 2007 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.V336642.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.V336642.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 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.V336642.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th July 2006 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 property. 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 £364.74 to £742. Hairdressing, chiropody and any personal items are charged extra. Ellerslie DS0000064584.V336642.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 home and takes into account the views and experiences of people using the service. Two inspectors, one of whom is a pharmacist employed by the Commission for Social Care Inspection, undertook this unannounced inspection of Ellerslie on one day in June 2007. The pharmacist inspector examined all the processes for medication administration, storage, recording and any medication training undertaken. The other inspector chose the care of three of the residents for particular scrutiny. She met each of these people, read all their relevant care records and observed their interaction with members of staff. The inspector read selected personnel and recruitment records and examined the opportunities provided for training. The complaints files were also inspected. She walked around the property, and observed the service of a mid day meal during her visit. She also observed the residents’ participation in activities during the course of the inspection. She examined the opportunities for residents to exercise choice and to maintain social contacts. She also spoke with some of the staff who were on duty on this day, checking their understanding of some of the home’s policies and procedures and discussing their experiences within the establishment. Finally, she had the opportunity to talk to the manager, her deputy, and to the administrator, particularly in relation to general management issues. The inspectors extend their thanks to all the staff who provided assistance during the inspection processes. Prior to the inspection, CSCI surveys were distributed to residents and relatives of those living in the home. Twelve were returned from residents although in the majority of cases, a relative or named member of staff completed the form for them; three responses were also sent in from relatives and advocates. Many of their opinions are reflected in the content of this report. Ellerslie DS0000064584.V336642.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Ellerslie DS0000064584.V336642.R01.S.doc Version 5.2 Page 7 Following a detailed pharmacy inspection, a number of shortfalls have been identified, which must now be addressed. As a privacy and dignity issue was identified on this visit, staff are reminded that residents must be treated with respect at all times. Members of staff must be able to demonstrate that they have a good understanding of their responsibilities when abuse issues arise. Specific maintenance repairs identified under Standards 19, 24 and 26 must be addressed. The management of recruitment processes still require improvement. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Ellerslie DS0000064584.V336642.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.V336642.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are provided with adequate information so that they are able to make an informed decision regarding their admission. They may also be assured that their needs will be met, as there is an effective assessment process in place. EVIDENCE: Since the last inspection, the Statement of Purpose and Service User Guide have been fully reviewed and upgraded; the contents of the draft document are currently being checked corporately prior to the imminent distribution to current and prospective residents in the home. A copy will then be provided to the Commission for Social Care Inspection. 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.V336642.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. Residents and/or their advocates are provided with clear details about any additional financial contributions to which the resident may be entitled. Available records in the residents’ care files showed that thorough assessments are undertaken of each person to ensure that the home is able to meet his or her care needs. These details are all documented for reference when the admission processes are carried out. In some cases these were supported by information provided by other health and social care professionals previously involved in the care of the individual. The relative of one resident described in her survey, the visit she had made to the home prior to her Mother’s admission; she had been most reassured by the support she had received from the staff at this very difficult time. Another person wrote, “I liked the reception we received when we first came to visit.” The family of another prospective resident visited the home during the inspection. Intermediate care is not provided at this home. Ellerslie DS0000064584.V336642.