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Inspection on 30/11/05 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 30th November 2005.

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

The inspector 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 comprehensive Statement of Purpose and Service Users Guide give prospective service users the information required enabling them to make an informed choice about where they live. The atmosphere of the home was relaxed and staff treated service users with respect and consideration. Service users are encouraged to treat Elstree Court as their home. There is a stable staff team who provide a consistent level of care. The staff were approachable, friendly and professional and were observed to interact well with the service users. Complaints are handled satisfactorily and follow the guidelines set by the organisation

What has improved since the last inspection?

Good practice was observed in the moving and handling of service users during the inspection. Care plans in respect of activities have improved, but still need to be developed further. There is a registered manager in post, who is competent and knowledgeable.

What the care home could do better:

Care plans need to be further developed in respect of their social and recreational needs. This will ensure that all service users 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. The quality of food at Elstree Court has deteriorated over the past month, this was acknowledged in a follow up conversation with the registered manager. The meals provided need to be reviewed and an agency chef brought in whilst interviewing and filling the post of second chef. At present existing staff employed in the home are covering the hours.

CARE HOMES FOR OLDER PEOPLE Elstree Court 64 Meads Road Eastbourne East Sussex BN20 7QJ Lead Inspector Debbie Calveley Unannounced Inspection 30th November 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Elstree Court DS0000013982.V249460.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Elstree Court DS0000013982.V249460.R01.S.doc Version 5.0 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 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.V249460.R01.S.doc Version 5.0 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 25 May 2005 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 BUPA Health Care, 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. The home have adequate assisted bathing facilities for the needs of the service users. 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 DS0000013982.V249460.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 30 November 2005. It commenced at 10.00am and was conducted over six hours. There were twenty-five service users 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 seven service users and informal interviews with eight service users, two relatives and five members of staff. What the service does well: What has improved since the last inspection? What they could do better: Care plans need to be further developed in respect of their social and recreational needs. This will ensure that all service users are stimulated and enabled to live a full and satisfying life. Elstree Court DS0000013982.V249460.R01.S.doc Version 5.0 Page 6 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. The quality of food at Elstree Court has deteriorated over the past month, this was acknowledged in a follow up conversation with the registered manager. The meals provided need to be reviewed and an agency chef brought in whilst interviewing and filling the post of second chef. At present existing staff employed in the home are covering the hours. 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.V249460.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Elstree Court DS0000013982.V249460.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. The comprehensive Statement of Purpose and Service Users Guide give prospective service users the information required, enabling them to make an informed choice about where they live. A contract/ statement of terms and conditions is given to all service users on admission to Elstree Court, so service users are aware of the conditions agreed. A pre-admission assessment is performed on all prospective service users 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. There is obviously a need to update the document with information regarding the change of ownership. Elstree Court DS0000013982.V249460.R01.S.doc Version 5.0 Page 9 There is a written contract/ statement of terms and conditions that all service users receive on admission to the home. Seven pre-admission assessments were viewed whilst case tracking, and the pre-admission assessment document was found completed and informative. There is an assessment tool, which covers all the needs as defined in standard 3.3. The management team endeavour to involve the prospective service user’s relatives whenever possible. The assessment takes place at the service users’ place of residence, and input from other relevant professionals is sought when required. One service user said they remembered someone from the home coming to see them before they left hospital. A further two service users had lived in the flats adjoining the care home, so were knowledgeable of the home and staff before admission. As previously mentioned pre-admission assessment identifies any specific needs of the prospective service user and this informs the admission process. These can then be discussed with the service user 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 service users can visit the home to meet the service users, to look at rooms that are available and the facilities provided before they make any decision regarding accepting a place. One of the service users mentioned that she had known four other service users that had come to live at Elstree Court and that had been the main reason why she had chosen to live at the home. 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. Three service users confirmed that they had visited the home prior to admission. One service user had no recollection of visiting the home but said her family had chosen the home. Elstree Court DS0000013982.V249460.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Service users benefit from a comprehensive care planning system that guides staff in all aspects of personal and health care and all risks are identified and planned for. However social and recreational care plans need to be extended to ensure positive outcomes. There has been a decline in the medication administration documentation and practice since the last inspection, putting service users at risk. The service users are treated with respect and courtesy in all aspects of their care. EVIDENCE: The care plans of seven service users 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. The reviews of some care plans were slightly behind the review date. Risk assessments were in place and were found to be up to date and relevant to the specific needs of the service users. Elstree Court DS0000013982.V249460.R01.S.doc Version 5.0 Page 11 It was identified in interviews with service users that they felt that their needs were met health wise, but that “staff were too busy to stay and chat”. One service user mentioned that the “staff were lovely but only had time to do the necessary”. The care plans viewed did not show how their social and recreational needs are being met, and this is an area that was previously identified that needs to be developed within the home. There is evidence of service user/representative consultation in individual plans. Two service users said that they did get to talk with the nurses regarding their care, whilst four were not aware of any such involvement. Service users 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. 