Inspection on 18/10/06 for Eltandia Hall Care Centre

This inspection was carried out on 18th October 2006.

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.

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 19/10/05

Eltandia Hall Care Centre 17/05/05

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 O`Reilly Unannounced Inspection 18th October 2006 10:00 X10029.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 Eltandia Hall Care Centre DS0000019089.V316550.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 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 DS0000019089.V316550.R01.S.doc Version 5.2 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 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) Lifestyle Care PLC Connie Baker Care Home 83 Category(ies) of Dementia (63), Dementia - over 65 years of age registration, with number (63), Old age, not falling within any other of places category (63), Physical disability (20) Eltandia Hall Care Centre DS0000019089.V316550.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. As agreed on 19/06/2006, Service users with Dementia, age 60 years and above can be accommodated within the home. 19th October 2005 Date of last inspection 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 accommodation 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 DS0000019089.V316550.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of the service. The fieldwork visit to the home was carried out by three regulation inspectors who had discussions with residents and staff and examined a sample of the records. Following the visit to the home questionnaires were provided to a sample of residents, relatives, friends, staff and other professionals who are connected with the service. Twenty one questionnaires were returned from residents, six from relatives or friends, five from staff and five from other professionals. Judgements in this report are based on information gathered from all these sources as well as observations made by the inspectors during the visit to the home. What the service does well: What has improved since the last inspection? All staff have now been provided with training on the protection of vulnerable adults. This ensures that all staff are aware of abuse should they see it and what they must do if they have any concerns. The food provided has improved since the last inspection with snacks available at all times for residents. All staff spoken to had a good knowledge of the people they were supporting and their preferences regarding going to bed and getting up. Eltandia Hall Care Centre DS0000019089.V316550.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Eltandia Hall Care Centre DS0000019089.V316550.R01.S.doc Version 5.2 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 Outcomes 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, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Eltandia Hall Care Centre DS0000019089.V316550.R01.S.doc Version 5.2 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. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) 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. (YA NMS 4) 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 &3 (older people) & 2 (younger adults) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are given information about the home through the Service User Guide. Further work should focus on making sure that people are given sufficient information before they move in. To make sure that staff understand the full needs and wishes of each person pre admission assessments need to include information on the social, cultural and emotional needs of individuals as well as any medical needs along with the reason for admission. EVIDENCE: The home has produced a Service User Guide which gives residents information on what they can expect from the service. Each resident is Eltandia Hall Care Centre DS0000019089.V316550.R01.S.doc Version 5.2 Page 9 provided with a copy of this document and they were seen to be available in bedrooms. A number of residents particularly in the younger persons unit fed back to us that they felt they did not get enough information before they decided to move in. This is something the management of the home could look to improving. Assessments are carried out before each person moves into the home. Copies of the local authority assessment are provided and, for long stay residents, staff from the home also carry out their own pre admission assessments. In order to make sure that the service can meet the needs of each person the pre admission assessments need to include the social, cultural and emotional needs and wishes of residents. This will also ensure that staff can provide a more extensive initial care plan. It was noted that assessments seen for residents on the respite unit did not include the reason for their admission. If staff are to provide appropriate support and care for each person they do need to know why each person is being admitted to the home. Eltandia Hall Care Centre DS0000019089.V316550.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 (older people), 6, 9, 18, 19 & 20 (younger adults) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. We found differences in the quality of care planning across the units in the home. If staff are to support residents to achieve personal goals and lead as full a life as possible as much emphasis needs to be placed on the social, emotional and cultural needs and wishes of residents as is at present placed on their medical and health needs. Risk assessments need to be completed and used when updating care plans. Staff need to take more care when writing daily notes. The health care needs of residents are met. Generally medication is well managed. Eltandia Hall Care Centre DS0000019089.V316550.R01.S.doc Version 5.2 Page 11 EVIDENCE: Each person is provided with an individual care plan which sets out their needs and how these will be met. Generally the care plans focused on the physical and medical needs of individuals. The information on social, emotional, sexual, education and cultural needs and wishes must be improved. Care plans did include some information on the likes and dislikes of residents in relation to day to day and social activities. However if staff are to provide support for residents to achieve their individual goals then more information on how this is to be achieved needs to be available. Staff need to work with residents, particularly in the younger persons unit, to provide an agreed care plan with clear goals and timescales. Care plans