Inspection on 18/03/08 for Elreg House

This inspection was carried out on 18th March 2008.

CSCI found this care home to be providing an Adequate service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Elreg House 22/01/09

Elreg House 29/05/07

Elreg House 11/04/06

Elreg House 05/09/05

Similar services:

1 Marten Road

Daubeney House

Three Gables

Deepdene Care Centre

Aldwick House

49 Glendale

Ferndale Residential Care Home

David Gresham House

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

CARE HOMES FOR OLDER PEOPLE Elreg House 58 Rosslyn Road Shoreham By Sea West Sussex BN43 6WP Lead Inspector David Bannier Unannounced Inspection 18th March 2008 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 Elreg House DS0000064568.V359326.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. Elreg House DS0000064568.V359326.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elreg House Address 58 Rosslyn Road Shoreham By Sea West Sussex BN43 6WP 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) 01273 454201 01273 453431 elreghouse@aol.com Miss Angela Louise Brown Mr Anthony Robert Brown Post Vacant Care Home 23 Category(ies) of Dementia - over 65 years of age (23), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (23) Elreg House DS0000064568.V359326.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Only service users age 65 and over may be re-admitted. The total number of service users accommodated must not exceed 23. Date of last inspection 29th May 2007 Brief Description of the Service: Elreg House is a care home registered to provide personal care and accommodation for twenty-three older people who have dementia or a mental disorder. The home is located near to the town centre of Shoreham-by-Sea, West Sussex, with the usual amenities of a small town. Elreg House is a two-storey building with a single storey extension to the rear. Fifteen of the resident’s bedrooms are single and four have the benefit of ensuite facilities. There is no passenger lift. There is an enclosed rear garden that is accessible to residents. The range of fees charged by the home is £411- £600 per week. Elreg House is privately owned by Mr Anthony Brown and Miss Angela Brown. Miss Angela Brown has been identified as the responsible individual and is responsible for supervising the management of the care home. A manager has been appointed some two and a half years ago. However, this person has not yet registered with us. Elreg House DS0000064568.V359326.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The inspection has followed the Inspecting for Better Lives methodology and is called a key inspection as it assesses those standards determined by the Commission as key standards. This inspection will also determine the frequency of inspections hereafter. The registered provider returned an Annual Quality Assurance Assessment (AQAA) prior to the inspection. The information received from this document will be referred to in this report. Residents their relatives and the staff were sent surveys by the Commission entitled “Have Your Say.” These are designed to enable residents, relatives and staff to give their opinions about how the care home is being run. Unfortunately these documents were not available at the time of writing this report. A visit to the care home was made on Tuesday 18th March 2008. This was an unannounced inspection. We were unable to have meaningful conversations with all the residents, however we spent time with some of them during our visit in order to form an opinion of what it is like to live in this care home. We spoke to four staff on duty in order to gain a sense of how it is like to work at the care home. We also spoke to a health care professional who was visiting to provide treatment to residents. We also viewed the accommodation and observed care practices. Some records were also examined. The visit lasted approximately seven hours. The manager was present and kindly assisted us with our enquiries. What the service does well: Elreg House continues to ensure residents live a relaxed and homely atmosphere. Staff have been trained and supported by the manager in providing good quality care to residents who have dementia. We observed staff approach people living at the home in a kind and respectful manner. Visitors to the home are made welcome and people’s rights to not see visitors are respected. Elreg House DS0000064568.V359326.R01.S.doc Version 5.2 Page 6 Meal times are relaxed and residents are offered a choice of menu at lunch and tea time. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Elreg House DS0000064568.V359326.R01.S.doc Version 5.2 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 Elreg House DS0000064568.V359326.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care needs of all prospective residents have been assessed before they move in. We found no evidence that intermediate care is being provided at Elreg House. EVIDENCE: We identified four residents for case tracking purposes. Documents and records seen confirmed that the needs of the identified residents had been appropriately assessed before they have been admitted. The manager also demonstrated they had obtained assessments carried out by the resident’s social worker or health care professional. Elreg House DS0000064568.V359326.R01.S.doc Version 5.2 Page 9 We spoke to staff on duty who were able to demonstrate they had been fully briefed about the needs of each resident. We also noted that residents had been well cared for. One resident told us, “They look after me very well!” Information supplied to us prior to our visit confirmed that improvements have been made to the assessment documentation and process. It was also confirmed that, “The prospective service user is offered the opportunity to spend time at Elreg House to meet staff and residents, assess the environment and taste the food. A social worker assessment is obtained prior to every admission.” Elreg House DS0000064568.V359326.R01.S.doc Version 5.2 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. 