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. 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. Medications brought forward by nurses also need signing and dating. The staff were seen throughout the inspection treating service users with respect and dignity. The service users were complimentary in the main regarding the staff at Elstree Court. One service user said “they look after me alright, but they are too busy” “I don’t go out of my room much now as staff do not always have the time to take me back to my room, when I want to go back”. Elstree Court DS0000013982.V249460.R01.S.doc Version 5.0 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. Service users would benefit from a daily programme of activities based on their preferences. Visitors are welcome to the home at all reasonable times to ensure service users maintain links with family and friends. Service users are encouraged to exercise choice over their daily lives. EVIDENCE: The activity co-ordinator works four hours a day, five days a week. Some of the time allocated is used to prepare the programme of activities which impacts on one to one sessions. Service users mentioned outings; some that had been enjoyed and some that had proved disappointing. One service user mentioned that she used to go to the bingo sessions, but they were cancelled as many of the service users fell asleep. Individual shopping trips are arranged and are enjoyed by the more able service users. However, a planned programme of activities based on the service users preferences needs to be created and implemented. This would ensure service users are given the opportunity to continue with past hobbies and pastimes. Service users social and leisure interests need to be recorded in both pre-admission documents and in care plans. The activities for the day of the inspection was nails at 11.00 am Elstree Court DS0000013982.V249460.R01.S.doc Version 5.0 Page 13 and hairdresser at 1.30 pm, at 3pm some service users were still waiting for the hairdresser and when asked what was happening, the staff realised the hairdresser had not turned up. The activities were also targeted just for the women and nothing for the men. On the day of the inspection most service users remained in their rooms while five sat in the lounge. Service users said there was often not much to do, but also said it was due to not enough people wanting to do things. During this inspection only six service users were seen in the communal areas, five service users visited in their bedroom said that this was their preference, but it was not clear as to why other service users remained in their rooms for lunch. The dining room was not used by anyone. This needs to be incorporated into the social care plan to encourage interaction and stimulation and prevent service users becoming isolated. The midday meal was observed and the menu offered braised steak followed by apple charlotte, an alternative was available. The evening meal was to be soup followed by salad or sandwiches and yogurts. The kitchen was seen and was found to be clean however some equipment was seen to be broken. The feedback from service users concerning the food raised issues in that the quality of food was said to have deteriorated over the past month, this it was said to be due to the fact that one of main chefs had left, and different staff members were cooking. One service user said, “the food was often cold, and that it was not attractively presented”, another said the “food was not as good as it used to be” Two service users were seen to have left most of their lunch and when asked why, said, “the meat was very tough and stringy”. Two other service users also said that they felt that the food had deteriorated and that they had had a lot of different cooks lately. A service user audit has been recently performed, but was not available to view at this time as the manager was off duty. This is an area that needs investigating by the management as to why the food is not meeting the expectations of the service users and an action plan devised as to how to raise the standard of food. Elstree Court DS0000013982.V249460.R01.S.doc Version 5.0 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 The complaint procedure is clearly detailed in the Statement of Purpose and Services Users guide and is available to service users and their families. Staff demonstrated a good understanding and knowledge of Adult Protection policies and procedures, which protect the service users from harm and abuse. EVIDENCE: There are appropriate policies and procedures in place and it was confirmed that these are followed when investigating any concerns raised at the home. The staff interviewed, were knowledgeable of the complaint procedure and of how to start the process if the manager is not available. The complaint book was viewed during the inspection and showed the details of investigation, outcome and action taken. Three of the service users referred to the Service Users Guide when asked if they knew how to make a complaint, whilst one service user said, “she didn’t know of a proper procedure, but would go the senior nurse and that it would be dealt with”. Two relatives said that if they did have a complaint they would go straight to the manager, they have found her approachable and always takes their concerns seriously. There have been no complaints received by the CSCI. 