Inspection on 16/10/06 for Elstree Court Nursing Home

This inspection was carried out on 16th October 2006.

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

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

Other inspections for this house

Elstree Court Nursing Home 27/06/07

Elstree Court Nursing Home 30/11/05

Elstree Court Nursing Home 25/05/05

Elstree Court Nursing Home 16/11/04

Elstree Court Nursing Home 04/05/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

Thorndene

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

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

CARE HOMES FOR OLDER PEOPLE Elstree Court 64 Meads Road Eastbourne East Sussex BN20 7QJ Lead Inspector Debbie Calveley Key Unannounced Inspection 16th October 2006 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 Elstree Court DS0000013982.V314797.R02.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. Elstree Court DS0000013982.V314797.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elstree Court Address 64 Meads Road Eastbourne East Sussex BN20 7QJ 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) 01323-732691 01323-411543 ANS Homes Limited Mrs Linda Ann Shorman. Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34), Physical disability (34) of places Elstree Court DS0000013982.V314797.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. That a maximum number of thirty four (34) service users to be accommodated. Service users must be aged sixty five (65) years and over on admission. Service users may have a physical disability. Date of last inspection 30th November 2005 Brief Description of the Service: Elstree Court is a care home registered to provide nursing care for up to thirtyfour residents that meet the category of older people and also individuals with physical disabilities. The home is part of a group managed by BUPA Health Care. Elstree Court is situated in a residential area, ten minutes from Eastbourne town centre; it is convenient for local shops and public transport. The accommodation is on three floors and offers twenty single bedrooms, three with ensuite facilities and seven double rooms of which one has an ensuite facilitity. Level access to all areas of the home is provided by a lift, stair lifts and ramps. There are three lounges on the ground floor in the home, with a small dining area. The home provides specialist equipment to meet the needs of residents, including lifting devises (hoists) and specialist mattresses. An adequate amount of communal bathrooms with either a shower or assisted bath are provided. There are attractive gardens with seating to the front and rear that are accessible to residents and used when weather permits. A gazebo has recently been built in the rear garden. Copies of inspection reports and the home’s Statement of Purpose are made available on request prior to admission and a service users guide is in every bedroom. Fees charged as from 1 April 2006 range from £696-£883. Additional charges are made for hairdressing, chiropody, newspapers and toiletries. Intermediate care is not provided. Elstree Court DS0000013982.V314797.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001 often use the term ‘service user’ to describe those living in care home settings. For the purpose of this report those living at Elstree Court Care Home will be referred to as ‘residents’. This was a key inspection that included an unannounced visit to the home, and follow up contact with resident’s representatives and visiting health and social care professionals. The unannounced visit also included a meeting with the registered manager who received the inspector’s feedback at the end of the inspection. On the day of the home visit, 16 October 2006, there were twenty-eight residents living in the home. The inspection process included meeting with the residents and their visitors, speaking with staff and observing practice in the home. During the inspection visit six residents care documentation was reviewed in depth. A further selection of documentation was reviewed as part of the inspection process and this included the statement of purpose and service users guide, staff duty rotas, training records, five recruitment files, records relating to health and safety and a number of policies and procedures. Four staff members were also interviewed in private. In addition service users surveys were given to ten residents or their representatives and surveys were sent to health care professionals that have contact with the home. The information contained in the returned surveys has been incorporated into this report. What the service does well: The comprehensive Statement of Purpose and Service Users Guide give prospective residents the information required enabling them to make an informed choice about where they live. One resident said “ I refer to it when I need to, I find it very helpful”. A Service Users Guide is provided in each resident’s room. Systems are in place to regularly consult with residents via residents meetings and surveys. There is an open-house policy, which welcomes visitors at all reasonable times, “ I am always welcomed to the home, they treat me as a valued guest”. Satisfactory arrangements are in place to safeguard resident’s finances. Residents are supported and protected by robust recruitment practices. There is a training programme in place that ensures staff are competent to care for the residents living in Elstree court. The management structure of the home is strong and competent, identifying shortfalls with internal audits and compiling an action plan. Elstree Court DS0000013982.V314797.R02.S.doc Version 5.2 Page 6 The home is run in a way that promotes and protects the safety and welfare of residents and staff 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. Elstree Court DS0000013982.V314797.R02.