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 this service. The resident’s health, personal and social care needs are set out in an individual plan of care. Residents’ health care needs have been met. Residents are partially protected by the home’s practices for administering medicines. Residents are treated with respect and their right to privacy is upheld. EVIDENCE: Elreg House DS0000064568.V359326.R01.S.doc Version 5.2 Page 11 Care plans have been drawn up from the information gathered when residents’ needs were assessed. They include information about each resident’s physical needs such as mobility, sight, hearing, speech, oral health and foot care. They also include information about each resident’s medical history, their current diagnosis and medication requirements. In addition there is information about each resident’s personality and temperament, family, friends and significant others, preferred morning and night time routines, food likes and dislikes, leisure interests, religious and cultural needs. Where possible residents or their relatives are asked to sign this document to confirm it has been shared with them. The care planning system includes risk assessments for manual handling and mobility. It also records visits to each resident by doctors and other health care professionals together with any treatment prescribed. We were informed that the manager reviews care plans every month. The records seen also provided evidence that this does take place. This means that care plans reflect residents’ current care needs. We also noted that care plans do not always have clear instructions to staff with regard to how residents’ needs should be met. We discussed this with the manager, who agreed to ensure, where necessary, care plans include clearer information and guidance for staff to follow. This will mean that residents’ needs will be met on a consistent and continuous basis. Information we received before our visit confirmed that, “By adapting our care plans, we are able to meet the individual needs of the service user, with a clearer insight and approach to meet health care needs, personal needs and preferences, supporting them in maintaining their personal identity and creating a path of consistency.” We spoke to a District Nurse who was visiting to provide treatment to residents. We were told this care home works well with visiting health care professionals and ensures and treatment prescribed is carried out. The District Nurse said, “The standard of care is very good. No one is left unattended to. If the staff have concerns they will phone us. When we walk in the door we are made welcome. Staff do notice things about residents and will ask us for advice. I find the staff are really friendly and have a professional approach to their work.” We saw that residents we spoke to during our visit were well cared for and were comfortable. Some of them were able to tell us the staff treated them well and looked after them. Following discussions about the needs of identified residents, the staff team were able to demonstrate they were fully briefed about the care residents required and what was expected of them. We also noted that staff are expected to sign a sheet within the resident’s care record to confirm they have read and agree to follow the care plan. We saw staff provided care in a manner that ensured their dignity and privacy has been Elreg House DS0000064568.V359326.R01.S.doc Version 5.2 Page 12 maintained. Staff were courteous when speaking to residents and ensured doors were closed when personal care was being provided. Appropriate systems have been put in place for the recording, storing, handling, and disposal of medication. Medication is stored safely and securely. There was no evidence of medication being stock piled. Medication record sheets were seen. During our last visit it was observed that there were occasional gaps in the medication administration record. During this visit we noted that there were also one or two gaps. This means it was not possible to determine if, on these occasions, residents had been given prescribed medication. We spoke to the manager, who informed us that this had been identified as a result of the home’s own monitoring system. We were also informed that the manager was already taking appropriate steps to address this. We were also shown how staff administer medication. This was satisfactory and ensured the safety of residents. We also noted that practices were in accordance with the home’s own written procedures and in line with good practice guidelines. We looked through records of staff training. This indicated that staff have been given appropriate training in the safe administration of medication. Information supplied by the provider before our visit confirmed that, “Service users are supported appropriately with their medication needs and are fully protected by the home’s medication policies and procedures.” Elreg House DS0000064568.V359326.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. 