on the units for older people must be reviewed monthly. It was noted that care plans on the older persons units have improved over time and that staff have shown clear commitment to improving this area. Staff on Scott unit reported that they are going to start some “life story” work with residents and that they intend to resume the key worker role. This action should assist in providing more person centred care planning. It is acknowledged by the inspectors that information provided to the home in relation to residents staying on the respite unit is not as comprehensive as that provided for residents who are staying for a longer term. However it was noted that information which was provided was not always used by staff. Post admission assessments had not been completed and in one instance the fact that a residents partner was also in the home was not included in the care planning. The plans for this couple had not taken into consideration their relationship. We also found that daily recording focused on the physical and health care needs of individuals. Little information was provided in some units on social activities. In one instance staff had written that a resident had been visited by their son. Records showed that this resident had no children. Staff must take care that daily recoding is accurate. Staff were seen to respect residents privacy and dignity when assisting with personal care. Residents on one unit informed the inspectors that their personal toiletries were being used for other residents. Staff must be reminded to respect the personal belongings of residents. The health care needs of residents were seen to be met. Staff have good relationships with other health care professionals. Referrals were seen to have been made for individuals to dieticians, speech therapists, physiotherapists and other health care professionals as needed. Staff on the nursing units keep Eltandia Hall Care Centre DS0000019089.V316550.R01.S.doc Version 5.2 Page 12 good wound care records. Residents have access to regular dental, optical and chiropody checks. Staff are provided with guidance and information on dementia, pressure ulcers, nutrition, continence and communication. Medication is appropriately stored and recorded. Staff who administer medication have completed medication training. It was noted that in one instance a resident had been prescribed painkillers to be taken up to three times a day. Staff informed the inspector that as this person could not tell them how much pain they were experiencing they were only giving the medication once a day. Staff must review this action and investigate other ways of assessing pain for individuals who are unable to tell them how much pain they are in. Eltandia Hall Care Centre DS0000019089.V316550.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 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. Service Users have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15(older people), 7, 11, 12, 13, 14, 15 & 17 (younger adults) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff were found to be committed to providing opportunities for residents to take part in activities in and outside the home. The lack of easily accessible transport restricts the opportunities for activity in the community. Further work needs to be done particularly in the nursing units to improve mealtimes. Eltandia Hall Care Centre DS0000019089.V316550.R01.S.doc Version 5.2 Page 14 EVIDENCE: The home employs two activities organisers who were found to be committed to expanding the opportunities for residents to participate in a variety of activities. An activities room and a snoozelan ( a quiet/relaxation room with soft lights and music) are available. Staff on the units were also found to be enthusiastic about supporting residents to take part in outings and activity in the home. Residents on Scott unit made positive comments about the outings they had been on in recent months which included a visit to the Imperial War Museum, a boat trip and tea rooms at the local garden centre. Staff have displayed photographs of the trips. The activities organisers have contacts with adult learning centres whose staff will come to the home to carry out assessments if residents are interested in courses e.g. computing, French. Staff from the centres will provide support but not personal care. Staff write an individual report after each activity. This is kept separate from the main files. To make sure that all staff are aware and can contribute towards the social care of residents individual information on activities needs to be included in the care planning. Within the home residents can watch television, read magazines and newspapers, take part in arts and crafts sessions, card and board games, word searches, quizzes, bingo, reminiscence and film afternoons. Residents in each unit are consulted on what they would like to do and activities are organised in line with the majority decisions. A number of staff reported one of the main obstacles for providing more community activity is the restricted access to transport. A minibus is available once a week but this is shared among the whole home which means each unit has access only once every four weeks. Residents on the younger persons unit do have taxi cards. The manager reported that a representative from the catholic church visits the home every week and that residents will be supported to attend religious services or centres of their own choosing. The home has a draft policy on expressing sexuality which covers most areas however little information is available on same gender sexuality and specific issues. Staff should be provided with training on sexuality. It was noted that a couple were staying at the home. The inspectors were informed that plans were in place for this couple to be split up with one person being moved to another unit. Staff must ensure that where they are aware of relationships Eltandia Hall Care Centre DS0000019089.V316550.R01.S.doc Version 5.2 Page 15 between residents and that they work with the individuals to maintain these relationships in line with their wishes. Lunchtime on Scott unit was well managed and seen to be a relaxing, pleasant experience for residents who were offered choices, received their meals on a tray from staff and had a cup of tea or coffee after their meal. Residents comments about the food were positive and included “the food is good”, and “I like the food here”. The home provides a main course with a vegetarian alternative. Staff and residents confirmed that a different meal could be provided