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Inspection on 25/05/05 for Elstree Court Nursing Home

Also see our care home review for Elstree Court Nursing Home for more information

This inspection was carried out on 25th May 2005.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The atmosphere of the home is pleasant with good interaction seen between residents and staff and between the staff. There is plenty of good nutritious food and fresh fruit is readily available. The home is safe and well maintained. There is a stable work force of reliable and caring staff.

What has improved since the last inspection?

This is the first inspection by the inspector and six of the eight outstanding requirements from the last inspection have been fulfilled. Service users care plan now includes action plans with regard to weight loss and nutrition. Policies and procedures have been developed and linked with the provision of appropriate care and support for service users as their needs change. Good practice was observed in regard to Infection control policies and procedures. Staff employed in the nursing home are found to be available at all times. There has been regular updating of all staff in respect of moving and handling.

What the care home could do better:

There needs to be evidence of choice and flexibility to residents lifestyle experienced in the home. Care plans need to be developed in respect of their social and recreational needs. This will ensure that residents are stimulated and enabled to live a full and satisfying life. The medication procedures within the home need to be followed, to ensure the safety of all service users. Staffing levels need to be assessed against the specific needs of the service users and increased as necessary to meet those assessed needs. There needs to be continued monitoring of the moving and handling techniques used by staff when transferring from chairs to wheelchairs and vice-versa. This will ensure the safety and well being of residents.

CARE HOMES FOR OLDER PEOPLE Elstree Court 64 Meads Road Eastbourne East Sussex BN20 7QJ Lead Inspector Debbie Calveley Unannounced 25 May 2005 09:00 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 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 H59-H10 S13982 Elstree Court V221616 250505 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Elstree Court Address 64 Meads Road Eastbourne East Sussex BN20 7QJ 01323 732691 01323 411543 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) ANS Homes Limited Vacant Care Home with nursing (N) 34 Category(ies) of Physical disability (PD) registration, with number Old age, not falling within any other category of places (OP) 34 Elstree Court H59-H10 S13982 Elstree Court V221616 250505 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: 1. That a maximum number of thirty-four (34) service users to be accommodated. 2. Service users must be aged sixty-five (65) years and over on admission. 3. Service users may have a physical disability. Date of last inspection 16 November 2004 Brief Description of the Service: Elstree Court is a nursing home registered to provide nursing care for up to thirty-four service users, older people and individuals with physical disabilities.The home is part of a group managed by Associated Nursing Services (ANS), situated in a residential area, ten minutes from Eastbourne town centre, it is convenient for local shops and public transport. The accommodation offers twenty single bedrooms, three with ensuite facilities and seven double rooms, one with an ensuite facilitity. There is a combination of a lift, stair lifts and ramps, which provides level access to all areas of the home.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 service users, including hoists and pressure mattresses. There are attractive gardens to the front and rear that are accessible to service users and used when weather permits. Elstree Court H59-H10 S13982 Elstree Court V221616 250505 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 25 May 2005. It commenced at 7.30am and was conducted over six hours. There were twenty-seven residents living in the home on this day. The methodology of the inspection included a tour of the building, inspection of documentation and records, the delivery of care for ten residents and informal interviews with six residents, three relatives and six members of staff. What the service does well: What has improved since the last inspection? This is the first inspection by the inspector and six of the eight outstanding requirements from the last inspection have been fulfilled. Service users care plan now includes action plans with regard to weight loss and nutrition. Policies and procedures have been developed and linked with the provision of appropriate care and support for service users as their needs change. Good practice was observed in regard to Infection control policies and procedures. Staff employed in the nursing home are found to be available at all times. There has been regular updating of all staff in respect of moving and handling. Elstree Court H59-H10 S13982 Elstree Court V221616 250505 Stage 4.doc Version 1.20 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Elstree Court H59-H10 S13982 Elstree Court V221616 250505 Stage 4.