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 Elstree Court DS0000013982.V249460.R01.S.doc Version 5.0 Page 15 vulnerable service users. There is on-going training for all staff in Adult Protection. Elstree Court DS0000013982.V249460.R01.S.doc Version 5.0 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 the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. The home provides a comfortable, clean and safe environment for those living there and those visiting. Service users are enabled and encouraged to personalise their room, and rooms are homely and reflect the service user’s personalities and interests. There is specialist equipment in the home for service users’ use to maximise their independence. EVIDENCE: Elstree court is well maintained and provides a safe environment for the service users. The communal areas are pleasant and comfortable with good quality furniture. A few maintenance shortfalls were found and fed back to the nurse in charge as an immediate requirement. The lounge areas were seen to be less cluttered and provide a comfortable place to sit. As previously mentioned, the lounge and dining areas were seen Elstree Court DS0000013982.V249460.R01.S.doc Version 5.0 Page 17 to be underused and it would be beneficial for the service user’s long term social needs if they are actively encouraged to mix with each other at certain times of the day. The garden areas are well tended and accessible for all service users. The home has the specialist equipment necessary to maximise service users, independence. The hoists were clean and in good working order and there were a sufficient number for the needs of the service users, which was endorsed by the staff. Grab rails are in place and call bells are provided in all rooms used by service users. The feedback from service users regarding the response to call bells remains unchanged from the previous inspection, two service users said they often had to wait for the call bell to be answered, especially after meals, whilst three 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 busy that it was difficult to answer call bells promptly, but they felt that they usually managed well. There are adequate communal bathing facilities and toilets for the needs of the service users, hot water temperatures were randomly tested and were of the required temperature, regular testing is performed by the maintenance person. All bedrooms have domestic lighting, but some rooms were found with naked bulbs, which impacts on the homeliness of the home. The majority of service users’ bedrooms had been personalised and were seen to be homely and comfortable. Three service users 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 service users. The home was in the main clean and tidy and had no unpleasant odours. The sluices were clean. 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. New policies are in the process of being introduced by the new organisation; these will be viewed at the next inspection. Some carpets were seen to be badly stained and need deep cleaning and the mechanical beds were dusty/dirty and in need of attention. Elstree Court DS0000013982.V249460.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27. The staffing levels in place on the day of the unannounced inspection were adequate to meet the assessed needs of the service users. EVIDENCE: The staffing for the morning shift comprised of two trained nurses and five carers staff on duty for twenty-five service users, in the afternoon there was four carers and one trained nurse. This was adequate to meet the needs of the service user on the day of the inspection, however from the feedback from service users indicated that this is not always the case and it is asked that staffing levels are reviewed on a regular basis to allow flexibility of staffing levels to meet the fluctuating needs of the service users. Elstree Court DS0000013982.V249460.R01.S.doc Version 5.0 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): 33, 35 and 38. The ethos of the home is open and transparent enabling service users to participate in the running of the home, should they wish to. All aspects of service user’s health, safety and welfare are protected and promoted. EVIDENCE: The atmosphere of the home on this unannounced inspection was positive, calm and inclusive. The staff were observed doing their work competently and showing respect to their colleagues and the service users. The service users and relatives spoken with were in the main appreciative of the manager and her care staff. Regular staff meetings and supervision sessions encourage the staff to communicate their views and if appropriate act on them. Relative and service Elstree Court DS0000013982.V249460.R01.S.doc Version 5.0 Page 20 user meetings are held regularly and are well attended and beneficial. The records were available for viewing. Handover sessions at every shift are greatly valued by the staff and enable staff to be brought up to date on any changes or problems. The formal quality assurance and quality monitoring systems in place enable the provider to critically evaluate the service and ensure it is run in service user’s best interests. There are suitable systems in place to safeguard the service user’s finances. The administrator works full time in the home and is knowledgeable regarding the service users financial status and endeavours to ensure that the policies and procedures in place are adhered to. Policies and procedures regarding gifts and money rewards have all been issued to staff. The staff confirmed that they 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 the manager kept them up to date with changes to policies in connection with their job description. The staff are issued with certificates after attending the courses, 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 and as previously mentioned will be updated by BUPA. All relevant legislation and procedures are in place in respect of Health and safety. However staff need to ensure that all wheelchairs are used with the appropriate foot rests in place when transferring service users. The lighting on the stairs needs to be working at all times to protect the safety of service users, staff and visitors to the home. Elstree Court DS0000013982.V249460.R01.S.doc Version 5.0 Page 21 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 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X 3 X X 2 Elstree Court DS0000013982.V249460.R01.S.doc Version 5.0 Page 22 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 Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP7 OP9 Regulation 15(1) Requirement Timescale for action 01/02/06 01/01/06 3 OP12 4 OP15 5 OP26 6 7 OP38 OP38 That social and recreational care plans are developed.( previous timescale of 31/8/05 not met.) 13(2) Medication administration record charts must reflect current medication profile and must be a true and accurate record.(Previous timescale of 25/5/06 not met.) 16(2) That an activity programme is devised to ensure all service users social needs are met.(Previous timescale of 31/08/05 not met.) 16(2)(i)12 That the quality and appearance (1)(2)(3) of the food offered to service users is reviewed to ensure that it meets the service users expectations and needs. 13(3) That all areas of the home are kept clean and hygenic, in particular the carpets in bedrooms and the mechanical beds. 23(2)(4) That footrests are in place on wheelchairs when in use to prevent injury to service users. 23(2) That the lighting in the home is in working order. DS0000013982.V249460.R01.S.doc 01/02/06 01/02/06 30/11/05 30/11/05 30/11/05 Elstree Court Version 5.0 Page 23 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.V249460.R01.S.doc Version 5.0 Page 24 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. Extracts may not be used or reproduced without the express permission of CSCI Elstree Court DS0000013982.V249460.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!