if required. Staff can offer residents snacks in between meals. On the younger persons unit only seven residents were using the dining room at lunchtime. The dining area in this unit is not large enough for all residents to join together at meal times. Feedback on the food provided was positive and comments included:- “food very nice, am a vegetarian and needs are catered for”, “can have alternative if don’t like”. Little interaction was observed between staff and residents. Work on making meal times a more social event should be carried out. The inspectors remain of the opinion that this unit should be provided with a kitchen dining area where residents could participate in preparing and or cooking their own meals with staff support and or assistance. On the older persons nursing unit most of the residents need help from staff to eat their meals. At lunchtime eleven residents were using the dining room with eight residents taking their meal in the lounge. Eight residents remained in wheelchairs to take their meals. Staff were observed to put bibs on all residents without offering any alternatives. Residents were not provided with any salt, pepper or sauces with their meal. Staff were required to work between residents to assist or encourage them to eat. Time was taken up with removing chicken from the bone for most residents. The vegetarian option had to be returned to the kitchen as the temperatures were not adequate. Two residents were observed to be not eating well alone and one resident fell asleep over their food. Overall staff were observed trying to deal with a large number of residents who needed assistance. Good interactions between staff and residents were observed. Staff were encouraging residents to look at and smell the food to stimulate their appetite. Eltandia Hall Care Centre DS0000019089.V316550.R01.S.doc Version 5.2 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 (older people) 22 & 23 (younger adults) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents felt they were listened to and expressed confidence in the management to deal with any problems they might have. The manager uses the outcomes of complaints to improve the service. Staff training includes protecting residents from abuse. EVIDENCE: Feedback from residents indicated that they were aware of who to speak to if they have a complaint. Residents commented that they felt the manager or the deputy would listen to them if they had any worries. The home keeps good records of any complaints with details of the problem, action taken and outcomes. The staff have a good understanding of how complaints received can help to improve the service they provide. No complaints were made to the inspectors during this visit. We saw a large number of complimentary letters from previous residents and families. To help in protecting residents from abuse all staff have now been provided with training on the protection of vulnerable adults. A Whistleblowing procedure is in place which obliges staff to report any concerns they may have about working practices or other staff members. Eltandia Hall Care Centre DS0000019089.V316550.R01.S.doc Version 5.2 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 live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 23 & 26 (older people) 24 & 30 (younger adults) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is purpose built and reasonably well maintained. As noted previously the facilities in the younger adults unit could be improved to allow for the development of more independence. Residents are encouraged to personalise their own rooms. Overall the home was seen to be clean and tidy. The standards of cleanliness in the home were excellent. Eltandia Hall Care Centre DS0000019089.V316550.R01.S.doc Version 5.2 Page 18 EVIDENCE: This is a purpose built home where all residents are provide with their own bedroom and en suite toilet facilities. Shared en suite shower rooms are available on the younger adults unit. A number of residents have personalised their own rooms with furniture, photographs, ornaments and plants. Staff were seen to have made communal areas more homely. The lounge in the younger persons unit has been refurbished resulting in a more modern look for this area. Staff reported that residents were consulted on the furnishings and decoration. Each unit is furnished with a small dining room. These rooms are not large enough for all residents to sit down together particularly in the nursing units. Residents were seen to be provided with aids and adaptations to assist them in daily living tasks. One resident was experiencing some difficulty with using their call bell and in sitting on the sofa. This was fed back to staff at the time of inspection. Overall the home was found to be well maintained, clean and tidy. A number of bedroom walls are showing signs of wear and tear and need cleaning or repainting. Feedback from residents on their rooms and communal areas was good. Residents felt the home was “always clean and fresh”. Eltandia Hall Care Centre DS0000019089.V316550.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 (older people) 32, 34 & 35 (younger adults) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Feedback from residents on the staff and their approach was good. Sufficient staff are available to meet the present needs of the residents. Residents are protected by the recruitment checks carried out. Training opportunities are good. Further training on disability rights would benefit staff and residents. EVIDENCE: Sufficient care and nursing staff are available in each unit to meet the needs of the present resident group. Separate housekeeping, maintenance, administration and catering staff are employed. Two staff are also employed to provide and support residents with activities. As noted previously the organisation of meal times in some of the units needs to be reviewed. The inspectors were informed that the team leader on the Eltandia Hall Care Centre DS0000019089.V316550.R01.S.doc Version 5.2 Page 20 younger adults unit left some time ago and has not been replaced. This unit is managed by the deputy manager and nurses. The inspectors are of the opinion that these residents would benefit from the employment of a senior staff member who has knowledge and experience in supporting younger adults with disabilities. A sample of staff files were examined and these showed appropriate checks have been carried out, including Criminal Records Bureau checks and references, before staff start work in the home. Staff are provided with good training