Inspection on 13/12/05 for Elliott House

This inspection was carried out on 13th December 2005.

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

Elliott House 23/10/08

Elliott House 14/09/06

Elliott House 17/08/05

Elliott House 04/01/05

Elliott House 16/08/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Elliott House 22 Reculver Road Beltinge Herne Bay Kent CT6 6NA Lead Inspector Jenny McGookin Unannounced Inspection 13th December 2005 10:00 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 Elliott House DS0000023385.V270054.R01.S.doc Version 5.0 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. Elliott House DS0000023385.V270054.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Elliott House Address 22 Reculver Road Beltinge Herne Bay Kent CT6 6NA 01227 374084 01227 740750 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) Mr Ian George Nicoll Mrs Linda Valerie Elks Care Home 71 Category(ies) of Old age, not falling within any other category registration, with number (70), Physical disability (1) of places Elliott House DS0000023385.V270054.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. People with a physical disability is restricted to 1 person whose date of birth is 18/06/37 Registration is restricted to one (1) person with a date of birth of 03.12.1916 17th August 2005 Date of last inspection Brief Description of the Service: Elliott House Home is registered to give care for up to 71 older people, and this currently includes (by special arrangement) one individual with a physical disability. Mrs Elks is the registered manager. The property is an impressive Listed building, comprising three floors, and situated in its own extensive, landscaped grounds. It was previously known as Heronswood, and was purchased by Mr Nicoll, the current Registered Individual, in 1997. It then underwent a major re-furbishment programme, but retains many of its original period features, including a rotunda room. Each floor is characterised by its own colour scheme, and the floors are linked by two shaft lifts and four stairways. Elliott House has 49 single bedrooms which have en-suite facilities, and six which do not. There are also eight double rooms, all of which have ensuite facilities. Only two of the bedrooms are slightly undersize, but in one case, this is compensated for by the provision of an en-suite WC and basin. Many bedrooms far exceed the National Minimum spatial standard.In terms of access and scope for community presence, the home is one mile from Beltinge and two miles from Herne Bay. It is a short distance from the A299 linking it to London, Margate and Ramsgate. There are bus stops directly outside the front boundary, to Herne Bay, Whitstable and Canterbury with all the further transport links that implies.There is ample parking space along the circular driveway at the front, and an access road to one side to another parking area for trade and staff. Elliott House DS0000023385.V270054.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which was used to check progress with matters raised from the last inspection (August 2005,) accepting that a number of timeframes had yet to run their course; and to reach a preliminary view on other aspects of the day-to day running of the home. The inspection process took five hours, and involved meetings with the manager and deputy manager, three residents over lunch, and one in his room along with his visiting relatives. The inspection also involved an examination of records and policy documents and those areas of the home where matters had been raised for attention at the last inspection. Interactions between staff and residents were observed throughout the day. What the service does well: What has improved since the last inspection? What they could do better: Elliott House DS0000023385.V270054.R01.S.doc Version 5.0 Page 6 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. Elliott House DS0000023385.V270054.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Elliott House DS0000023385.V270054.R01.S.doc Version 5.0 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 the following standard(s): 1, 2, 3, 4, 5, 6 1. The homes’ Statement of Purpose and Service User Guide are only fully compliant with all the elements of this standard, when read in conjunction. When this is the case, it does mean, however, that the resident or their representatives (families or representatives as well as funding authorities) have all the information required to make appropriate decisions about placements. 2. There are contracts governing each placement between the home, but some matters are raised for amendment. 3, 4. Prospective residents are assessed prior to admission to establish the extent to which their needs can be met by the home, and how potential risks will be managed. Service users are generally content with the way they are supported by the home. 5. Prospective residents, or their representatives, have the opportunity to visit the home before proceeding with the admission and there is a trial stay to further inform their choice. 