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 Elstree Court DS0000013982.V314797.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Prospective residents and their representatives are provided with information about the home in order to make an informed choice about whether to live at the home. The pre-admission assessment procedures ensure residents admitted can have their care needs met within the home by experienced staff. EVIDENCE: There is a range of well-documented information about the home and the services it provides. This includes a statement of purpose and service user guide. Copies of these are available in the front entrance area. A social care professional that had recently visited the home confirmed that relevant information was provided to a prospective resident. It was confirmed whilst talking to residents that the contract arrangements were clear and understood. A review of the care documentation confirmed that pre-admission assessments are completed, and are currently completed by the manager or a senior nurse. Six of the seven assessments were found to be completed and were used to ensure new admissions to the home were suitable and that the home have the Elstree Court DS0000013982.V314797.R02.S.doc Version 5.2 Page 9 staff and environment to meet the care needs of the new resident. The information contained in these assessments is then used to provide the basis of the care documentation in the home. The prospective residents’ are seen either in their home or hospital before admission and the manager confirmed that wherever possible the family or representative is involved. Two relatives confirmed that they were consulted about the pre-admission visit and were given the opportunity to attend. Elstree Court DS0000013982.V314797.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. Generally care plans provide a good framework for the delivery of care, however these need to provide clear guidance to care staff on all the care needs of all the residents. EVIDENCE: The care documentation pertaining to six residents were reviewed as part of the inspection process. These were found to include plans of care, nutritional assessment, and personal histories and risk assessments. On the whole the care documentation available was full and demonstrated that the care was reviewed and evaluated, however it was noted that the plans of care did not always cover all the care needs of residents and reviews for some were two months behind. For example one resident who has communication problems did not have any guidance in the documentation to facilitate this vital need, another resident whose sight has deteriorated and coping strategies had not been recorded or her care plan updated. One resident had little documentation available regarding their frustration and subsequent altered temperament and there was no guidance for staff to follow as to how to deal with it. Elstree Court DS0000013982.V314797.R02.S.doc Version 5.2 Page 11 The moving and handling risk assessments were not all completed in full and some risk assessment were inaccurate and did not reflect the current needs of the residents. Staff would benefit from guidance/training in the use of appropriate wording when. The quality of the care plans has not been maintained to the standard previously seen, however the Registered Manager has identified this and training sessions for staff are being arranged. Staff spoken to confirmed that they received a full report on each resident daily and read the care documentation that at present due to the redecorating is kept in the clinical room. They felt that their views were taken into account when planning resident’s care. There is little evidence of service user/representative consultation in individual plans. Two visiting family members said that they did get to talk with the nurses regarding the care when they visited, but did not have any input into the care plan. Three residents spoken with were not aware that they had a care plan and it would be beneficial for resident outcomes for staff to actively pursue resident/ representative involvement. Discussion with General Practitioners and social workers confirmed that the home communicates well with other professionals as necessary with regard to the care of residents. Relatives spoken to were very satisfied with the care provided at the home one saying that the home ‘should be commended for its care’. Residents spoken to were also very satisfied comments included’ I am very happy and content here’ ‘ I am well looked after’. Others mentioned that there had recently been staff shortages, “ the staff are always too busy” there is not enough staff” “ I think there is a staff shortage”. There are policies and procedures in place for the receipt, recording, storage, handling, administration and disposal of medicines. The clinical room was found to be clean and fairly well organised. The fridge was of the correct temperature as was the clinical room and both temperatures are recorded daily. Out of date eye drops were found in the fridge and disposed of by the Nurse in Charge. The medicine administration charts have been monitored internally since the last inspection