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Inspection on 27/06/07 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 27th June 2007.

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

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

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 Manager of the home is qualified and experienced and provides a stable environment for people in the home. The Manager assesses the needs of each person to ensure they can be met before they move in. the staff in the home have a good understanding of each persons needs and the nursing staff ensure their health needs are fully met. The people living in the home are asked for their views about the service regularly and are asked how they would like to spend their time during the day. They are kept safe in the home and are happy with that the environment of the care home meets their needs and expectations.

What has improved since the last inspection?

The care plans have been updated to make sure that staff know exactly how to meet peoples needs. It is planned that this is going to be improved more within the next month. The risks of people falling have been assessed and reduced. An activity committee has been formed to plan a programme of activities for the home. People living in the home and their relatives are involved in this committee. The quality, choice and presentation of meals have improved greatly since the last inspection. People living in the home say they are now very happy with the meals provided. The Manager has completed the NVQ Level 4 Award in management.

What the care home could do better:

The care plans could be further improved to ensure that the information about people is easy to access for staff. This should be achieved with the plannedintroduction of new care plans. It is recommended that the records made daily in the care plan include details of how people spend their time so that staff can easily see that peoples` social needs are being met. It is recommended that the call bells in the lounge areas are reviewed to ensure that people can access them to call for staff help if they need to. The Manager is also advised to get a copy of the latest infection control guidance to ensure the home is up to date in this area. A permanent solution to the temporary ramp on the first floor should be sought to ensure people with mobility difficulties can access the bathroom. The complaints procedure that is displayed in the hall should be updated wit the reviewed copy so that people know how to contact CSCI if they need to. People living in the home would benefit from more staff obtaining a qualification relevant to their role.