6. The home does not provide intermediate care. Elliott House DS0000023385.V270054.R01.S.doc Version 5.0 Page 9 EVIDENCE: There is a Statement of Purpose and Service User Guide (which also doubles as a Welcome Pack), each of which usefully describes the facilities, services and principles of care. It was noted that a number of elements listed by this standard in respect of the Service User Guide had been incorporated into the Statement of Purpose instead. Only when taken in conjunction, does the prospective resident or anyone representing their interests (families, key workers, care managers or funding authorities) have all the information required to make each placement effective. A number of matters have been reported back to the home separately for further attention or consideration to improve these documents. It was not clear whether this information is available in other languages or formats (e.g. audio tape). Discussion with residents largely confirmed feedback obtained at the last inspection, specifically that the decision to apply to this home was influenced more by its locality (i.e. close to where the resident or their friends or relatives lived) and by personal recommendation, or through having visited other people there, than by any public information produced by the home itself. Although there had been some shared sense of loss over possessions and property left behind, the residents were generally content with the services provided by this home. The home carries out a preadmission assessment, which has a standard format to ensure a consistent approach. The prospective resident or representative is invited to visit the home, and meet the staff and residents. Only one of the residents spoken to on this occasion was able to confirm this process as described, and could recall having stayed at this home once before when convalescing. The others they had entrusted the choice of home to the judgement of their representatives. Each resident is offered a month’s trial stay. On their admission, the home carries out further assessments and risk assessments. The manager confirmed that this home does not provide intermediate care There are contracts governing each placement. Although these documents are written in plain English, and are generally compliant with the elements of this standard, the sample copy supplied was printed in a font style and size which do not conform to recommended standards for people with a reading or visual impairment and it made reference to outdated legislation and registration arrangements. Elliott House DS0000023385.V270054.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 7. A new format for this home’s care plans, makes a conspicuous link to preadmission assessments and is sufficiently holistic in its scope to provide the basis for the care delivered. 8. The home is served by a range of healthcare professionals, to promote good health and has adequate facilities for privacy. 9. The manager has taken a number of steps to ensure that the home’s medication policy and practice adheres to best practice, and any residents wishing to self-administer is supported to do so, subject to safeguards and periodic review. 10. Residents confirmed that staff treat them well, and that their privacy is respected. 11. The home’s policy on managing the death of residents is judged holistic, but two matters are raised for inclusion to ensure compliance with regulations. Elliott House DS0000023385.V270054.R01.S.doc Version 5.0 Page 11 EVIDENCE: The preadmission assessment covers the residents’ most critical health and personal care needs. This is then developed into a care plan, the format of which has been amended to obtain a more holistic approach. The manager said that she had introduced a key worker system. All the care staff were asked to identify six residents they felt best able to relate to plus one other and allocations were made accordingly, subject to periodic review. This is judged a very promising development, though it was too soon to judge whether its effectiveness would be enduring. Elements of the care plans are generally reviewed monthly. Only where changes are indicated, the inspector was shown how these are being detailed as appendix documents. None of the residents spoken to showed any recognition of an active care planning / review process. One or two did generally recall being asked questions about their care needs and they also confirmed feedback obtained at the last inspection, that the line management were always available to residents or their relatives to discuss any issues or concerns. The manager said that mail-shots were being used to obtain a greater level of participation in care planning reviews by friends, families and other stakeholders and estimated that 60 had shown an interest in the process as a result. The first such review was held the week before this inspection visit and was said to have been successful. At the last inspection, the medication storage and administration arrangements were not judged robust enough. The manager said that a new medication policy file had been set up since the home’s arrangements were inspected at the last inspection, and the home’s own policy had been amended to comply with the Royal Pharmaceutical Society Guidance, as required. New processes have been set up, which should provide a more robust audit trail. One of these is a mini contract designed to commit residents who selfadminister their medication to keep their medication secure, and to a periodic review to ensure the arrangements remain safe. Inventories are used for any medication taken off the premises and risk assessments of the medication arrangements are now an integral part of the care plans. The administration of medication is now being divided into two separate rounds, each the responsibility of a senior carer, so that rounds can be completed earlier and free up staff for other duties. This is likely to be appreciated by residents, who had said at the last inspection that they felt staff were not as readily available as they would have liked. Elliott House DS0000023385.V270054.R01.S.doc Version 5.0 Page 12 The inspector was also shown one room on the first floor, which is scheduled for conversion into a clinical room to meet accredited guidance. See section on “Staffing” for details on training investments. This element of the home’s operation will be subject to further assessment at the next inspection. Most bedrooms in this home are single occupancy (only four are doubles), and have en-suite facilities, which means personal care and treatments can be given in privacy. Shared rooms have screening to afford occupants some privacy. Feedback from the residents has confirmed on