Inspection on 17/05/05 for Eltandia Hall Care Centre

This inspection was carried out on 17th May 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Eltandia Hall Care Centre 14/12/09

Eltandia Hall Care Centre 22/04/09

Eltandia Hall Care Centre 29/04/08

Eltandia Hall Care Centre 25/09/07

Eltandia Hall Care Centre 18/10/06

Eltandia Hall Care Centre 19/10/05

Eltandia Hall Care Centre 25/11/04

Eltandia Hall Care Centre 09/06/04

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Eltandia Hall Care Centre Middle Way Norbury London SW16 4HA Lead Inspector Liz OReilly 17 and 19 th th Announced May 2005 10:00 am 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 and Care Homes for Adults 18 – 65*. 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. Eltandia Hall Care Centre G54-G04 S19089 Eltandia V221633 170505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Eltandia Hall Care Centre Address Middle Way Norbury London SW16 4HA 020 8765 1380 020 8765 1399 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) Lifestyle Care PLC Connie Baker CRH Care Home 83 Category(ies) of OP Old age (63) registration, with number PD Physical Disability (20) of places DE (E) Dementia - Over 65 (63) Eltandia Hall Care Centre G54-G04 S19089 Eltandia V221633 170505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th November 2005 Brief Description of the Service: Eltandia Hall Care Centre is a purpose built home arranged over two floors with two residential units on the first floor and two units offering nursing care on the ground floor. The residential units comprise of one unit providing respite care for older people and one unit providing long term care for older people with dementia. One nursing unit offers long term care for older people. The second nursing unit provides care for younger adults with physical disabilities. All residents are provided with their own single bedroom accomodation with en suite toilet facilities. The home is situated in a residential area of Mitcham. Public transport in the form of local bus services are close by. Parking is available within the grounds. Eltandia Hall Care Centre G54-G04 S19089 Eltandia V221633 170505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was carried out by two regulation inspectors on 17th and 19th May 2005 over twelve hours. During the course of these visits the inspectors had the opportunity to speak with nine residents, six staff, two visitors to the home and the registered manager. This inspection focused on the nursing units of the home. What the service does well: What has improved since the last inspection? What they could do better: The home could improve the social care provided to residents through more person centred care planning and an expansion of the keyworker role. More regular access to an appropriate vehicle would offer more opportunities for residents to participate in community and social activities. The provision of ongoing more in depth training on dementia care would provide staff with a broader knowledge and understanding of the difficulties Eltandia Hall Care Centre G54-G04 S19089 Eltandia V221633 170505 Stage 4.doc Version 1.30 Page 6 people with dementia face in their day to day lives and how they can assist individual residents. Consideration should be given to introducing life story work which may allow residents and in some instances their families, the opportunity to share their life experiences with staff who will gain a greater understanding of individual residents. Staff felt that the introduction of regular relatives meetings on the older peoples units of the home would be of benefit in further improving communication between the home and families. Consideration should be given to improving the opportunities for residents to be involved and influencing the way in which the service is delivered. 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. Eltandia Hall Care Centre G54-G04 S19089 Eltandia V221633 170505 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Standards Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6-10 and 18–21) (Standards 11–17) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37–43) Eltandia Hall Care Centre G54-G04 S19089 Eltandia V221633 170505 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. 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. Prospective service users have an opportunity to “test drive” the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 and 3 Delays in the production of a local authority contract/statement of terms and conditions means the home is not able to provide a contract to the majority of people moving into the home. Residents and their families do not therefore have access to information on the arrangements made on their behalf. Staff take care to ensure they understand and can meet the needs of each person before they move into the home. EVIDENCE: The home is unable to provide an up to date contract/statement of terms and conditions to those people who have moved into the home via the local authority in this area. The local authority stopped issuing contracts and is in the process of designing a new contract. Once this is completed the manager should send a copy to the Commission. Eltandia Hall Care Centre G54-G04 S19089 Eltandia V221633 170505 Stage 4.doc Version 1.30 Page 9 Before anyone moves into the home, if they are placed via a local authority, an assessment of each persons needs is carried out by staff from social services. Staff in the home also carry out an assessment to ensure that they are able to offer the support the person needs. The assessments seen were comprehensive and provided good information on the needs of the person moving in. Eltandia Hall Care Centre G54-G04 S19089 Eltandia V221633 170505 Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6-10 and 18 –21 (Adults 18-65) 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. Including their physical and emotional health needs. 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. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. Service users receive personal support in the way they prefer and require. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 7, 9, 18, 19 and 20 (Adults 18-65) are 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 and 10 (older people). Standards 6, 7, 18 and 20 (younger adults) Staff are making good progress in continuing to developing the care plans to take into account the wishes of individuals. Further information regarding the social and emotional needs of residents must be included in the care plan to ensure that these are fully addressed. The health care needs of residents are met. The health and welfare of residents is protected by well managed medication procedures. The privacy and dignity of residents was seen to be generally met. Eltandia Hall Care Centre G54-G04 S19089 Eltandia V221633 170505 Stage 4.doc Version 1.30 Page 11 EVIDENCE: The standard of care planning has improved since the last inspection of the home. Care plans provide good details for staff, particularly the personal care and nursing needs of residents. Good information was available to staff on supporting individual people with dementia and with hallucinations. Staff have made some progress in including the individual interests and preferences in care plans. Staff should ensure that where problems arise with one area of care action is taken to review the care plan. Within the younger persons unit it is not necessary to carry out monthly reviews of the care plan. Reviews should be carried out six monthly or more frequently if required. Keyworkers should ensure that all those whom the resident wishes to be invited are informed of the details. Staff were observed to discuss the care planning with one relative of a newly admitted resident in the main lounge. Staff should consider making formal arrangements to meet with residents representatives to explain and go through the care plan in a more private area. Where residents needs have changed and developed the care plan should be reviewed so that the same aims which have already been achieved are not repeated. The strengths and needs of individuals in relation to their social and emotional life were not addressed or documented with the same detail. Keyworkers in the younger persons unit have been working on development plans but these are stored separately from the main care plan. The development and care plans should form one document. In order to further develop the care plans to provide a full picture of the strengths, needs and wishes of each person consideration should be given to keyworkers developing life story work with the older people on the units. Consideration should be given to developing the keyworker system. All grades of staff should be provided with training on effective keyworking which would benefit residents who would receive a more personal service from their keyworker. In order to move away from care focused mainly on the nursing needs of residents consideration should be given to keyworkers being allocated from the whole staff group including qualified staff. Staff should be provided with training on person centred planning. Arrangements are in place for all residents to be registered with a GP. Staff consult with other professionals on wound care, continence and mental health problems. Good records are kept on wound care. Arrangements are in place for residents to have regular eye tests, dental check ups and chiropody. Eltandia Hall Care Centre G54-G04 S19089 Eltandia V221633 170505 Stage 4.doc Version 1.30 Page 12 On the older persons nursing unit only one hoist is available. This was seen to be used on a very regular basis. An assessment of the needs of residents on this unit must be carried out to ensure that this equipment is sufficient and of an appropriate type for all residents who need to be assisted with a hoist. Action must be taken to ensure that all residents throughout the home are assessed for wheelchairs or walking aids if appropriate. Medication records are well maintained. Records were up to date. Medication was stored, administered and managed in a manner which protects the health, safety and welfare of residents. Generally staff were seen to take care to respect the privacy and dignity of each resident. On the younger persons unit staff were seen to sit on high stools while assisting residents to eat. This does not respect the dignity of residents and alternative chairs must be provided of the same height as those used by residents. Eltandia Hall Care Centre G54-G04 S19089 Eltandia V221633 170505 Stage 4.doc Version 1.30 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 11 – 17 (Adults 18-65) are: 12. 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. Including opportunities for personal development. Service users engage in appropriate leisure activities. Service users maintain contact with family/ friends/ representatives and the local community as they wish. And have appropriate personal, family and sexual relationships. 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. 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15, 16 and 17 (Adults 18-65) the 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 (older people). Standards 12, 14, 15 and 17 (younger adults). Further development work needs to be undertaken in order to fully meet the social and recreational interests and wishes of residents. Information on how the spiritual and or religious needs of residents will be met needs to be available. The policy on intimate personal relationships gives insufficient guidance and information to staff in order to protect individual rights. A varied menu is available but in order to meet the cultural and religious needs of residents further choices need to be available to residents on a daily basis. EVIDENCE: The home has one full time activities organiser who impressed as being committed to developing the activities on offer in house and outside the home. Eltandia Hall Care Centre G54-G04 S19089 Eltandia V221633 170505 Stage 4.doc Version 1.30 Page 14 They are in the process of recruiting