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. Residents are provided with activities that satisfy their recreational interests and needs. Residents maintain contact with family and friends as they wish. Residents are helped to exercise choice and control over their lives. Residents receive a wholesome appealing balanced diet in pleasing surroundings. EVIDENCE: Whilst the home does not have an entertainment or activity programme we were informed they do have a folder with evidence and information of activities provided. We did not look at the activity folder. However, we were informed that activities provided within the home include quiz sessions, Elreg House DS0000064568.V359326.R01.S.doc Version 5.2 Page 14 skittles, exercise sessions and bingo. Arrangements are made for visits by musicians and travelling actors to put on performances and shows for residents to enjoy. We were also informed that art and craft sessions are planned where residents will be able to make Easter cards and paint Easter eggs. We also saw three residents and a member of staff enjoying a game of quiz in the dining room during the afternoon. When we arrived we noted that there were notice boards in the dining room. They included pictures and information with regard to the date and the weather, the staff who were on duty and the menu for the day. We also noted that a member of staff was helping a resident to change some of this information to ensure it is up to date. The resident was clearly interested in and enjoying the task they had been given. Information we have been given before are visit confirmed, “A picture food menu has been created to enable service user’s to make informed choices; this allows them to identify food easily. All information relating to food and drink are displayed on boards situated in the dining area.” We examined care records and found they included information with regard to residents’ leisure interests, food preferences and religious and cultural needs. Records seen also included details of residents’ preferences with regard to daily routines. We spoke to staff on duty who told us that they are expected to be aware of who likes to get up early and who likes to get up later. We met one resident who had decided to have a day in bed. She was clearly very comfortable and was enjoying the rest. Information supplied by the registered provider prior to our visit confirmed, “Residents’ preferences for leisure and activities are taken into account within the assessment process before admission. An appointed activities coordinator within the staff team works to present a range of activities suitable to the needs and abilities of the service user.” Care records also include information about the social network of each resident, including contact they have with family and friends. We did not meet any relatives during this visit, however the home’s visitor’s book indicated residents receive frequent visits from friends and relative. Staff on duty were also heard taking about who was expecting a visitor during the day. Information supplied by the registered provider confirmed, “Service users are fully supported to maintain contact with family, friends and significant others.” The main meal is taken at approximately 12.30 each day. During our visit we saw the meal being served to residents. It consisted of a choice of either chilli con carne or toad in the hole with roast parsnips, cabbage, peas and mashed potatoes followed by trifle. We noted the meal was presented in an appealing manner to encourage and stimulate residents’ appetite. We saw residents were enjoying the meal provided. Elreg House DS0000064568.V359326.R01.S.doc Version 5.2 Page 15 Residents are encouraged to take their meals in the dining room. This ensures mealtimes are enjoyable, social occasion. The surroundings were very comfortable and tables were attractively presented with fresh linen table clothes and napkins. Some residents required assistance with cutting up food and with eating. Assistance is provided where necessary ensuring residents’ dignity is maintained. We saw menus of food provided which confirmed that residents have been provided with a varied, wholesome and nutritious diet. A choice is provided for the main meal and for the teatime meal. We noted that, as part of the care plan, a record is kept of the food eaten by each resident. The manager informed us that this ensures resident’s nutritional intake can be monitored. Information supplied by the registered provider confirmed that, “Menu choices are offered in a format that is understandable to the service user. Staff support residents’ with dietary needs where required. Staffing levels increase at meal times to ensure the appropriate level of support can be applied. Meal times are more of a social event with interaction encouraged appropriately.” Elreg House DS0000064568.V359326.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered manager has ensured any complaints made by residents, their relatives or friends will be listened to, taken seriously and acted upon. The registered manager has ensured residents are protected from abuse or neglect. EVIDENCE: During our last visit to Elreg House we found evidence to confirm that the home’s complaints procedure enables those using the service to know that any complaints will be taken seriously and responded to. During this visit we noted that the complaint procedure was displayed in a communal area of the care home. Information supplied by the registered provider before our visit confirmed that complaints received about the care home have been resolved to the satisfaction making the complaint. We have also received a complaint about Elreg House. We informed the registered provider and asked them to investigate the matter using their own procedure. This was dealt with appropriately by the care home. Where the investigation found shortfalls in the service provided, the manager has taken action to resolve them and make improvements where necessary. Information supplied by the registered provider also confirmed, “We strive to improve the service Elreg House DS0000064568.V359326.R01.S.doc Version 5.2 Page 17 we provide, by promoting use of the complaints procedure to relatives and to service users.” During this visit we found the manager has kept a record of all training that staff have received. We looked through this and found that all staff have been provided with appropriate training in identifying all forms of abuse and reporting any allegations made. We spoke to the staff on duty. They were able to tell us about identifying different types of abuse and to whom they should report any instances they may find. They also confirmed that they have received training with regard to safeguarding adults procedures and using the home’s whistle blowing procedures. We have been made aware of a recent investigation conducted by West Sussex Social Services under safeguarding adults procedures. The manager and the registered provider collaborated fully with this process. The investigation found that the allegations made have been unsubstantiated. Elreg House DS0000064568.V359326.