both inspections this year that their privacy was respected and that staff generally treated them well. The home accesses a range of healthcare professionals, but residents would need to pay for chiropody, physiotherapy or any special or private treatment or medication themselves. If the home needs further nursing advice it can use the District Nurses, and the home is served by four GP practices, so individuals have some choice. The home has policies on managing dying residents, which usefully makes reference to the relevant National Minimum Standards and covers a range of health and personal care principles as well as the need for companionship and support for the resident, families, friends and staff. There is also a procedure to follow in the event of death, which includes the principle that certain documents would need to be retained after death, such as care notes but it does not specify the timeframes involved (three years from the date of the last entry), or address the question of retaining medication for seven days in case of a Coroner’s Enquiry. Nor does it address the duty to inform the Commission of all deaths (Regulation 37). These elements are required. Elliott House DS0000023385.V270054.R01.S.doc Version 5.0 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, 15 12. Most residents are generally content with their lifestyles in this home, and the home has been able to match their expectations. This home offers a range of activities inside and outside the home, but is currently still having to cover the work carried out by its activities co-ordinator following her abrupt departure. 13. There are open visiting arrangements, and the home is well placed for access to local shopping and seafront outlets. 14. There is choice and control over most aspects of daily routines. Personal care is offered in a way, which protects residents’ privacy and dignity. 15. The meals in this home are generally satisfactory, offering both choice and variety and catering for special diets. Residents can also opt to eat where they and at different times. Work has been done to remind residents of menu options available to, or already made by them. EVIDENCE: The residents were not on this occasion able to give many examples of any particular interests and hobbies being promoted by the home but were aware of some of the communal activities organised for them, and records and staff was able to supply more examples. Examples include Bingo; films; art classes, Elliott House DS0000023385.V270054.R01.S.doc Version 5.0 Page 14 Reminiscence; a regular Tuck Trolley; board games (snakes and ladders, Ludo, draughts). Musical events include Karaoke, piano session and there are traditional celebrations include Valentines Day, VE Day, birthdays, Easter bonnets and Christmas. The communal events are rotated between different communal areas to encourage participation. Following the abrupt departure of its activities coordinator, the home has still not been able to recruit a replacement and will be running another recruitment drive after Christmas. In the meantime it has been trying to maintain the programme set up, to the credit of one member of staff in particular. Some work has been done to set up a resource file of local resources and events but this work had not yet been completed. Most residents indicated that they were generally content with their lifestyles in this home. One interesting development, which has been attributed to the new care planning processes, has been the emergence of one residents’ musical abilities, which are being promoted and supported by the home in the formation of a singing group and a Christmas event for the other residents. The Statement of Purpose commits the home to making arrangements to enable residents to pursue their religious inclinations, and the inspector was advised that the local Roman Catholic Church sends two representatives to hold services, and that one-to-one visits are also made by a representative of a local Church of England church. Since the last inspection, work has been done on assessing the facilities and accessibility of two local churches and this will be extended to other religious places of worship such as the synagogue in Canterbury. The plan is to draw up a directory on local resources, and plan how prospective residents would in practical terms be supported to access religious services of their preference. This is judged a promising development. The home has open visiting arrangements, and meals can be provided for visitors if required at “reasonable” cost, though this did appear to the residents or relatives spoken to on this occasion. The daily routines are as flexible as healthcare needs will allow, and residents confirmed that they can choose when to get up and go to bed. Residents can choose where to take their meals (there is a choice of attractive dining facilities as well as bedrooms), and also have some choice over meal times. Since the last inspection, carers have been tasked to establish their allocated residents’ choices (rather than giving this to a dining room assistant to do), on the basis they are obtaining a closer understanding of their individual preferences and special needs (e.g. any hearing or cognitive impairment). Another promising development is that at tea times residents are presented with the available options on display rather than having to plan in advance, and this is proving popular (some are choosing both options!). Elliott House DS0000023385.V270054.R01.S.doc Version 5.0 Page 15 Not surprisingly, all of the residents spoken to on this occasion said they were generally very satisfied with the meals. Elliott House DS0000023385.V270054.R01.S.doc Version 5.0 Page 16 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, 18 16. There is a complaints procedure readily available, though one version still requires amending, and residents feel that any complaints they had would be listened to and acted on. There are no independent advocates. The home relies on staff, or the residents’ families and friends to raise issues and represent the interests of the less able residents. The complaints register is being used as required. 