a second person for this role. An activities programme is produced. The home has a sensory/relaxation room and a separate activities room. The social needs and preferences of individual residents is one area which should be further developed. Staff must ensure that the religious and spiritual needs and wishes of residents are recorded along with information on how these needs will be met. Comments made by residents and staff suggest that the lack of regular access to an appropriate vehicle restricts residents from engaging in individual and group activities. The home has access to a small mini bus once a week. Given the number of residents in this home a very small percentage of residents can use this on a weekly basis. The home has made efforts to use other community transport but this has proved unworkable in many instances. Residents said they enjoyed going out for pub lunches, shopping and trips to London and local parks. Action must be taken to ensure that residents have access to suitable transport to meet their social and educational needs. Staff have organised and joined in celebrations for St Georges’ Day, VE Day anniversary, pancake day, Easter, and St Patrick’s Day. The activities organiser was in the process of arranging college courses for two of the residents. The record of activities for one person indicated that other than watching TV or listening to the radio this person had no other activities between January 2005 and May 2005. There was no record that this person had left the home at all during this time. Action must be taken to review the activities available to each individual person. The development of the keyworker system would support residents in ensuring individual activities and interests were met. Consideration should be given to activities organisers supporting and advising keyworkers to enable them to meet individual needs. A newsletter is produced by the home. Consideration should be given to involving residents in the production of the newsletter. Residents are encouraged to handle their own money for as long as they are able and wish to do so. Residents are encouraged to personalise their own room and are free to bring to the home items of their own furniture. Residents are free to redecorate their room and or choose the colours. In order to ensure a balance between the safety of residents and their right to freedom of movement here the code for exiting the unit has been withheld Eltandia Hall Care Centre G54-G04 S19089 Eltandia V221633 170505 Stage 4.doc Version 1.30 Page 15 from a resident this is recorded and staff are making progress in ensuring that all those involved in this decision sign an appropriate document. The home’s policy on intimate personal relationships provides insufficient information to safeguard the rights of residents and must be reviewed. Staff must be provided with clear guidance and if necessary training on sexuality and relationships in relation to all resident groups. Resident described the food in the home as “very good”, “ok”, “lovely” and “it has got better, these is more choice”. Residents who were not able to comment were seen to eat well. One resident stated they enjoyed the afro Caribbean food provided by the home but would prefer this to be available more often. Staff must ensure that an appropriate menu with alternatives is available to meet the social, cultural or religious needs and wishes of residents. The food was attractively presented and staff were seen to check that residents were happy with their meal. Other things were offered if residents did not appear to be enjoying the food. Staff worked well in the older persons unit to ensure that all resident who needed help with eating received their meal in good time. Staff sat with residents when assisting people. As noted previously the seating in the younger persons unit was too high for assisting people. Staff said they “occasionally had sandwiches” for residents in the evenings. Care must be taken to ensure that a snack is offered to all residents in the evening to ensure that the gap between the last meal or snack of the day and breakfast is no more than twelve hours. On the older persons unit it was noted that no salt, pepper or other condiments were made available on the dining table at lunchtime. This would indicate that residents are restricted in the choices available to them. Action must be taken to ensure these are made available at each meal time. Eltandia Hall Care Centre G54-G04 S19089 Eltandia V221633 170505 Stage 4.doc Version 1.30 Page 16 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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. Including neglect and selfharm. The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 (older people) 22 and 23 (younger adults) Complaints were seen to be well handled and investigated. The home is making progress to ensure all staff will have completed training on the protection of vulnerable adults in the near future which is a key indicator that service users are protected from abuse. EVIDENCE: The home has a clear complaints procedure which is issued to all residents and is available on display in the home. The records showed that the management of the home take complaints seriously, carry out a full investigation and make changes in the home if needed. At the time of this visit the manager was in the process of investigating one complaint. This had been discussed with social services. Procedures are also in place for dealing with allegations of abuse. Not all staff in the home have received training in this area. The manager said this was being arranged. In order to increase the protection of residents the registered persons must ensure that everyone who works in the home has training on recognising abuse and what action they should take. Eltandia Hall Care Centre G54-G04 S19089 Eltandia V221633 170505 Stage 4.doc Version 1.30 Page 17 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) 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. Shared spaces complement and supplement service users’ individual rooms. Service users have sufficient and suitable lavatories and washing facilities. Provide sufficient privacy and meet their individual needs. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. And lifestyles. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 25 and 26 (older people). Standards 24 and 30 (younger adults). The home is well maintained and provides a comfortable environment for residents. Consideration is being given to improving the kitchen facilities within the younger adults unit to enable more independence. As noted in previous inspection reports residents are not provided with access to a telephone where they can make and receive calls in private. EVIDENCE: The home is well maintained. Grounds are well looked after, neat and tidy. As noted in previous inspection reports access to the garden area from residents rooms on the ground floor could be better for those residents who use a wheelchair or mobility aid. In previous inspection reports it was recommended that the kitchen area in the younger persons unit be extended to allow the option of more Eltandia Hall Care Centre G54-G04 S19089 Eltandia V221633 170505 Stage 4.doc Version 1.30 Page 18 independence for residents in assisting with or making their own meals and snacks. The manager stated that an area of the home adjacent to this unit and not in use at present was being considered for this purpose. The home has a central laundry area on the top floor of the home. The laundry equipment available and the manner in which laundry is handled ensures residents are protected from cross infection. The home was found to be clean, tidy and free from offensive odours, providing a pleasant environment for residents. One carpet in a residents room was clearly in need of cleaning. The manager was aware of this and was considering a different type of flooring for this particular room as the carpeting was difficult to keep in good order. Eltandia Hall Care Centre G54-G04 S19089 Eltandia V221633 170505 Stage 4.doc Version 1.30 Page 19 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 36 (Adults 18-65) are: 27. 28. 29. 30. • • • Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. 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. Service users benefit from clarity of staff roles and responsibilities. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers standards 27, 29 and 30 (Older People) and Standards 34 and 35 (Adults 18-65) the key standards to be inspected at leat once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 30 (older people). Standard 35 (younger adults) The home was seen to have sufficient staff on duty to meet the needs of the present resident groups. Staff are provided with good opportunities for training. Staff working with people with dementia should be provided with on going, more in depth training on all aspects of dementia care. This will ensure residents are supported by staff with up to date specialist knowledge. Staff would benefit from training on person centred planning to enable staff to produce care plans which address the individual needs of residents. EVIDENCE: A rota showing who is on duty each day is made up for each unit in the home. This home is staffed twenty four hours a day with staff awake on duty at night. The home has a mix of qualified nurses and care staff. The numbers of staff on duty at the time of these visits was sufficient to meet the needs of the residents living in the home at the time. Eltandia Hall Care Centre G54-G04 S19089 Eltandia V221633 170505 Stage 4.doc Version 1.30 Page 20 Staff are provided with good opportunities to take part in training. Future training plans over the next year include risk assessments, record keeping, pressure ulcer prevention and wound care, diabetes, continence, medication and complaint handling. This training ensures residents are supported by staff with up to date knowledge. Staff are provided with opportunities to take part in training on dementia. In order for residents to receive up to date specialist care and support on going in depth training on dementia care should be provided to all staff working on units providing dementia care. Staff would benefit from training on person centred care planning to ensure that the care plans in place address the total needs of the individual resident. Eltandia Hall Care Centre G54-G04 S19089 Eltandia V221633 170505 Stage 4.doc Version 1.30 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 37 – 43 (Adults 18-65) are: 31. 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 a well run home and from competent and accountable management of the service. 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. Service users are confident their views underpin all self-monitoring, review and development by the home. 32. 33. 34. 35. 36. 37. 38. • The Commission considers standards 33, 35 and 38 (Older People) and Standards 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 35 and 38 (older people). Standard 36, 42 (younger adults) Residents benefit from a well run and managed home. Further work should be carried out to provide residents with opportunities to influence the way in which the service is delivered including the recruitment of staff. The financial interests of residents are safeguarded. The lack of appropriate supervision for staff providing direct care to residents leaves a gap in the systems for the protection of residents. Checks are carried out on the building and equipment to ensure the health and safety of residents, staff and visitors to the home. Two specific areas noted in the evidence section of this section need further attention. Eltandia Hall Care Centre G54-G04 S19089 Eltandia V221633 170505 Stage 4.doc Version 1.30 Page 22 EVIDENCE: Staff gave positive comments on the management of the home. The manager was said to give a good sense of purpose and support and was open to listening to new ideas. Further work needs to be done to give residents more opportunities to be involved in decisions about the home including staff