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection Elstree Court H59-H10 S13982 Elstree Court V221616 250505 Stage 4.doc Version 1.20 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 standard(s) 1,2, 3, 4 & 5 The comprehensive Statement of Purpose and Service Users Guide give prospective residents the information required to enable them to make an informed choice about where they live. A contract/ statement of terms and conditions is given to all residents on admission to Elstree Court so residents are aware of the conditions agreed. A pre-admission assessment is performed on all prospective residents before admission to ensure the home can offer them the care they require. EVIDENCE: The statement of purpose and service users guide was viewed, it was found to be up to date and contained information that prospective service users need to make an informed choice of where to live. A recommendation is that all residents in the home receive an up to date copy in their room to incorporate any changes in the home. There is a written contract/ statement of terms and conditions that all residents receive on admission to the home. Elstree Court H59-H10 S13982 Elstree Court V221616 250505 Stage 4.doc Version 1.20 Page 9 Ten pre-admission assessments were viewed whilst case tracking, and the preadmission assessment document was found completed and informative. ANS have an assessment tool, which covers all the needs as defined in standard 3.3. The management team endeavours to involve the prospective resident’s relatives whenever possible. The assessment takes place at the residents’ place of residence, and input from other relevant professionals is sought when required. Two residents said they remembered someone from the home coming to see them before they left hospital. As previously mentioned pre-admission assessment identifies any specific needs of the prospective resident and this informs the admission process. These can then be discussed with the resident and their representative to ensure that the home can meet their needs. The statement of purpose also gives information regarding the services they provide. Prospective residents can visit the home to meet residents, to look at rooms that are available and the facilities provided before they make any decision regarding accepting a place. Unplanned admissions are avoided whenever possible but should they occur, then an assessment is undertaken within forty eight hours and a GP is requested to visit as soon as possible. One service user said that she had been in Elstree court for respite care, before the death of her husband and then had decided to make it her home permanently. Two others mentioned that they had visited prior to their admission to the home. A recent admission said that she was not consulted and that she had not seen the home before arriving there to stay. This was relayed to the manager, who explained that the son had had arranged the short stay and that she would talk to the resident and explain the circumstances to her. Elstree Court H59-H10 S13982 Elstree Court V221616 250505 Stage 4.doc Version 1.20 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 standard(s) 7, 8, 9, 10 All residents have an individual care plan, which meet their health needs, however the social and recreational care plans were insufficient. There has been a decline in the medication administration documentation and practice since the last inspection, putting service users at risk. The residents are treated with respect and courtesy in all aspects of their care. EVIDENCE: The care plans of ten residents were viewed, and were found to be clear and informative. All were found to have a comprehensive plan of care, which is generated from the initial pre-admission assessment. The care plans clearly identify the specific needs of the service users. However it was found that not all monthly reviews had been completed, a yellow sticker was in place to remind the staff concerned that it was due. This indicates that the systems in place for review are working, but two were outstanding for May. Risk assessments need to be updated and reviewed on specific residents and this was discussed at the time. There is evidence of resident/representative consultation in individual plans. Three service users said that they did get to talk with the nurses regarding their care, whilst two were not aware of any such involvement. Elstree Court H59-H10 S13982 Elstree Court V221616 250505 Stage 4.doc Version 1.20 Page 11 Residents are registered with GP’s and have access to allied health professionals as required including physiotherapy and chiropody. Pressure relieving aids are in place and there are links with the tissue viability nurse. It was evident from the chats with residents that they felt that their needs were met health wise, but that “staff were too busy now to stay and chat”. The staff also said they “don’t have the time to do the little extras that mean so much” The care plans did not show how their social and recreational needs are being met, and this is an