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living in the home may be assured that their care needs are being met although some aspects of the medication administration systems require improvement. EVIDENCE: Clearly written care plans are developed for each resident; those relating to the three people chosen as part of a case tracking exercise were read in detail on this visit. In each case a full assessment had been undertaken followed by the preparation of specific care plans. These provided the information required to guide the members of staff who were providing personal and nursing care. Each document had been reviewed appropriately and appeared to reflect the resident’s current condition. In addition, detailed risk assessments are documented as appropriate; these are reviewed as necessary, but at least once a month. Ellerslie DS0000064584.V336642.R01.S.doc Version 5.2 Page 12 There were records to indicate that care from other healthcare professionals is sourced when required. During the inspection, two General Practitioners visited the home to attend to residents, at the request of the staff. There was evidence to show that people living in the home had received chiropody, dental care, physiotherapy and attention from the continence care nurse, as required. In recent months, there has been considerable focus on improving the nourishment of the residents. As a result, there was evidence that the medical conditions and general well being of some of these people had benefited. In the surveys, one person wrote, “I have had to ask that my mother’s finger nails are cleaned and cut”, but another wrote, “the staff provide good physical care and emotional support to residents”. Standard 9 – MedicationA local pharmacy provides most medicines each month in a monitored dose system with printed medicine charts on which staff record the medicines administered. There are records of medicines received, administered and disposed of to make sure there is no mishandling. Handwritten changes or additions on the charts were double signed as checked. The medicines needed by people who live in this home were in stock ready to give according to the doctors’ directions. Medicines are administered by nurses who attend training about the safe handling of medicines. The correct arrangements are in place for the disposal of medicines no longer needed. The following points are noted for attention – • • Where a variable dose of medicine is allowed the records must note what dose is given as this will help to make sure the right amounts of medicine are used. Staff generally complete the medicine charts when they administer medication; occasional gaps were evident. In one case two tablets were still in the pack but the chart was signed as though they had been administered. Inaccurate records can put people at risk of receiving the wrong doses of medicines. Some medicines are prescribed to use ‘as required’ or ‘as directed’; written protocols are needed for each of these to clearly describe to staff how that medicine is used for the benefit of a particular person or the doctor asked to include more information on the prescription. The deputy manager was knowledgeable about how the medicines are used but this needs to be easily available for all staff who administer medication to refer to. Some people living in the home are prescribed creams or ointments. A care plan looked at did mention the use of skin moisturiser and barrier creams and carers do sign the care plan each day. In order to help demonstrate that each person has the right treatments records should indicate what has • • Ellerslie DS0000064584.V336642.R01.S.doc Version 5.2 Page 13 • • • • • • • • been applied. Some such medication is printed on the MAR charts but records of use are not always made on these. Medicines for one person are given via a feeding tube and there are various records in place. More information could be added in the plan about the way the medicines are given including relevant information about any tablets that are not suitable to use this way. The instruction ‘via peg’ was on some but not all medicine prescription directions. This gives the nurse authority to give the medicine this way and the pharmacist an opportunity to know how the medicine is used and to comment if this is not safe. A seven-day antibiotic syrup course prescribed by an out of hours doctor for one person had stopped the morning of the inspection after only 3½ days as the bottle was empty. There was no indication of the quantity received so it is not possible to check what had happened. It is important that a whole antibiotic course is used for the treatment to be effective. The medicine chart for one person indicated that staff had been unable to instil two different eye treatments for several days. As this treatment can be important the care plan should indicate the action agreed with the doctor if treatment is routinely refused. Staff described how they give a medicine to one person in a drink. The agreement of the doctor was noted in the care plan. It is not clear if this person understands she is being given the medicine. There needs to be informed written consent before putting medication in a person’s food or drink. If this is not possible the care plan should note that the person’s doctor, relatives and those significant others involved with her care have been included in discussions as agreeing this is in her best interests. The records for one person recently admitted to the home clearly indicated an allergy to two medicines. The medicine chart from the pharmacy stated ‘none known’ in the allergy box. This could be dangerous. The pharmacy must be advised of any important information like this so the record chart can be corrected. Some people have two