CARE HOMES FOR OLDER PEOPLE Elstree Court Nursing Home 64 Meads Road Eastbourne East Sussex BN20 7QJ Lead Inspector Jo Griffiths Key Unannounced Inspection 27th June 2007 10:45 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 Nursing Home DS0000013982.V340052.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. Elstree Court Nursing Home DS0000013982.V340052.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elstree Court Nursing Home 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 0113 411534 sharmani@bupa.com ANS Home’s 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 Nursing Home DS0000013982.V340052.R01.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 16th October 2006 Brief Description of the Service: Elstree Court is a care home registered to provide nursing care for up to thirtyfour older people that may or may not have some 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-eight single bedrooms, some with ensuite facilities and three double rooms. 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 the people living there, including lifting devices (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 2007 range from £730 - £920 per week dependant on individuals assessed needs. Additional charges are made for hairdressing, chiropody, newspapers and toiletries. Elstree Court Nursing Home DS0000013982.V340052.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and was carried out by Jo Griffiths. A number of methods were used to gather evidence about the quality of the home. This included sending surveys to the people living at the home and their relatives, contacting GPs for their views and a visit to the home on 27th June 2007 between 10.45am and 5.30pm. The Manager also completed the annual quality assurance assessment for the home (AQAA) and sent this to CSCI. The inspector spoke with a number of people living at the home, some relatives and some staff during the visit to the service. What the service does well: What has improved since the last inspection? What they could do better: The care plans could be further improved to ensure that the information about people is easy to access for staff. This should be achieved with the planned Elstree Court Nursing Home DS0000013982.V340052.R01.S.doc Version 5.2 Page 6 introduction of new care plans. It is recommended that the records made daily in the care plan include details of how people spend their time so that staff can easily see that peoples’ social needs are being met. It is recommended that the call bells in the lounge areas are reviewed to ensure that people can access them to call for staff help if they need to. The Manager is also advised to get a copy of the latest infection control guidance to ensure the home is up to date in this area. A permanent solution to the temporary ramp on the first floor should be sought to ensure people with mobility difficulties can access the bathroom. The complaints procedure that is displayed in the hall should be updated wit the reviewed copy so that people know how to contact CSCI if they need to. People living in the home would benefit from more staff obtaining a qualification relevant to their role. 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. Elstree Court Nursing Home DS0000013982.V340052.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 Elstree Court Nursing Home DS0000013982.V340052.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): Standards 1, 3, and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People looking to move to the home are provided with the information they need to make a decision about moving to the home. Individuals have a full assessment of their needs and are only offered a place in the home if their needs can be met. EVIDENCE: The Statement of Purpose is available in the entrance hall of the home and provides people with up to date information about the home and the service it provides. The Service User Guide is provided to each person when they move into the home and gives them key information that they will need during their residence in the home. The Manager, or a nominated senior person, carries out an assessment of each person’s needs before they are offered a place in the home. The assessment Elstree Court Nursing Home DS0000013982.V340052.R01.S.doc Version 5.2 Page 9 documentation covers all the required areas of need and is reviewed regularly to take account of people’s changing needs. BUPA are currently introducing a new format for the assessment of people’s needs that will link clearly to the care plan. Training is planned for all staff in this area within the next few weeks and the new documentation will be completed under guidance of the registered Manager. People spoken with in the home said they felt the service was able to meet their needs and that they were regularly consulted on any changes in their needs. The Manager confirmed that places in the home are offered in writing to people and only where their assessed needs can clearly be met. Elstree Court Nursing Home DS0000013982.V340052.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): Standards 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. People living in the home have a care plan that meets their needs, but will benefit from a review of the format of plans to ensure staff can easily access the information they need. Individuals’ health needs are fully met and they are protected by the home’s procedures for managing their medicines. People living in the home are treated with respect and their right to privacy is maintained. EVIDENCE: Each person living in the care home has a care plan that addresses the needs identified in the assessment. The care plans provide the information that staff need to support the person, but it is not presented in an easy to follow format. To address this BUPA has introduced a new format for assessment and care planning. As described above this will be implemented over the next month. Elstree Court Nursing Home DS0000013982.V340052.R01.S.doc Version 5.2 Page 11 Life mapping has been introduced so that staff have information about events in people’s lives that have been important to them along with information about their cultural needs. Evidence within the care plans showed that people’s healthcare needs are clearly identified and addressed either through nursing care within the home or through consultation with the GP or other specialist. Various health assessments are included within the plan. Individuals are provided with equipment and mattresses to reduce the risk of pressures sores to their skin. The nursing staff manage any incidents of pressure areas effectively and the home prides itself on maintaining people’s skin integrity well. Records within the care plan supported this. People that live in the home told the inspector that the nursing staff respond quickly to any concerns they have and that they can see their GP when they wish to. The nursing staff said that carers are effective in reporting any concerns noted during personal care. All the people living in the home have their medication managed by the nursing staff, although they are offered the opportunity to self medicate if they are assessed as able to do so safely. The medication is stored securely and is only administered by qualified registered nurses. The nurses update their skills and knowledge through annual update courses in medication administration. Records are maintained accurately. Personal care is delivered by care staff that undergo a full induction before they work unsupervised. The induction includes how to manage privacy, dignity and equality issues and how to provide sensitive personal care. It also covers safe moving and handling of people and good practice infection control guidance. Safe moving and handling assessments have been updated for individuals since the last inspection. People spoken with said that the personal care they receive is to a high standard and they do not feel they are rushed in any way. The people living in the home spoke very highly of the care and nursing staff and comments included “I am fully satisfied with the care I receive, but know if I have a problem it will be dealt with” and; “ I cannot speak highly enough of those that take care of me.” Elstree Court Nursing Home DS0000013982.V340052.