area that needs to be developed within the home. There are policies and procedures in place for the receipt, recording, storage, handling administration and disposal of medicines. During the inspection same areas of poor practice were identified. An unlocked medicine trolley was found with pills on top and no nurse in sight for approximately ten minutes in a corridor. This was immediately brought to the managers’ attention. The reason given was that the blister packs are too large for the trolley and that a new trolley has been ordered. Unidentified pills were found on the floor of a residents’ room. Records in the medication administration record charts were on several occasions incomplete. There were gaps for when a medication was missing in the blister pack and presumably administered. Some verbal orders needed dates and signatures as did some ‘course completed’ medications. The clinical room was clean and tidy, the fridge was at the correct temperature and records of the room and fridge temperatures are kept. The staff were seen throughout the inspection treating residents with respect and dignity. All the residents spoken to were full of praise for the staff, and said that they were always polite and attentive. Elstree Court H59-H10 S13982 Elstree Court V221616 250505 Stage 4.doc Version 1.20 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 standard(s) 12, 13, 14 and 15. The residents are not enabled to exercise the choice and control of their every day life. The activities in the home are not meeting the individual preferences of the residents. The dietary needs of residents are well catered for and offer a balanced and varied selection of food that has been updated in line with the personal likes and choices of residents EVIDENCE: There is an activity programme in place and the activity co-ordinator is popular with the residents. No activities took place on the morning of the inspection. Two residents said they “chose not to go to the activities, but the co-ordinator visits us in the room”, one service user said she has recently been shopping, whilst another said she would love to the leave the building. It was identified that there needs to be a review of the activities to ensure all residents receive stimulation and their social and recreational needs are met. There is an “open” visiting policy in place, and two relatives were visiting in the morning. One relative said he always visited at lunchtime so he could help his wife eat. He said that the staff were lovely but always seemed very busy, and that they always made him feel welcome. Elstree Court H59-H10 S13982 Elstree Court V221616 250505 Stage 4.doc Version 1.20 Page 13 From discussions with service users it identified that they do not feel they can exercise choice and control over their lives especially in how they spend their time. One resident said she used to go downstairs for lunch, but now if she goes down she has to wait” until staff are free” before going back to her room. Another said she felt “quite isolated at times”, and hadn’t been offered the opportunity of going out or spending time in the quiet lounge. A relatively new resident said “ I have lived my way for 99 years and now I am told how I will live”. Two services users said they would like more baths but are not offered the choice. It has been previously discussed at the last inspection and again with the acting manager at this inspection. Resident surveys and meetings will hopefully empower those residents. Breakfast and the midday meal were observed at this inspection. There was choice and variety offered and the meals looked attractively presented and nutritious. The menus were discussed with both the chef and the kitchen manager. They were seen to be nutritious and offered a wide choice and variety of foods. The staff feedback to the kitchen daily, on what was eaten and quantities and the menu will be adjusted accordingly. On the day of inspection the summer menu was being set up, the kitchen manager demonstrated a good knowledge of residents personal tastes and said she went and discussed menus and choices with each individual resident. The residents feelings regarding the meals offered were varied, one resident said “I used to love cooking, the food here is alright, but not the same as I used to cook, they give me a supplement but its far too sweet for me, so I don’t drink it all”. She also expressed an interest in her weight, “they weigh me but don’t tell me what I weigh”. A resident said “ mustn’t grumble, but they give me fish fingers, I have never eaten fish fingers and am not going to start now” A relative said the food is always nicely presented and seemed to be enjoyed by the residents, “not many empty plates”. The midday meal taken by services in the lounge areas by eleven residents, which according to a relative was unusual as usually only four or five were there, and three only in the dining room. The dining room is fairly small, but is attractively decorated and congenial. The rest of the residents took their meals in their room, three said it was their choice. Elstree Court H59-H10 S13982 Elstree Court V221616 250505 Stage 4.doc Version 1.20 