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered provider has ensured residents live in a safe, well-maintained environment. The registered provider has ensured the home is clean and hygienic. The registered provider has yet to commence work on the planned improvements to the property. EVIDENCE: During our last visit we found evidence that some areas of the environment are basic but a planned rebuilding project will improve some private and communal Elreg House DS0000064568.V359326.R01.S.doc Version 5.2 Page 19 areas so that people using those areas have better facilities. During this visit we noted that the rebuilding project had not been started. This means that some of the accommodation, particularly those rooms in the single storey extension to the rear of the property, the laundry and some bathrooms were still only basic. However, we did see that new carpets had been laid in corridors and communal areas and that some residents’ bedrooms had been redecorated. In addition the kitchen floor had been re-laid. The private accommodation of several residents was also viewed along with the communal areas, including the dining room and the lounge. These areas were clean, decorated and furnished in a comfortable manner meeting the needs of the residents accommodated. Bedrooms have also been appropriately decorated. Residents have been encouraged to bring personal effects and small items of furniture in order to make bedrooms as individual as possible. This care home does not have a lift to allow residents with mobility problems access to the upper floor. There are also significant level changes on the ground floor, particularly in the dining room. This means that residents must be able to use flights of stairs to access all areas of the building. We noted that residents’ mobility is assessed and reviewed regularly to ensure the premises continue to meet their needs. We also visited the kitchen area, the laundry, and several bathrooms. We noted that all areas of the premises have been maintained to a satisfactory state of cleanliness. The manager confirmed with us that policies and procedures are in place for staff to follow to ensure the risk of cross infections is reduced. Information supplied by the registered provider confirmed that, “We employ staff to help maintain the home inside and out. The home employs a domestic five days a week who keeps the home clean and fresh, and free from odours.” Information supplied by the registered provider prior to this visit also confirmed the premises has been visited by the Fire Officer and Environmental Health officer to ensure it is safe and meets requirements in terms of fire safety and health and safety regulations. Equipment such as gas installations, electrical wiring and equipment have been regularly checked and maintained to ensure they are safe to use. Elreg House DS0000064568.V359326.R01.S.doc Version 5.2 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. 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 this service. The registered provider is working towards ensuring that there are sufficient staff on duty with the appropriate mix of skills to meet the needs of residents accommodated. Additional staff will ensure residents are in safe hands at all times. Residents are supported and protected by the home’s recruitment policy and practices. The registered provider has ensured staff are trained and competent to do their jobs. EVIDENCE: We were given copies of staff rotas to look through. The staff rota showed four care assistants from 8am to 8pm each day. From 8pm to 8am each night there are two waking night staff. In addition housekeeping staff are on duty to cook Elreg House DS0000064568.V359326.R01.S.doc Version 5.2 Page 21 meals and to clean the premises. Care staff are expected to carry out laundry duties as well. After looking through a selection of residents’ care records we concluded that staffing levels are sufficient to meet the current needs of residents. We have been made aware that the recent investigation conducted by West Sussex Social and Caring Services under the safeguarding adults procedures identified that members of staff tend to work many hours during the week. This was brought to the attention of the registered provider and the manager. It was agreed that, given the needs of the residents and the potentially stressful nature of the work, it was not acceptable for staff to work exceeding long shifts as it put residents and staff at risk. We saw that the rotas we were given continue to demonstrate staff routinely work long hours during the week. They also routinely work double shifts, working 12 hours each day for up to four shifts in a week. We spoke to the manager who informed us that the registered provider is currently recruiting more staff so that the number of hours each person works can be reduced. During our visit we were introduced to a new member of staff who had commenced work the week before. We were told they were shadowing existing staff as part of their induction to Elreg