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home are provided with a range of activities each week that they can choose to participate in. They can receive visitors when they wish and in private. Individuals are supported to make their own decisions and these are respected. People in the home enjoy a choice of meals and a nutritionally balanced diet. Mealtimes are enjoyable and relaxed. EVIDENCE: The home provides a range of activities through the week that people can choose to join in. A programme of activities is displayed for the forthcoming week on the residents’ notice board. Weekends are generally kept free as most people receive visitors at weekends. Elstree Court Nursing Home DS0000013982.V340052.R01.S.doc Version 5.2 Page 13 Recently the activity coordinator for the home has left and a new person has been recruited to the role and was undertaking her induction at the time of the visit. The Manager stated that, due to the changes, the activity programme has not been as full as usual over the last few weeks. However, it was noted that the staff and Manager have made great efforts to maintain a basic programme of activities to keep people occupied during the day. The usual activities programme was discussed. This includes Games, Bingo, 11 time, reading, music, Films, outings fortnightly including trips to the pub, theatre and shows. The Manager said that the activity programme is being reinstated in full within the next few weeks. People spoken with said that they enjoy the activities and feel that there is plenty to keep them occupied during the day. They also confirmed that they are consulted on the types of activities they would like to see in the home. An activities committee has been formed recently and includes representatives from the people that live in the home, staff and relatives. The first meeting is scheduled for July 2007. In addition to the standard programme of daily activities a “Mediterranean Cruise” has been planned. This is an in house activity that takes place across six weeks and is based on the activities of a cruise ship. Each week the home is decorated to represent a different country and activities, meals and costume are provided throughout the week. For example, one week is Barcelona with Spanish meals, Sangria, Spanish lessons, dancing and costume. The “Cruise” finishes at week six with the “Ships ball” and dinner at the captain’s table. This is an excellent example of an activity that has been carefully planned to meet the needs of the people living in the home. The staff are very enthusiastic about the activity and everyone in the home is looking forward to it. The activity coordinator holds a record of activities that are provided in the home. It is recommended that each individual’s daily notes also include reference to how people have been occupied during the day. This should also include a record of any informal activities that care staff carry out with people, for example reading to them or taking time to sit and chat. This gives a holistic picture of how their social needs are being met within the care plan. Visitors are welcome at anytime and during the day a number of visitors were seen in the home. Some were asked their views of the home and the feedback was very positive about the standard of care provided. People commented on how they are always made to feel very welcome when they visit. People living in the home were seen to be offered choices throughout the day, for example meals, drinks, where they would like to spend their time and what activities they would like to do. Those spoken with said that they can generally get up and go to bed when they wish to, but said that staff are very busy so there are some limitations to this choice if they require lots of support with their personal care or mobility. Everyone spoken with confirmed that the staff listen to them and respect their decisions. Elstree Court Nursing Home DS0000013982.V340052.R01.S.doc Version 5.2 Page 14 Since the last inspection the meals in the home have greatly improved. All people spoken with, including relatives and staff, confirmed this. People can choose where they wish to eat their meals. There is a small dining room and the Manager stated that extra dining tables could be made available if more people in the home wished to use the dining room. The Chef Manager spent time with the inspector explaining how the menus are planned and choices are given. A system called Menu Manager is used to ensure that the planned 4-weekly menu is nutritionally balanced. Specialist diets are catered for as needed and examples were given. The home cannot however cater for anyone requiring a Kosher diet, as the facilities required are not available. They would be made aware of this at the point of referral. Individuals are given a choice of two meals at each mealtime and are made aware of other alternatives that are available should they not want the menu choices. Extra care is now being taken with the presentation of meals. Staff and people living in the home confirmed that they had noticed this. The meals seen to be served in the home looked appetising and well presented. The Chef Manager regularly visits people to ask for their views of the food and feedback forms are sent out every two weeks to get peoples views on the quality of meals. The Chef Manager was able to describe action that had been taken in response to this feedback. The Chef Manager is completing a learning course on nutrition. There is a team of chefs and kitchen assistants that ensure that all mealtimes are covered. During the night a “nite bite” system is in place to allow people to order any snacks they would like after the chefs finish for the day. Jugs of water and juice were seen in each lounge for people to help themselves to. Elstree Court Nursing Home DS0000013982.V340052.R01.S.doc Version 5.2 Page 15 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): Standards 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home know how to make a complaint if they need to and know they will be taken seriously. They are protected from harm and abuse. EVIDENCE: The home has a clear complaints procedure that is included within the Service User Guide and displayed on the notice board. The Manager was advised that the procedure must be updated to reflect the change of contact details for CSCI so that people can contact CSCI if they have any concerns they do not feel can be dealt with through the complaints procedure. The complaints log was viewed and it was found that any concerns or complaints had been recorded appropriately and dealt with quickly by the Manager to ensure the satisfaction of people living in the home. Those spoken with said that they knew who to talk to if they had any concerns and felt that the staff and Manager listen to them and take their concerns seriously. All staff have undertaken training in safeguarding adults and are made aware of the policy for safeguarding adults and the whistle blowing policy through their induction. All staff have a CRB check and are not allowed to work unsupervised in the home until this is received. Elstree Court Nursing Home DS0000013982.V340052.