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 standard(s) 16 &18. The complaint procedure is clearly detailed in the Statement of Purpose and Services Users guide and is available to residents and their families. Staff interviewed had a good understanding and knowledge of Adult Protection policies and procedures, which protect the residents from harm and abuse EVIDENCE: There are appropriate policies and procedures are in place and it was confirmed that these are followed when investigating any concerns raised at Elstree Court. The complaint book was viewed and this demonstrated that all complaints are recorded, along with the outcome and action taken by the home to resolve the complaint. The staff interviewed were knowledgeable on the ANS complaint procedure and of how to start the process if the manager is not available. The Adult Protection policy in the home was found to be up to date and staff interviewed were knowledgeable about the systems in place to protect vulnerable service users. There is on-going training for all staff in Protection of Vulnerable Adults. The recruitment process was seen to be thorough and the files of four new staff members were viewed and contained all the necessary references, Criminal Record Checks and completed application forms. Elstree Court H59-H10 S13982 Elstree Court V221616 250505 Stage 4.doc Version 1.20 Page 15 Elstree Court H59-H10 S13982 Elstree Court V221616 250505 Stage 4.doc Version 1.20 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 23, 24, 25 & 26. The home provides a comfortable, clean and safe environment for those living there and visit. EVIDENCE: Elstree court is well-maintained and provides a safe environment for the residents. The communal areas are pleasant and comfortable with good quality furniture. There is a fairly large main lounge area which was overcrowded with chairs placed around the outside of the room, the physiotherapist was observed having to move chairs to use the bars for her clients. This is a health and safety issue and this current practice of lifting furniture needs to be addressed. It is also inappropriate for physiotherapy to be done in full view of other residents and relatives. It was discussed of ways to use the other smaller lounge and conservatory to the best advantage for residents. Two residents spoke of the sun lounge which they said they enjoyed using on the occasions they went downstairs. The garden areas are well-tended and accessible for all service users. Elstree Court H59-H10 S13982 Elstree Court V221616 250505 Stage 4.doc Version 1.20 Page 17 The home has the specialist equipment necessary to maximise residents, 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 service users. One resident said she often had to wait for her call bell to be answered, especially after meals, whilst two others said they often had to wait in the mornings and they felt the “staff were very busy”. On the day of the inspection the majority of call bells were answered promptly. Staff interviewed did say that some shifts were so busy that it was difficult to answer call bells promptly. The majority of residents’ bedrooms had been personalised and were seen to be homely and comfortable. Four residents said that they had been encouraged to bring in their photographs and personal items. The rooms were furnished with good quality furniture to meet individual preferences and needs of the residents. The home was clean and tidy and had no unpleasant odours. The sluices were clean, however some equipment was seen to be stained. There were ample supplies of aprons and gloves, which were worn appropriately. Staff were knowledgeable about infection control measures, and policies and procedures are in place. It was discussed that the policies and procedures are updated on a regular basis, they were last updated in 2002. Elstree Court H59-H10 S13982 Elstree Court V221616 250505 Stage 4.doc Version 1.20 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28,29 & 30. The staffing levels in place on the night and day of the unannounced inspection were inadequate to meet the assessed needs of the residents. Robust recruitment procedures go towards ensuring the protection of the residents. The arrangements for the induction of staff are good with the staff demonstrating a clear understanding of their designated roles. Staff are provided with training pertinent to meeting the needs of the residents. EVIDENCE: The night shift at Elstree Court is staffed by one trained nurse and two carers. Due to the layout of the home and the needs of the service users the number of staff on the night shift is not considered sufficient. One staff member said “out of the twenty seven service users only three are self caring, the rest need a lot of input, it’s a struggle and we do not have the time to do the little things that matter for the residents”. She also said that it was difficult to supervise staff. The morning shift consisted of two trained nurses and five carers, again due to the needs of the residents the staffing was seen to be insufficient. One member of staff said that “it was difficult to give residents the time they required, especially as one