Inspection on 29/04/08 for Eltandia Hall Care Centre

This inspection was carried out on 29th April 2008.

CSCI found this care home to be providing an Adequate service.

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 25/09/07

Eltandia Hall Care Centre 18/10/06

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 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Eltandia Hall Care Centre Middle Way Norbury London SW16 4HA Lead Inspector Jon Fry Unannounced Inspection 10:25 29 April & 6th May 2008 th 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 Eltandia Hall Care Centre DS0000019089.V364819.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Eltandia Hall Care Centre DS0000019089.V364819.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eltandia Hall Care Centre Address Middle Way Norbury London SW16 4HA 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) 020 8765 1380 020 8765 1399 eltandia@schealthcare.co.uk www.schealthcare.co.uk Southern Cross (LSC) Ltd 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.V364819.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. 25th September 2007 Date of last inspection Brief Description of the Service: Eltandia Hall Care Centre is a purpose built home arranged over two floors. It has two residential units on the first floor and two units offering nursing care on the ground floor. One residential unit provides a mix of respite and permanent care for older people and the other unit provides long term care for older people with dementia. The nursing units offer long-term care for older people and care for younger adults with physical disabilities. People living there are provided with their own single bedroom accommodation with en suite toilet facilities. The home is situated in a residential area of Norbury. Public transport in the form of local bus services are close by. Current fees for this service are: From £426.55 per week for older people From £725 per week for younger people with nursing needs. Eltandia Hall Care Centre DS0000019089.V364819.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced inspection was carried out over two days. Two inspectors visited the home on the first day and one inspector returned for a second day. Both visits concentrated on the care provided for older people in two units – Ivy and Irving. One inspector used the Short Observational Framework for Inspection (SOFI). This involves an observation of the activity taking place for a small number of people with dementia in a communal area. We spoke with fifteen people who live there, three relatives or friends of individuals and five staff members. Completed surveys were received from five people who live at the home and one relative or friend. What the service does well: What has improved since the last inspection? A new manager is in post and he has already started to work with staff to look at the way they work. Care plans are being more fully completed and contain some good information about individuals. Life story books have been put together for some people. Some good work has started to make units more user friendly for people with dementia with the addition of memory boxes by bedroom doors and some soft Eltandia Hall Care Centre DS0000019089.V364819.R01.S.doc Version 5.2 Page 6 toys kept in the hallway. A new raised decking area in the garden has also been provided. 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.V364819.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Eltandia Hall Care Centre DS0000019089.V364819.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 3. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are given information on what they can expect from the home before they move in. Assessments are carried out to make sure that the needs of individuals are known, and can be met, before they move in. EVIDENCE: There is a Statement of Purpose and User Guide available. Extracts of the Statement of Purpose are available on audiotape on request. We saw that the User Guide is provided in a document holder in each room. This tells people about things like keys, valuables, healthcare facilities and mealtimes. The guide given to us had last been updated in October 2007 but the documents available on one unit were older versions and contained details Eltandia Hall Care Centre DS0000019089.V364819.R01.S.doc Version 5.2 Page 9 of the previous organisation that ran the service. A copy of an old inspection report from 2002 was also provided with each user guide. We have recommended that the User Guide be made more user friendly with pictures of staff, places within the home and the local community. Assessments are carried out to make sure that the needs of people coming to live there can be met. We saw that these were all completed by staff and the information used to inform the persons care plan. We have recommended that the service look at the format in use to make sure that good quality information be captured especially around the person’s life, their preferences and the things they are still able to do. Relatives or friends of individuals could be given questionnaires as part of the assessment process to help gather information if needed. It may be helpful for staff to discuss the section ‘expressing sexuality’ when looking at completing assessment forms and then using this information in care plans. We saw entries such as ‘wears make up’ on some assessments. Negative language we saw used in some documentation such as ‘suffering from dementia’ and ‘can be difficult at times’ should also be looked at by staff. Removing these may help to concentrate on positives and focus on people retaining their independence and being purposeful in their day to day lives. This is important to prevent ‘labelling’ when someone first comes to the home. More consideration needs to be given around how the respite care is given within the service. Ivy unit has both permanent and respite beds and this clearly can present problems for both the people living there and the care staff in trying to meet many different needs. The organisation should look at this issue again and perhaps consider changes to the environment to help with this. Eltandia Hall Care Centre DS0000019089.V364819.