recruitment and to influence how the home operates. Residents can deposit small amounts of money and or valuables in the home for safekeeping. The home keeps a separate record for each resident. These records were well maintained, up to date and accurate. It is important that all staff are provided with one to one regular supervision from a more senior member of staff. Staff meetings including unit meetings should be carried out on a regular basis to ensure consistency, to identify training and development needs, to monitor work with individual residents and to ensure good communication between staff members. Regular checks are carried out on equipment and the building to ensure the safety of residents, staff and visitors to the home. Staff must ensure that daily checks are carried out on the fridges in each unit. The fridge on the younger persons unit had not been checked daily and temperatures that were recorded were high with no information about the action staff had taken. This was discussed with the manager and action was taken on the day of inspection. Staff must ensure that risk assessments are carried out for any resident who is using raised bed sides to ensure the safety of residents. Eltandia Hall Care Centre G54-G04 S19089 Eltandia V221633 170505 Stage 4.doc Version 1.30 Page 23 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 x 2 2 3 3 4 x 5 x 6 x HEALTH AND PERSONAL CARE ENVIRONMENT Standard No 19 20 21 22 23 24 25 26 STAFFING Score 3 x x x x x x 3 Score Standard No 7 8 9 10 11 Score 2 3 3 2 x Standard No 27 28 29 30 3 x x 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No 16 17 18 Score 3 x 2 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 3 33 2 34 x 35 3 36 x 37 x 38 3 Eltandia Hall Care Centre G54-G04 S19089 Eltandia V221633 170505 Stage 4.doc Version 1.30 Page 24 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. Standard 2&5 Regulation 5(3) Requirement The Registered Persons must ensure that where a local authority has made arrangements for the provision of accommodation, nursing or personal care to the service user at the care home, the Registered Persons shall supply to the service users a copy of the agreement specifying the arrangements made. (timescale of 01.04.05 not met) The Registered Persons must ensure that the social, education, leisure and emotional needs and wishes of service users are included in the service user plan. Information on the religious needs of individual service users along with how these needs will be met must be available to staff. The Registered Persons must ensure that appropriate equipment is provided in the home to support individual service users mobility and for staff to support service users who require assistance with Timescale for action 1st Septmeber 2005 2. 7&6 15(1) 1st September 2005 3. 10 & 18 12(1)(4) 1st September 2005 Eltandia Hall Care Centre G54-G04 S19089 Eltandia V221633 170505 Stage 4.doc Version 1.30 Page 25 eating. 4. 8 13(5) The Registered Persons must carry out a review of the hoist equipment available to ensure sufficient number and type of hoist are avaialble to meet the needs of service users. The Registered Persons must ensure that service users have access to appropriate transport facilties to meet their social, leisure, employment and religious needs. The Registered Persons must ensure that a review of the policy on intimate personal relationships is reviewed. Clear guidance and training if necessary must be made available to staff on sexuality and relationships. The Registered Persons must ensure that a snack is provided each evening to ensure that the gap between the last food of the day and breakfast is no more that twelve hours. The Registered Persons must ensure that the record of food provides evidence of a well balanced diet for all service users. The Registered Persons must ensure that a menu is produced with alternatives to meet the cultural and or religious needs of service users. The Registered Persons must ensure that condiments are provided on dining tables at meal times. The Registered Persons must ensure that all staff working in the home are provided with 1st September 2005 5. 12,13,14 16(2)(m) 1st September 2005 6. 13 12(1)(2) (3)(4) 1st September 2005 7. 15 & 17 16(2)(i) 12(4)(b) 17(2) Schedule 4 (13) 1st September 2005 8. 18 & 23 13(6) 1st September 2005 Page 26 Eltandia Hall Care Centre G54-G04 S19089 Eltandia V221633 170505 Stage 4.doc Version 1.30 9. 36 18(2) training on the protection of vulnerable adults. The Registered Persons must ensure that all staff involved in direct care are provided with one to one supervision from a more senior member of staff at least six times a year. 1st September 2005 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 7&6 Good Practice Recommendations The Registered Persons should expand the role of the keyworker to provide more person centered planning and care. The Registered Persons should ensure staff are provided with training on person centred care. The Registered Persons should review the manner in which the social and leisure interests of service users are met, to include care planning, keyworking and the role of the activities organiser. The Registered Persons should ensure that staff working with people with dementia are provided with on going in depth training on dementia care. The Registered Persons should ensure that opportunities are made available for service users to influence the way in which the service is deliviered including the recruitment of staff. The Registered Persons should consider the introduction of life story work with residents and or families who wish to participate. The Registered Persons should consider the introduction of regular residents and relatives meetings. 2. 3. 7&6 12, 13, 14 4. 5. 30 33 6. 7. 7&6 33 Eltandia Hall Care Centre G54-G04 S19089 Eltandia V221633 170505 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection Ground Floor - CSCI 41-47 Hartfield Road Wimbledon SW19 3RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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