resident was very unwell and was dying”. The staff Elstree Court H59-H10 S13982 Elstree Court V221616 250505 Stage 4.doc Version 1.20 Page 19 worked very hard to fulfil their role. One resident said that “the staff don’t have time to talk like they use to” and she misses the socialising that she used to enjoy. One relative mentioned that he had noticed how “hard the staff worked, but also how they didn’t get the chance to chat anymore”. Staffing levels need to be adjusted according to the changing needs of the residents. All new staff receive an induction and foundation training in line with the National Training Organisation and staff training is on-going. Three members of staff said that the training in the home is “very good, lots of it” and that they receive regular supervision. For staff files were viewed and demonstrated that robust procedures are followed. All files contained the necessary work permits, identification photographs, criminal record bureau checks, two written references and a completed application form. The training file was seen and there was evidence of the continuing training sessions that cover a wide variety of subjects. The manager is very pro-active of accessing courses that provide additional knowledge of resident related diseases for the staff. Elstree Court H59-H10 S13982 Elstree Court V221616 250505 Stage 4.doc Version 1.20 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 36, 37 & 38 All staff receive formal supervision at least six times a year and this promotes good practice and provides a support system for staff. There are policies and procedures in place that safeguard residents’ rights and best interests, however they have not been updated since 2002. The environment and working practices of the staff protect and promote the residents health, safety and welfare needs EVIDENCE: The home has produced a training programme that is suitable for the staff and for the needs of the residents. The staff training files were seen and displayed a wide variety of training for the staff. Elstree Court H59-H10 S13982 Elstree Court V221616 250505 Stage 4.doc Version 1.20 Page 21 Staff are supported by the manager on a daily basis and more formally through supervision. Staff spoken to confirmed they received supervision and annual appraisals. They are in a written format and copies are kept in the staff files. 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 again, were able to discuss the training they received and said that the manager kept them up to date with changes to policies in connection with their job description. The staff are issued with certificates yearly for Manual Handling, twice yearly for Fire Safety and Food and Hygiene. There is still some poor practice regarding safe moving and handling techniques, but senior staff were seen to be vigilant and corrected staff when seen and showed them how to move the service user correctly. 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. Elstree Court H59-H10 S13982 Elstree Court V221616 250505 Stage 4.doc Version 1.20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION 3 3 x x 3 3 3 3 STAFFING Standard No Score 27 2 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x 3 2 2 Elstree Court H59-H10 S13982 Elstree Court V221616 250505 Stage 4.doc Version 1.20 Page 23 yes 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. 1. 2. Standard 7 9 Regulation 15 (1) 13 (2) Requirement That social and recreational care plans are developed. Medication administration record charts must reflect current medication profile and must be a true and accurate record. That medicines are correctly and safely stored at all times. That an activity programme is devised to ensure all service users social needs are met. Service users to be enabled to make choices and exercise personal autonomy.(Previous timescale of 30/12/04 not met That all equipment in sluice areas for the use of service users are kept clean and hygenic. That staffing levels are increased so as to meet the assessed needs of service users. That moving and handling techniques are monitored. That the position of the lounge area furniture is reviewed and staff are not put at risk by moving chairs. That all policies and procedures are reviewed and updated on a regular basis. (Previous timescale of 31/03/05 not met) Timescale for action 31 august 2005 25 May 2005 25 May 2005 31 august 2005 25 May 2005 25 May 2005 25 May 2005 25 may 2005 31 August 2005 31 august 2005 3. 4. 5. 9 12 14 13 (2) 16 (2) 12 (2) (3) 6. 7. 8. 9. 26 27 38 38 & 20 13 (3) 18 (1) (a) 13 (5) 13 (4) (a) (b) (c) 17, 12. 10. 37 Elstree Court H59-H10 S13982 Elstree Court V221616 250505 Stage 4.doc Version 1.20 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Elstree Court H59-H10 S13982 Elstree Court V221616 250505 Stage 4.doc Version 1.20 Page 25 Commission for Social Care Inspection 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. Extracts may not be used or reproduced without the express permission of CSCI Elstree Court H59-H10 S13982 Elstree Court V221616 250505 Stage 4.doc Version 1.20 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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