18. Residents feel well cared for and safe there is a policy on adult protection. Staff expressed a commitment to protect residents from abuse EVIDENCE: The home’s complaints procedure is on display and describes the process and timeframes involved, in general compliance with the provisions of Regulation 22. There is another version of the complaints procedure in the Statement of Purpose, which gives the Commission as an option if the complaint is not satisfactorily resolved by the manager. This is not a correct interpretation of the National Minimum Standard or Regulation 22. The residents confirmed feedback obtained at the last inspection, that they would know who to talk to if they had a complaint and felt safe. The home still does not use any independent advocacy services but relies on staff, or the residents’ families and friends to raise issues and represent the interests of the less able residents. Elliott House DS0000023385.V270054.R01.S.doc Version 5.0 Page 17 Since the last inspection, the home’s complaints register has been redesigned and is now being used as a comprehensive record of all complaints and the action and timeframes taken to resolve them. The home has a policy on abuse, and all the residents spoken to on this occasion said they felt safe at this home. Elliott House DS0000023385.V270054.R01.S.doc Version 5.0 Page 18 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, 20, 21, 22, 23, 24, 25, 26 19, 25, 26. The layout of this home is generally suitable for its stated purpose, and its features are attractively presented, safe and comfortable. All areas inspected were free from any unpleasant odours. Records confirm it is being maintained and regularly inspected for safety. 20. Residents have a choice of communal areas, and furnishings tend to be domestic in character. There are homely touches throughout. 21. Lavatories and washing facilities are generally accessible to bedrooms and communal areas. 22. There is a range of equipment and adaptations to support residents and staff in safety in their daily routines and to maximise residents’ independence. 23, 24. Most residents have access to the privacy of their own bedrooms and most rooms have en-suite facilities. Elliott House DS0000023385.V270054.R01.S.doc Version 5.0 Page 19 EVIDENCE: The layout of this home is generally suitable for its stated purpose and well maintained and decorated. As reported in the last inspection, each floor (including all the bedrooms on it) is characterised by its own colour scheme pink, apricot, or yellow. While this may assist residents recognise their floor, it does give bedrooms a hotel atmosphere, and the colours of bedrooms may not always be gender appropriate. The floors are linked by two shaft lifts and four stairways. The corridors are wide but hand-rails have in most areas only been installed down one side, which could disadvantage anyone reliant on the strength of only one arm. Upstairs bedroom windows all have restrictors but communal areas don’t. This is required. All areas are linked with a call bell system and there is adequate specialist equipment and adaptation. There are 49 single bedrooms which have en-suite facilities, and six which do not. There are also eight double rooms, all of which have en-suite facilities. Only two of the bedrooms are slightly undersize, but in one case, this is compensated for by the provision of an en-suite WC and basin. Many bedrooms far exceed the National Minimum spatial standard, and since the last inspection a number of locks have been replaced to meet the National Minimum Standards. However, the provision of a second comfortable chair in each room is a matter which was raised for attention at the last inspection and found to be still outstanding The home provides adequate communal space for each resident. There are five lounge areas (including a library on the ground floor and a quiet room on the 1st floor) as well as a choice of dining areas. All furnishings within the communal areas are domestic in character and of good quality, suitable for the service users needs. All areas seen were clean, well maintained and in satisfactory decorative order. There are five bathrooms (two of which have Parker baths) with WCs, a shower room with a WC and six WCs i.e. convenient to bedrooms and communal areas. One of these bathrooms, which is not in practice being used, is scheduled for conversion into a clinical room, which (along with the acquisition of a second medication trolley) should obtain more satisfactory standards of storage and administration. Since the last inspection, the home’s laundry has been re-vamped and the home has an industrial washing machine with a sluice cycle and two dryers. Clinical waste is appropriately managed. There were no unpleasant odours in any of the areas visited in this inspection, and comfortable temperatures and lighting levels were maintained throughout. Elliott House DS0000023385.V270054.R01.S.doc Version 5.0 Page 20 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, 30 These standards were only partially assessed on this occasion. 