paracetamol-containing medicines included on their medicine chart. Directions for use must be really clear to avoid the risk of people receiving too much paracetamol. The method used to reorder prescriptions each month means that the home does not see the doctors’ original prescriptions as a check that all details are correct before the pharmacy dispenses the medicines. Seeing the prescription in the home first, as is recommended best practice, can help to make sure the printed directions are the latest doses. From care plans looked at there was evidence of contact with doctors and other health professionals to support the health needs of people living in the home. Care plans should reflect what choices people are given and have made about their medicines but this was not seen. Nobody at the time of the inspection was assessed as able to look after his or her medicines safely themselves. Staff said this does happen if a person wishes to and a risk assessment demonstrates this is safe. Locked storage is provided in bedrooms. In one bedroom visited the prescribed creams were in an unlocked cupboard and drawer. There was also an inhaler in the drawer DS0000064584.V336642.R01.S.doc Version 5.2 Page 14 Ellerslie • although this person did not self-administer medicines. If medicines are stored in bedrooms this must be assessed as safe for all people living in the home. Suitable arrangements for handling controlled medicines were in place. The receipt of one type of medication is only included in the record book with one nurse’s signature (although the home policy indicates that two nurses should check these in). The recommended practice is to write all doses administered in this book as well. A stock balance is noted on each medicine chart and at the inspection this agreed with the stock in the cupboard. There is a medicine policy and procedures so that staff should know how the home expects medicines to be managed. There is a recent medicine reference book available for staff to refer to if they need information about the medicines they are using. Medicines are stored safely with one exception. The medicine trolley upstairs needed some repairs to make sure that it would lock securely. This was taken out of use after the inspection. Most containers have opening dates written on the labels, which is good practice to make sure stock is rotated properly and helps with audit checks. The latest Medical Device Alert about lancing devices should be looked at again to see about using a lancet that will be safer for staff to use with less risk of a needle stick injury. In the main, members of staff were observed and overheard addressing the residents in a respectful but friendly and encouraging fashion. Members of staff were also observed knocking on doors prior to entering bedrooms. An issue relating to the dignity of one resident was eventually reported to the manager and rectified immediately. Ellerslie DS0000064584.V336642.R01.S.doc Version 5.2 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home are able to exercise control and choice in their daily lives, enabling them to live as independently as possible. EVIDENCE: During the visit, residents were observed walking around the home, spending the day as they chose. Some preferred to remain in their bedrooms; others sat in one of the three communal lounges. Staff appeared to be relating well to the residents, stopping for a short chat and assisting them with their day-to-day activities. During the afternoon, some people were taken out for a short walk in the garden; others were watching a sporting event on the television. It was observed that entertainers are engaged to visit the home on a regular basis; one person commented that she enjoyed a ‘sing song’. A summer garden fete was being arranged later in the summer. The Home continues to have the benefit of a fully equipped sensory room, which, it was reported, some of the residents do find beneficial. The room was not utilised on this occasion. Ellerslie DS0000064584.V336642.R01.S.doc Version 5.2 Page 16 Families and friends appear to be welcomed into the home; one person commented that the staff were always friendly, “I never feel in the way”. The relatives who responded to the survey were most appreciative of the care the residents received with one person writing, “Mum always speaks highly of all the staff – “They are kindness itself”, and another saying, “We are most satisfied with the care here”. Residents go out with friends and family when possible. Discussion with some of the residents and observation during the inspection showed that residents were free to get up and retire when they liked. Two people chose to get up after 10:30 on this day. Although none of the current residents now handle their own financial affairs, arrangements are in place to assist them to make purchases when they wish. One person had been able to choose some new clothing at a recent sale in the home. The service of the mid day meal was observed on this visit. The majority of residents sat in the dining room with a few preferring to remain in their bedrooms or in one of the lounges. The meals are served in two ‘sittings’, giving residents choice in when they eat their food. Those residents requiring assistance to eat their food were helped in a patient and sensitive manner. Each person was given adequate time to eat their meal at the speed they chose. Every resident who was questioned spoke favourably about the meals with one person commenting that, “You get nice food here, I have no complaints.” It was observed, however, that the meal of the day advertised on the notice board, was not the meal served to the residents. Also this notice was in very small print and would have been illegible to the majority of people living there. The kitchen was clean and well presented. Ellerslie DS0000064584.V336642.