opportunities. Recent training has included manual handling, food hygiene, nutrition, the treatment and prevention of pressure sores, supervision, communication and the protection of vulnerable adults. Six staff were recorded as receiving training on dementia care this year. In order to make sure that staff are well informed and have up to date knowledge all staff must be provided with training on disability awareness and rights. Residents comments on the staff group including:- “the staff are nice”, “staff help me”, “I like the staff” and “staff are kind”. One resident felt there were “too many female staff”. Visitors to the home and other professionals also made positive comments about the staff. Staff were described as “very good” at communicating with other professionals and “very receptive to new ideas and suggestions”. The majority of visitors said they were happy with the home and felt welcome when visiting. Staff on Scott unit were described as “excellent” by families. Staff reported that they have good relationships with other professionals and can call on social workers, community nurses and speech and language therapists to provide advice and or support. Residents benefit from a well supported staff group with team meetings taking place at regular intervals and one to one supervision every two months. Comments from staff indicated that they felt confidence in the management of the home to provide them with support and assistance if needed. Eltandia Hall Care Centre DS0000019089.V316550.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 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. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 (older people) 37, 39 & 42 (younger adults) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home manager has the appropriate experience and qualifications for her role. The home keeps good records to protect the financial interests of residents. To ensure the health and safety of residents staff carry out regular checks on the building and equipment. Eltandia Hall Care Centre DS0000019089.V316550.R01.S.doc Version 5.2 Page 22 EVIDENCE: Facilities are available for residents to deposit cash in the home for safekeeping. Individual records were seen to be well maintained. A record of all transactions is maintained along with receipts for any money spent. It was noted that a small number of residents had a significant amount of money held on their behalf. Staff should investigate with the relevant local authority how this money might be more effectively held. The organisation has a quality monitoring system in place which includes gaining feedback from residents on their opinion of the home. The feedback from residents is published and available in the home. Records showed regular checks being carried out on the fire alarm system, call bells, emergency lighting, electrical equipment and hot water temperatures. These checks assist in ensuring the health and safety of residents. It was noted that a fire risk assessment had been carried out. However this was not dated. The manager should check that the risk assessment is up to date. Staff keep a record of any accident or incident in the home along with actions taken and outcomes. Eltandia Hall Care Centre DS0000019089.V316550.R01.S.doc Version 5.2 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 2 2 X 3 2 4 X 5 X 6 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 3 20 X 21 X 22 2 23 3 24 X 25 X 26 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 3 34 X 35 3 36 X 37 X 38 3 Eltandia Hall Care Centre DS0000019089.V316550.R01.S.doc Version 5.2 Page 24 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. Standard OP3 Regulation 14 The Registered Persons must ensure that pre admission assessments include the social, emotional and cultural needs and wishes of individuals. Staff must be provided with information on the reason for admission to the home. 2. OP7 15 The Registered Persons must ensure that care plans are compiled in consultation with residents and include the social, emotional, sexual, education and cultural needs and aspirations of individuals and how these will be met. 3. OP7 15 The Registered Persons must ensure that care plans for older people are reviewed monthly or more frequently if required. 12/02/07 12/02/07 Requirement Timescale for action 12/02/07 Eltandia Hall Care Centre DS0000019089.V316550.R01.S.doc Version 5.2 Page 25 4. OP9 12(1) The Registered Persons must ensure that staff are provided with tools to assess pain for those residents who have restricted verbal communication. 12/02/07 5. OP10 12(1)(2)(3)(4) The Registered Persons must ensure that the policy on intimate personal relationships is reviewed to include information on same gender sexuality and specific issues. Clear guidance and training if necessary must be made available to staff on sexuality and relationships. Staff must support residents to maintain and or develop relationships according to individual wishes. 12/02/07 6. OP15 12(1)(4) The Registered Persons must carry out a review of the way in which meals are organised and presented. 12/02/07 7. OP30 18(1)(c) The Registered Persons must ensure that staff are provided with training on disability awareness and rights. 12/04/07 Eltandia Hall Care Centre DS0000019089.V316550.R01.S.doc Version 5.2 Page 26 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 OP1 OP7 Good Practice Recommendations The Registered Persons should review how information is provided to prospective residents before they move into the home. The Registered Persons should consider providing residents with the opportunity to supply a life history for their file. The Registered Persons should ensure appropriate transport is available to enable residents to participate in community activities. The Registered Persons should provide a kitchen area in the younger persons unit which is accessible to residents. The Registered Persons should ensure that a person with knowledge and experience of supporting people with disabilites from a social perspective is part of the senior staff team in the younger persons unit. The Registered Persons should investigate ways in which residents can influence the manner in which the service is delivered including the selection of staff. 2. OP12 3. 4. OP19 OP27 5. OP33 Eltandia Hall Care Centre DS0000019089.V316550.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection SW London Area Office Ground Floor 41-47 Hartfield Road Wimbledon London SW19 3RG 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. 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