House. We saw the recruitment records of two members of staff who have started working at the care home since our last visit. These records demonstrated that the registered providers have obtained appropriate checks for these staff, including criminal records checks (CRB) and other documentation to confirm their identity. We looked at staff training records. They demonstrated that newly appointed staff undertake structured induction training. This includes providing an understanding of the principles of good care practices and covers the promoting of residents’ rights, independence, choice and dignity. Training records also provided evidence that confirmed staff have been provided with mandatory training such as identifying and reporting abuse, fire safety, health and safety, first aid, infection control and food hygiene. Staff spoken to confirmed the training and induction training they had received. They confirmed that they had received training in understanding how to work with people who have dementia and are confused. There was also evidence that demonstrated they receive regular support and supervision from the manager. Staff also told us they found the management does provide staff with the support they need. The manager informed us that one member of staff has obtained the National Vocational Qualification (NVQ) in Care at Level 3 whilst 2 members of staff have obtained the same qualification at Level 2. Three members of staff are Elreg House DS0000064568.V359326.R01.S.doc Version 5.2 Page 22 currently working towards this qualification at Level 3 whilst four more staff will be enrolling at Level 2 in April 2008. Information supplied by the registered provider before our visit confirmed, “Staffing levels are maintained constantly to ensure the needs of service users are met. Staffing levels are raised within peak times as needed. Regular staff support and supervision are given on a regular basis. All new staff are currently inducted using the common induction standards alongside the Elreg House induction process.” Elreg House DS0000064568.V359326.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 adequate. This judgement has been made using available evidence including a visit to this service. There is no registered manger as required by the Care Standards Act 2000. despite a manager being appointed some two and a half years ago, Generally there is evidence that Elreg House is being run in the best interests of residents accommodated however the long shifts that staff work could at times not be run in the best interest of residents. Residents’ financial interests are safeguarded. The health, safety and welfare of residents and staff are promoted and protected. Elreg House DS0000064568.V359326.R01.S.doc Version 5.2 Page 24 EVIDENCE: The registered provider appointed a manager some two and a half years ago. However, this person has yet to be registered with us as required by current legislation. We found evidence that the manager holds regular staff meetings. We looked at a selection of their minutes told indicated that the manager uses meetings to communicate with the staff team. The manager told us that meetings are used to discuss the needs of residents and other issues about the day to day running of the care home. We also found evidence that the manager holds regular meetings with residents. They are used to discuss planned activities and entertainments, and to discuss any issues related to the day to day running of the care home. The manager also informed us that relatives are invited to attend this meeting as a means of keeping them informed of plans for the home and to seek their views. The registered provider has set up a system for monitoring, reviewing and improving the care and services provided by the care home. The system also includes satisfaction questionnaires for residents, their relatives or other representatives to complete. This ensures their views are taken into account as part of this process. We also saw records of visits made by the registered provider. The providers also need to take action to reduce the long shifts that staff routinely work, double shifts working 12 hours each day for up to four shifts in a week, to ensure that they are protecting the interests and promoting the wellbeing of residents and staff. The manager informed us that the care home does not get involved in residents’ financial affairs. There is provision for residents to deposit money and valuables for safekeeping but currently residents have not made use of this service. The premises have been well maintained, ensuring a safe environment in which residents can live and staff can work. The registered provider has supplied information that indicates equipment such as boilers; other gas installations and electrical equipment have been regularly serviced and maintained. Residents have told us that they are satisfied with the accommodation and services provided. According to training records staff have been provided training in such subjects as fire safety training, moving and handling, food hygiene, infection control, health and safety. Staff on duty, who were spoken to confirmed the training they had received. Elreg House DS0000064568.V359326.R01.S.doc Version 5.2 Page 25 Elreg House DS0000064568.V359326.R01.S.doc Version 5.2 Page 26 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Elreg House DS0000064568.V359326.R01.S.doc Version 5.2 Page 27 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 Elreg House DS0000064568.V359326.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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. Extracts may not be used or reproduced without the express permission of CSCI Elreg House DS0000064568.V359326.R01.S.doc Version 5.2 Page 29 - 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!