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although people living at the home may be assured that any concerns or complaints they identify will be investigated and addressed, further steps are required to ensure that their rights are fully protected. EVIDENCE: Information on how to raise a concern or to make a complaint is provided to residents and their families in literature about the Home. The majority of people who responded to the survey and who spoke to the inspector confirmed that they were aware of the processes; most residents said that they would refer any worries or concerns to one of the senior staff. Observation of the ‘Complaints File’ showed that the formal complaints about Ellerslie received in recent months had been addressed promptly and appropriately; full investigations had been undertaken as required. The number and content of concerns and complaints is closely monitored by the Orders of St John Care Trust. The Home has published policies to address all forms of abuse. These are readily available for members of staff to read. Whistle blowing procedures are also included in this documentation. Ellerslie DS0000064584.V336642.R01.S.doc Version 5.2 Page 18 Discussions with members of staff revealed that most had received only minimal, if any, training on these issues. Their knowledge appeared to be lacking. This shortfall must now be addressed. Ellerslie DS0000064584.V336642.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 24 and 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents live in a clean home, which would benefit from further maintenance and decorative attention. EVIDENCE: Although much of this property remains ‘tired and a little ‘shabby’, it was evident on this visit that efforts had been made to make the house as homely as possible for the people living there. Some areas had been redecorated and carpets replaced. Flower arrangements, some natural, some artificial had been placed throughout the home giving a welcoming appearance to the property. However, some of the corridor carpets are worn and stained, and woodwork in the corridors of the newer wing does require maintenance attention. A block of flats is being built adjacent to the property, causing some temporary disruption in the garden. However it was apparent that some of the residents Ellerslie DS0000064584.V336642.R01.S.doc Version 5.2 Page 20 have enjoyed watching the construction work and appeared untroubled by this temporary inconvenience. A shower room and accessible toilet has been commissioned on the top floor, providing an additional facility for residents accommodated in that area. It was evident that the assisted bathroom on the first floor is a popular facility and well used in the home. However, the bathroom opposite room 10, which is also equipped with a hoist, is currently full of wheelchairs and other sundry equipment, making it totally inaccessible for residents accommodated in that part of the home. The bedrooms of the residents selected for case tracking plus a number of additional rooms were visited on this occasion. All were equipped with appropriate furnishings and many had been personalised with photographs and treasured possessions. It was observed, however, that rain damage in one bedroom had reoccurred, creating a crack and hole in the ceiling. This recurring problem must be addressed. All areas visited on this occasion were reasonably clean and there were no offensive odours in any areas visited. The laundry, although requiring urgent maintenance and decorative attention, was well organised. It was observed that the poor condition of the walls could pose a health and safety/infection risk. However, the laundry assistant on duty had good knowledge of infection control protocols and was ensuring that all clean bedding and clothing was in a well-presented condition, most was ironed prior to return. Particular care was taken with residents’ woollens and other delicate clothing. Ellerslie DS0000064584.V336642.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive care from a competent workforce but improved recruitment would help to ensure that they are fully protected. EVIDENCE: On this visit, there were twenty-six residents living in the Home; it is anticipated that the remaining four bedrooms will be occupied shortly. In the morning, the Manager and her deputy, both trained nurses, and seven 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. The staffing complement has been increased this year to provide more personalised care to the residents. There was only one comment raising concerns about occasional staff shortages in the surveys returned to the inspector. The majority of the carers are already qualified to the National Vocational Qualification in Care, Level 2 or are undergoing the training at the current time. Ellerslie DS0000064584.V336642.R01.S.doc Version 5.2 Page 22 Personnel files relating to all the staff employed since the last inspection were read in detail. Each person had completed an application form although most had not provided a full employment history, as is required. Records had been maintained of the interview processes and correct POVA (Protection of Vulnerable Adults) and CRB (Criminal Record Bureau) screening had been completed. Written references had been provided for each person. Each applicant is inducted to his or her new post. Staff have access to varied training appropriate to their respective roles. This includes attendance at mandatory annual training; records are maintained in the home to ensure compliance. All staff are currently completing training on the special needs of people with dementia. Ellerslie DS0000064584.V336642.