27. Work has been done to increase and redeploy staff to better address the needs of the residents and the size and layout of this home. 30. There has been further investment in staff training in the medication arrangements, to ensure compliance with accredited standards. EVIDENCE: The waking / working day is currently calculated on the basis of a 14-hour period from 7.15 till 9pm. The manager said the home aims to have the following staffing arrangements when the home is up to full occupancy: in such circumstances, there should be: • eight care staff in the mornings (i.e. from 7.15am till 2pm); • six care staff in the afternoons (i.e. from 2pm till 6pm); • five from 6-9pm and • four overnight (9pm till 7.30am). The home would also aim to have 3-4 domestic staff and one laundry person from 8am till 2pm. The home has a cook from 7am till 3pm and an assistant cook; plus a member of staff from 9am till 12pm to assist in the dining room. This represents an increase in, and/or redeployment of, staffing since the last inspection, where staffing shortages were raised as an issue by residents, Elliott House DS0000023385.V270054.R01.S.doc Version 5.0 Page 21 relatives and staff alike – an is judged a promising development. Staffing rotas and feedback from all three sources will be taken into account at the next inspection, in order to reach a finding on the effectiveness of this. At the last inspection, a number of matters were raised for attention in respect of the home’s medication arrangements. These are reported on elsewhere in the report (see sections on “Health and Personal Care” and “Environment” for more details). The manager said that since then, four staff had received training from an accredited source, with more training in prospect in February 2006. This judged a satisfactory development, and will be followed through at the next inspection. Elliott House DS0000023385.V270054.R01.S.doc Version 5.0 Page 22 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, 32, 36 These standards were only partially inspected on this occasion. 31. The registered manager is able to demonstrate good use of the inspection and regulatory processes. 32. The manager is ensuring there is an open and inclusive approach 36. The staff supervision arrangements are compliant with the National Minimum Standard. EVIDENCE: The manager has responded positively to matters raised at the last inspection, and there have been a number of promising developments, which are detailed throughout this report. Accepting a number of the time-frames set for matters requiring attention at the last inspection had yet to run their full course, this is judged a good use of the inspection and regulatory processes. Elliott House DS0000023385.V270054.R01.S.doc Version 5.0 Page 23 There was good evidence of residents’ participation in decisions about the running of the home through group meetings. There have been three since the last inspection and records show a range of matters under consideration in each case – premises, meals, activities, the new care planning process and day-to-day concerns (e.g. slamming doors, call bells). His is judged inclusive. Residents said they were confident that any concerns they had would be listened to and responded to. The inspector was shown the format of staff supervision sessions, which usefully review performance since the last session; agree targets for the work ahead; and identify training and support needs. These are reported to be apply every two or three months, which is at a variance from feedback obtained at the last inspection, and will, therefore be subject to closer inspection at the next inspection. Elliott House DS0000023385.V270054.R01.S.doc Version 5.0 Page 24 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 3 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 2 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 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X 2 X X Elliott House DS0000023385.V270054.R01.S.doc Version 5.0 Page 25 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 2 Standard OP9 OP9 Regulation 13(2) 13(2) Requirement The Controlled Drugs cupboard needs to be bolted to the wall The minimum and maximum temperature of the drug fridge must be recorded daily and action taken when outside normal limits Medicine is given at the manufacturers recommended time All upstairs windows must have restrictors The provision of furniture and fittings needs to be assessed against the elements of standard 24. Non-provision must be justified by properly documented consultation or risk assessment. Timescale for action 15/10/05 15/10/05 3. 4. 5. OP9 OP19 OP24 13(2) 13(4) 16(2) 17/08/05 31/12/05 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Elliott House DS0000023385.V270054.R01.S.doc Version 5.0 Page 26 1. OP11 2 OP16 3 4 OP19 OP23 5. 5. OP24 OP33 The home’s policy on death specify that records must be retained for three years from the date of the last entry after death, and that medication must be retained for seven days in case of a Coroner’s Enquiry. It should address the duty to inform the Commission of all deaths (Regulation 37). The version of the complaints procedure in the Statement of Purpose gives the Commission as an option if the complaint is not satisfactorily resolved by the manager. This is not a correct interpretation of the National Minimum Standard or Regulation 22 and should be amended. Consideration should be given to installing handrails on both sides of corridors, to maximise residents scope for moving around independently The manager should arrange for the provision of a second comfortable chair in each bedroom or justify non-provision with a properly documented consultation or risk assessment Consideration should be given to decorating bedrooms according to prospective residents individual choice of colours scheme The annual development plan should maintain a conspicuous link with a qualified assurance framework placing residents and their relatives and representatives at the centre. Regulation 26 reports will need to fully comply with the provisions of 26(4)(a)(b) Elliott House DS0000023385.V270054.R01.S.doc Version 5.0 Page 27 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU 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 Elliott House DS0000023385.V270054.R01.S.doc Version 5.0 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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