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 20, 22, 23 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment of the care home meets the needs of the people living there and is safe, clean, comfortable and homely. EVIDENCE: The home is clean and well maintained. There are 28 single bedrooms and 3 shared rooms. Those that are in a shared room have chosen to share and this has been recorded. There are three lounge areas and a dining room on the ground floor. These provide comfortable seating, television and radio or a space to relax quietly. Activities are held in the main lounge during the day. Call bells are situated in each person’s room and these were seen to have been placed within their reach whilst they were sitting in armchairs. The call bells are not as easily accessible in the lounge areas and would benefit from a Elstree Court Nursing Home DS0000013982.V340052.R01.S.doc Version 5.2 Page 17 review to ensure that people could reach a call point if they had mobility difficulties. However, it was noted that there are usually staff around on the ground floor at most times of the day. People living in the home said that staff responded quickly to the call bells. All areas of the home are accessible to the people living there with the provision of a lift to the first and second floors. However, one of the ramps that is situated on the first floor is only temporary and has to be erected every time a person who uses a wheelchair wishes to access the bathroom. A permanent solution should be sought. The home was clean and hygienic and appeared comfortable and homely for people to live in. Those spoken with said they were happy with the facilities available and that their own rooms met their needs. Elstree Court Nursing Home DS0000013982.V340052.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living in the home are supported by sufficient numbers of trained staff and qualified nurses to meet their needs. They would benefit from more care staff achieving the NVQ award. People living in the home are safeguarded by the home’s recruitment procedures. EVIDENCE: Feedback from people living at the home confirmed that they ere very happy with the care they receive from the nursing staff and the carers. Comments included “They treat you right” and “ The carers are so lovely, X is one of my favourites as she always takes time to have a chat even though I know she is very busy” The rotas show that there are sufficient numbers of staff on duty to meet the needs of the people that use the service. Discussion with staff and people living at the home confirmed that this is the case, although it was noted that Elstree Court Nursing Home DS0000013982.V340052.R01.S.doc Version 5.2 Page 19 some days can be busier that others depending on peoples needs. In addition to the nursing and care staff there is a kitchen team, domestic staff and administration staff. The Manager works in the home in addition to the staff numbers. Nursing staff are on duty at all times in the home and are supported by a team of carers. Recruitment files were checked for new staff and evidenced that robust procedures had been followed for recruiting new staff. This included a CRB check, two written references, confirmation of identification and evidence of qualifications. This ensures the continued protection of people living in the home. The training programme that is provided to all staff begins with their skills for care induction. This includes the basic training they need to undertake the role, for example health and safety, moving and handling, infection control and safeguarding adults. Other training courses are then booked by the Manager and provided by BUPA. The Manager monitors the training needs of all staff and ensures they are kept up to date. The nursing staff provide evidence of their registration status upon appointment and this is updated as it is renewed. Nurses also undertake training with the company to ensure their skills and knowledge is kept up to date. The training programme that is provided to BUPA staff is excellent at this home. Information received from the Manager confirmed that 25 of the care staff hold an NVQ. Four more staff have been registered to begin the award and it is planned that more staff will be undertaking their NVQ next year. Elstree Court Nursing Home DS0000013982.V340052.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a home that is run effectively by a qualified and experienced Manager. They are consulted on their views of the home at regular intervals. People in the home have their health, welfare and financial interest guarded. EVIDENCE: There has been no change to the Registered Manager of the home. The Manager is a registered nurse and has completed the NVQ4 in Management since the last inspection. The Manager has ensured that the requirements made following the last inspection have been implemented. Elstree Court Nursing Home DS0000013982.V340052.R01.S.doc Version 5.2 Page 21 BUPA carries out an annual quality survey of all its customers and has recently set up its own quality team to carry out audits of homes. The Manager of Elstree Court also monitors the quality of the service on a daily basis by sampling records, talking to people that live in the home and talking to staff. Surveys are used within the home to monitor different areas of the service, including meals, laundry and cleaning. The Manager was able to evidence how action had been taken to address issues that were raised in these surveys. Most people living at the home ask the home to retain some spending money on their behalf for safekeeping. The records of this were seen and receipts are provided to each person or their relative each month. Safe lockable facilities are provided in each person’s room if they wish to store personal items. There were no health and safety concerns noted during this inspection. Upgrades to the fire system have been completed and the fire officer is due to visit to confirm completion. Risk assessments are in place for individuals and for the general areas of the home. The Manager was advised to obtain a copy of the new Department of Health infection control guidelines to assess the home. Staff are trained in health and safety matters and the Manager monitors the environment of the home at least weekly. A maintenance man is employed to carry out any minor repairs and decorating. Elstree Court Nursing Home DS0000013982.V340052.R01.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 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 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 2 17 X 18 3 3 3 X 2 3 X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Elstree Court Nursing Home DS0000013982.V340052.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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 Home’s 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. 1 2 Refer to Standard OP7 OP12 Good Practice Recommendations It is recommended that the new system of care planning be implemented for all people in the home as proposed. It is recommended that the care plan records include details of the activities that people undertake during the day and includes any informal activities that care staff carry out with people. This will give a clear holistic view of how their social needs are being met. It is recommended that the copy of the complaints procedure that is displayed in the hall should be replaced with the updated version. It is recommended that the call bell system in communal areas be reviewed to ensure that the people living in the home are able to access it to call for help when staff are not in the near vicinity. DS0000013982.V340052.R01.S.doc Version 5.2 Page 24 3 OP16 4 OP22 Elstree Court Nursing Home 5 OP22 It is recommended that a permanent ramp be fitted to the steps by the upstairs bathroom to allow people with mobility difficulties independent access. It is recommended that at least 50 of care staff on duty hold an NVQ award. It is recommended that the Manager obtain a copy of the Department of Health essential steps to managing infection control document to assess the compliance of the home. 6 7 OP28 OP38 Elstree Court Nursing Home DS0000013982.V340052.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Maidstone Local 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 Elstree Court Nursing Home DS0000013982.V340052.R01.S.doc Version 5.2 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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