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The financial interests and the health, safety and welfare of people using the service are safeguarded by the robust management systems in place. EVIDENCE: The manager, a trained nurse, is experienced in the care of older people. She has also undertaken additional management training and is well supported in her role by the deputy and the administrator. There are a number of quality improvement measures undertaken at this home. A residents/relatives satisfaction survey was circulated during 2006; the Ellerslie DS0000064584.V336642.R01.S.doc Version 5.2 Page 24 results of this survey were collated corporately and an action plan prepared to address any issues identified. Many of these have now been addressed. Medication administration, care planning and any accidents are all monitored closely. Senior managers from the Orders of St John Care Trust also audit the home’s performance on a monthly basis. The home takes responsibility for the personal monies for the majority of the residents; the records relating to the three residents selected for case tracking were checked on this occasion. It was observed that meticulous records are maintained and that individual secure storage is provided. Residents’ status in relation to ‘Power of Attorney’ is also maintained on file. Records were provided to show that statutory maintenance/inspection of equipment and services is arranged in a timely fashion. Where faults are identified, they are rectified as necessary. The requirements issued by the Fire Officer in April 2007 have now been addressed. Ellerslie DS0000064584.V336642.R01.S.doc Version 5.2 Page 25 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 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 2 x 2 x x 2 x 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Ellerslie DS0000064584.V336642.R01.S.doc Version 5.2 Page 26 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(b) Requirement A copy of the reviewed Statement of Purpose and Service User Guide must be provided to the Commission for Social Care Inspection. This requirement has been repeated from the last inspection). When medication is administered to people who live in the home it must be clearly and accurately recorded and given in accordance with the doctor’s directions. There must be up to date medicine care plans to clearly describe how to use any medicines prescribed to use ‘as required’ or ‘as directed’. This will help to make sure people receive the correct levels of medication. All medicines must be stored securely at all times so as not to present any risk to anybody in the home. Residents’ dignity must be respected at all times. In particular, staff must ensure that commodes are emptied once DS0000064584.V336642.R01.S.doc Timescale for action 31/07/07 2 OP9 13(2) 31/07/07 3 OP9 13(2) 15/07/07 4 OP10 12(4)(a) 31/07/07 Ellerslie Version 5.2 Page 27 5 OP18 13(6) 6 OP19 23(2)(b) 7 OP24 23(2)(b) 8 OP26 23(2)(b) 9 OP29 Schedule 2.6 they have been used. Members of staff must be able to demonstrate a good understanding of their responsibilities when abuse issues arise. Maintenance repairs and decorative attention is required on the woodwork along some of the corridor areas. Maintenance repairs must be undertaken to the ceiling of the bedroom identified during the inspection. Maintenance repairs and decorative improvements must be undertaken in the laundry room to ensure that health and safety and infection control is not compromised. Each applicant for a post at Ellerslie must provide a full employment history so that this may be checked, if necessary. 31/08/07 31/08/07 31/08/07 31/08/07 31/07/07 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 OP15 OP9 OP9 Good Practice Recommendations The menu of the day should be advertised correctly and in a format, which the residents are able to read. Arrange to see and check all prescription forms in the home before they are sent to the pharmacy for dispensing. Care plans should reflect what choices people who live in the home are given about how their medicines are administered and their consent to the way in which nurses administer their medicines. Where consent is not possible because of lacking capacity records should be made of the agreement that the way in which medicines are administered is in the best interests of that particular DS0000064584.V336642.R01.S.doc Version 5.2 Page 28 Ellerslie 4 5 OP19 OP21 person. Corridor carpets should be thoroughly cleaned or replaced. The bathroom opposite Room 10 should be cleared of excess equipment and cushions so that it is readily accessible to residents accommodated in that part of the home. Ellerslie DS0000064584.V336642.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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