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are provided with an individual care plan. Care plans could be improved to be more individualised and focus more on wellbeing, occupation and engagement. The health care needs of people who use the service are generally met and medication is well managed. EVIDENCE: We looked at six care plans. We saw one care plan with some nice detailed information about how staff should support them at night and their particular preferences around access to their bedroom. Another care plan gave some more detailed information about the person’s routines and the things they liked to eat. Eltandia Hall Care Centre DS0000019089.V364819.R01.S.doc Version 5.2 Page 11 The majority of care plans we looked at were still too general. Most still had phrases like ‘requires some supervision and assistance with personal hygiene’, ‘offer shower once a week or when required’ and ‘encourage to participate as much as possible’. These are too generalised and staff need to think about how the person likes the care to be delivered and be specific in describing this. The plan needs to say when, where, what and how for each area of support needed. This should help to make sure that care is delivered in the same way and as the person likes it. The care plans for people coming in for respite care need to be reviewed more often. We saw that one person had come to stay at the home in late 2007 but their care plan had not been formally reviewed or updated since being written. If an individual continues to live at the home for more than a month then staff must start reviewing the plan each month. We have recommended that staff look more closely at the care planning for people with dementia. Phrases used like ‘can be confused and disorientated in their surroundings’ and ‘can be difficult at times’ can come across as negative. It may be better to think about why the individual becomes angry or what particular things make them frustrated and then look at how to respond. Care plans should help staff with more consistent ways of working with people – how are they to reply if someone is asking to go home or to catch the bus. We saw examples where staff were saying different things in response to questions like this. Monthly evaluations and daily notes should also be looked at to make sure that they contain good quality information. The ones we looked at tended to say the same thing and were again too general – ‘remains in safe environment’ or ‘repetitive statements and forgetfulness are a daily occurrence’. It is recommended that the home continues to develop life story books with the people living there and these could then be shared with others in the home. This work has already been started and some very good information put together. These books may help staff to relate to people as individuals and encourage more interaction. Staff may also wish to develop their own life story books as part of this process. Risk assessments we looked at were generally satisfactory and had been kept under review. We did however see one instance where a wound care plan was not in place and the assessments were not dated or fully completed. We have also strongly recommended that the home look at cot side assessments to make sure that this equipment is only being used when necessary. We discussed with the home where this equipment may not have been appropriate for one person. People who use the service have access to local GP services. Arrangements are in place for regular dental, optical and chiropody checks to be available. Eltandia Hall Care Centre DS0000019089.V364819.R01.S.doc Version 5.2 Page 12 We saw that staff consult with other health care professionals including the tissue viability and district nurses. Medication is managed well by staff. We saw that administration records were up to date and that items were generally stored properly and securely within both the units we spent time on. Eltandia Hall Care Centre DS0000019089.V364819.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service are given the opportunity to take part in a variety of activities but this area could still be improved upon. The food provided is of satisfactory quality and generally meets the needs of people using the service. Mealtimes are not the social occasions they could be. EVIDENCE: “I read the paper and watch TV”, “could be a bit more to do”, “there’s enough to do”, “no trips planned” and “I get bored sick” were comments from people who use the service. One person spoke very positively about a volunteer who comes to do quizzes and how they enjoyed this. A relative or friend said the person they knew “needs to be encouraged to do things that would benefit social and health needs”. They also commented that staff could try “to engage in conversation with residents”. Eltandia Hall Care Centre DS0000019089.V364819.R01.S.doc Version 5.2 Page 14 The home has two activities co-ordinators and they are responsible for providing activities across all four units. We saw people having their nails done, painting homemade toast racks and sewing dolls when we visited. There was a happy and relaxed atmosphere while these things were going on and individuals were clearly enjoying these. The home still has its own activities room, a relaxation room and a quiet room. Activities are provided on each unit by the care staff and these include ball play, reading, listening to music, singing and dancing. As discussed in the September 2007 inspection report, we thought that all staff could be more much more involved in supporting and engaging people in activities. There were times when staff could have spent more time talking and interacting with people rather than serving or clearing up items. This again showed particularly when morning drinks and lunch were being served. The home needs to continue look at how care staff could be more actively involved in social and emotional care. This is important in developing a service that is person centred rather than task based. Helping people to have purpose and to be engaged and occupied needs to be a central part of the homes culture. The activities co-ordinators could then take on more of an actual co-ordination role. We saw that one unit had made soft toys and dolls available for people with dementia. This is positive and needs to be more widespread along with other ideas such as washing lines, rummage boxes, hat stands, dressing tables and other sensory items. Individuals