and shortfalls are still being identified. There was evidence of a recent action plan that has been developed to improve staff practice. The medication round was observed and some areas of poor practice were discussed during feedback regarding administration techniques to residents. Staff were seen to be respectful and considerate to all residents and visitors. Each of the residents were addressed by their preferred term and dressed appropriately in well-laundered clothing. During the inspection it was noted that residents privacy was respected and staff were seen knocking on doors prior to entering. Areas that compromised a residents’ dignity were identified and consisted of not allowing the resident to exercise her independence and choice regarding her medication and her meals. Elstree Court DS0000013982.V314797.R02.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Social activities are creative and provide daily variation and interest for people living in the home. Residents are able to make a range of choices about their lives as well as maintaining links with friends and relatives. The meals provided are not always meeting the preferences and expectations of the residents. EVIDENCE: The inspector observed residents being able to spend time where and how they wanted moving around the home freely. Set routines are avoided as far as possible and residents are able to determine when they would like to go to bed and what time they would like to get up in the morning. There are two activity co-ordinators and the activities have been reviewed and improved since the last inspection. Residents are able to choose whether they want to join in the activity sessions, which are provided daily from 11:00 am until lunchtime and then from 2 pm until teatime. The range of activities provided is varied and are based on the personal interests and preferences of the residents. A life map is completed by the activity co-ordinators on all the residents with the help from family and friends if needed. The activities provided include reading sessions, music, bingo, flower watering and caring for Elstree Court DS0000013982.V314797.R02.S.doc Version 5.2 Page 13 the patio plants, singing, makeovers and movement to music. One to one sessions are also offered. Residents, their representatives and a contacted social worker felt the activities and entertainment provided was appropriate and fulfilling. Residents are encouraged and enabled to follow their religious beliefs, communion is held regularly. On speaking to residents and visitors it was clear that visiting is very positively encouraged with no restrictions being imposed. One visitor expressed a satisfaction that staff made an effort to be aware of who he was even though his relative was new to the home. Due to the lower floor being redecorated, the dining room was not being used and residents were having their meals in the lounge areas and in their rooms. The meal service observed was slightly disorganised for that reason, but the staff worked hard to ensure that minimum disruption affected the well being of the residents. The menus offer a choice of breakfast, lunch and supper and it was confirmed that the residents may also choose from an alternative light menu if desired. The presentation and quality of the pureed and the vegetarian meal on the day of the inspection was poor. Some residents were hindered being independent with eating due to poor seating positions and no available plate guard. Of the ten resident surveys received, only one was positive regarding the meals in the home, others stated “ the meals could be more interesting” “ a more varied menu would be appreciated” “the food is sometimes good”. From talking to residents on the day comments regarding food were mixed, “ food is not bad, has its up and downs”, “ I get a choice, but its not always the right choice” This is an area that needs re-investigating by the management as to why the food is not meeting the expectations and preferences of the residents living in the home. Elstree Court DS0000013982.V314797.R02.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Procedures in the home ensure that complaints and any allegation or suspicion of abuse made would be managed appropriately. EVIDENCE: The home has a clear complaints procedure and a copy of this is readily available in the home. A system of recording complaints was demonstrated to the inspector during her visit to the home. There have however been no complaints received recently to be processed using this system. Relatives and visiting professionals spoken to confirmed that they were confident that any complaints or concerns that they had would be listened to and responded to effectively. The home has relevant guidelines on the protection of vulnerable adults and staff have received appropriate training. The management team has a clear understanding of adult protection guidelines and have initiated this procedure appropriately in the past. The BUPA policy was seen and it is asked that it is reviewed on one point to ensure it has the same guidelines for initial investigation as the East Sussex Multi Agency policies and procedures. Elstree Court DS0000013982.V314797.R02.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 26 and 26. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home provides a comfortable, clean and safe environment for those living there and visiting. Residents are enabled and encouraged to personalise their room, and rooms are homely and reflect the resident’s personalities and interests. EVIDENCE: Elstree court continues to be well maintained and provides a safe environment for the residents. At present the lower floor communal areas and corridors are being redecorated which has had an impact on the residents’ daily life, though disruption has been kept to a minimum by the hard work of the homes’ staff. A few maintenance shortfalls were found and these were fed back to the maintenance man during the inspection. The garden areas are well tended and accessible for all residents, the addition of a gazebo has increased the residents’ enjoyment of the garden. Elstree Court DS0000013982.V314797.R02.S.doc Version 5.2 Page 16 The home has the specialist equipment necessary to maximise resident’s independence. The hoists were clean and in good working order and there were a sufficient number for the needs of the residents, which was endorsed by the staff. Grab rails are in place and call bells are provided in all rooms used by residents, however not all residents had access to this facility during the day and this needs to be continued to be monitored to ensure the safety and well being of all residents. The feedback from service users regarding the response to call bells remains unchanged from the previous inspection, three residents said they sometimes had to wait for the call bell to be answered, especially after meals, whilst others said they often had to wait in the mornings and they felt the “staff were very busy” “ not enough staff”. On the day of the inspection the majority of call bells were answered promptly. Staff interviewed did say that some shifts were busy that it was difficult to answer call bells promptly, but they felt that they usually managed well. The provision of bed barriers and bumpers need to be clearly documented in the individual residents care plans, and an appropriate action plan in place for those at risk from falling and at risk from bed barriers being provided as a preventative measure. There are adequate communal bathing facilities and toilets for the needs of the residents, hot water temperatures were randomly tested and were of the required temperature. All bedrooms have domestic lighting, and bulbs were being replaced during the inspection. The majority of residents’ bedrooms are homely and comfortable, many residents have personalised them with furniture and personal photographs and ornaments. One room was seen to be bursting with possessions and it might be preferable to move the resident to a more spacious room, the chest of drawers was also broken. Residents confirmed that they had been encouraged to bring in their photographs and personal items. The home was in the main clean and tidy and had no unpleasant odours. The sluices were clean with hand washing facilities. There were ample supplies of aprons and gloves, which were worn appropriately. Staff were knowledgeable about infection control measures, and appropriate policies and procedures are in place. Elstree Court DS0000013982.V314797.R02.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. A review of staffing levels based on residents’ dependency levels needs to be implemented to ensure there are sufficient staff, to meet residents needs. Staff training is provided and ensures that the needs of the residents living in the home are met. Residents are protected by the home’s recruitment policy and practices. EVIDENCE: At present there are twenty-eight residents living in the home, the staffing levels are two trained and five carers on the morning shift, one trained and four carers on the afternoon shift and one trained and three carers on the night shift. This is in addition to domestic, laundry, maintenance and kitchen staff. The manager is usually supernummery, however she was working as a team member on the day of the inspection. The staffing levels need to be flexible and dependant on the increased needs of residents. As mentioned previously feedback from residents staff and visitors identified that the staffing levels are not always enough to meet the assessed needs, the size, purpose and layout of the home of the and that there have been “staff shortages”. Without definite dates, it is not possible to highlight the shifts or incidences this applies to, and therefore staffing is to be continually reviewed and monitored on a regular basis. During the inspection the staff were seen to be rushed and the meal service was not smooth, but there were other contributory factors, such as decorating, new chef and use of agency staff due to illness of regular staff. Elstree Court DS0000013982.V314797.R02.S.doc Version 5.2 Page 18 The staff group on the whole is stable, both residents and their relatives spoke highly of all the staff saying ‘staff are always nice and kind’ ‘staff are helpful, approachable and are available to talk to’. The recruitment records for four staff members were reviewed in depth and were found to be full and contain the required information and demonstrated the appropriate induction and skills for care training had been completed in respect of the job they were to undertake in the home. Staff interviewed confirmed a high satisfaction with the training provided and stated that recent training being completed in conjunction with a college was most useful and interesting. Staff and records seen confirmed that they had undertaken compulsory training such as manual handling, adult protection, first aid, food hygiene and fire safety. In addition specialist training in dementia care was being completed. NVQ training is available and staff are encouraged to complete this. Elstree Court DS0000013982.V314797.R02.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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, 33, 34, 35, 36, 37 and 38. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The overall management of this home is good with effective systems in place to protect residents. Elstree Court DS0000013982.V314797.R02.S.doc Version 5.2 Page 20 EVIDENCE: The Registered Manager is a Qualified Registered General Nurse and has the experience to run the home effectively with support from the Responsible Individual. A deputy manager completes the management team. The management structure of the home is strong, competent and has clear lines of accountability. The manager is aware of the shortfalls in the care planning, medication and meals and is taking appropriate action to address them. Evidence was seen of her audit of the care plans and medication administration. The feedback from residents, relatives and staff indicated that they felt supported and were able to approach the management team at any time. The ethos of the home is to focus on the residents and the staff were observed doing this. Regular staff meetings and resident/relative meetings are held and records of the meetings are kept. The staff mentioned the staff meetings and how beneficial they were and the staff felt that areas of improvement they put forward were acted for the benefit of the residents. These form part of the quality assurance systems in the home. One resident mentioned that they attended the resident meetings and thought it gave them the opportunity to discuss the running of the home and areas that could be improved. Residents’ financial interests are safeguarded by the homes policies and procedures. All staff spoken with were aware that they must not be involved in any financial matters of the residents, they also said that they would not accept money or gifts from residents. The residents spoken with said they had no worries regarding their financial status, and felt they were supported in managing their affairs efficiently. The manager confirmed and the staff training records show that all staff are kept updated on the Health and Safety policies, the manual is available to all and clearly defined. Staff were able to discuss the training they received and said that they were kept up to date with changes to policies in connection with fire safety and health and safety. The staff are issued with certificates yearly for Manual Handling, twice yearly for Fire Safety and Food and Hygiene. The home has a comprehensive set of policies and procedures, which govern the running of the home. All relevant legislation and procedures are in place in respect of Health and safety. Evidence was seen of regular supervision sessions and all staff spoken with confirmed that they receive regular supervision. Throughout the inspection good practice was observed in regards to ensuring the safety and well being of the residents when being moved around the Elstree Court DS0000013982.V314797.R02.S.doc Version 5.2 Page 21 building. The accident forms were seen and had been correctly completed with appropriate referrals made as necessary. As mentioned previously staff need to ensure that all residents have access to a call bell facility in communal areas and in their bedrooms or a risk assessment with an appropriate plan of action for staff to follow. Elstree Court DS0000013982.V314797.R02.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 2 3 3 3 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 3 3 3 3 3 3 3 3 Elstree Court DS0000013982.V314797.R02.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation Requirement Timescale for action 31/01/07 15(2)(b)(c That a comprehensive plan of )12(1) care is generated from a comprehensive assessment is drawn up for/with each service user, and it is reviewed at least once a month. This to include social and personal care needs. That consultation with the service user/representative is evidenced Risk assessments must be undertaken in full for those service users with communication/visual problems, at risk of falls and moving and handling. Assessments must include the management of identified risks. Medication administration record charts must reflect current medication profile and must be a true and accurate record. (Previous timescales of 25/5/06 & 01/01/06 not met.) That the residents’ health needs in respect of food management DS0000013982.V314797.R02.S.doc 2 OP8 15(2)(b) 13(4)(b) 31/01/07 3 OP9 13(2) 31/01/07 4 OP10 12 (3)(4) 31/01/07 Elstree Court Version 5.2 Page 24 5. OP15 are conducted in a manner which respects the privacy and dignity of residents. 16(2)(i)12 That the quality and appearance 31/01/07 (1)(2)(3) of the food offered to service users is reviewed to ensure that it meets the service users expectations and needs. (Previous timescales of 01/02/06 not met.) 16 (1) That all service users have access to a call bell, or a method of recording that the staff are regularly checking those service users who cannot use this facility. That staffing levels are appropriate to the assessed needs of the service users, the size, layout, and purpose of the home at all times. 19/10/06 6 OP22 OP38 7 OP27 18 (1) (a) 31/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Elstree Court DS0000013982.V314797.R02.S.doc Version 5.2 Page 25 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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