should be encouraged to take part in purposeful activities such preparing food, cleaning, delivering the post and shopping. We were told that the service was looking at having its own shop. We have strongly recommended that the organisation look at providing the home with its own vehicle. This will allow for spontaneity and may encourage more activity outside of the home. “It’s alright”, “I like it”, “repetitive”, “not bad” and “I have what comes along” were comments about the food provided. We watched the lunch being served on both days of inspection. As at the previous inspection in September 2007, the mealtime still came across as a clinical rather than social occasion. The home has introduced ‘protected mealtimes’ and the dining areas improved but more thought needs to go into improving the actual experience. Care staff need to be part of the mealtime and encourage conversation and interaction with those at the table. Protected mealtimes should also mean that all staff in the home go to the dining rooms to help or be part of the mealtime. Relatives and friends of individuals should also be encouraged to actively take part. Eltandia Hall Care Centre DS0000019089.V364819.R01.S.doc Version 5.2 Page 15 The menus provided should be made more visual with photographs of the meal choices being provided. Any changes to the menu need to be communicated as the meals served on both days we visited varied from the actual menu displayed. We have made some other recommendations around meals. Staff could eat their meals with the people who live there, increased use of serving bowls rather than plating meals and more buffets, tea parties and finger foods. More snacks are provided to people in the communal lounges. We saw biscuits and fruit made available to individuals although, in one instance, they were difficult to access as covered by cling film. Eltandia Hall Care Centre DS0000019089.V364819.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Concerns about the care provided are listened to and acted on. The home understands the procedures for safeguarding adults and trains staff in how to do this. EVIDENCE: People who live there told us that they would speak to staff or their relatives if they were unhappy about anything. The home still needs to look at how the complaints procedure could be made more accessible. The procedure in the user guide needs to be in bigger print and could include pictures to help people know who to go to. An out of date notice in the foyer should be removed as this directs people to the local authority registration and inspection team that is no longer in existence. A record of complaints is kept which shows what the concern is, what action has been taken and the outcome. We saw that this record was fully completed and showed the action taken in response to individual issues. The record is regularly audited by the organisation as part of its quality assurance programme. Eltandia Hall Care Centre DS0000019089.V364819.R01.S.doc Version 5.2 Page 17 We saw that staff have training that teaches them how to recognise and report abuse. The organisation has a procedure for staff to follow in the event of any allegations being made. Eltandia Hall Care Centre DS0000019089.V364819.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22 and 26. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home generally enjoy a comfortable and safe living environment. The bathrooms are in need of attention. EVIDENCE: The home is generally well maintained and individuals are provided with comfortable bedrooms with en-suite facilities. We saw that people could personalise their rooms with their own furniture and pictures. The home was clean and smelt fresh when we visited. There is an attractive garden area and the home has created a pleasant decking area for people to sit out in when the weather is warm enough. Small raised garden areas are Eltandia Hall Care Centre DS0000019089.V364819.R01.S.doc Version 5.2 Page 19 also provided with herbs growing. We thought this area was underused when we visited given the fine weather. People said “my room is wonderful”, “it’s ok” and “I’ve got a lovely view”. There is still a lack of occupational items in the lounges. As stated previously, we saw that one unit has soft toys and dolls available for people with dementia. Memory boxes have also been put up by some doors in this unit to help people find their bedrooms. Lounges could have many more interactive items such as rummage boxes, typewriters, dolls houses and other sensory items. We think that the bathrooms need to be improved. They are not homely in appearance and feel very clinical. Some of the bathrooms on one unit were in need of repair and this was highlighted at the September 2007 inspection. As stated previously, consideration should be given to the environment of Ivy unit in order to help meet different needs. Eltandia Hall Care Centre DS0000019089.V364819.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Enough staff are available but routines need to be reviewed to make they are person centred not task centred. Staff are provided with good opportunities for training. In order to safeguard people who use the service appropriate checks are carried out on staff before they start working in the home. EVIDENCE: Feedback about the staff was generally positive. Comments included “the staff are nice”, “the attendance is good”, “kind to me”, “they’re alright” and “they do their best”. One person felt that staff could be abrupt at times and another said “polite” but sometimes there is “no choice”. Another individual said “some are very nice, some are alright” and another person said “they seem not to have time to listen to me”. We saw a range of practice with some staff interacting very positively with the people living there. Other staff were perhaps too focused on the task rather than the person and sometimes spoke to people as if they were children – “good girl” or directing people to “have your drink” or “eat a bit more”. As at Eltandia Hall Care Centre DS0000019089.V364819.R01.S.doc Version 5.2 Page 21 the last inspection, there missed opportunities where staff could have sat with people talking and doing things. Staff have good access to training and courses attended include manual handling, care planning, managing aggression, dementia awareness, Safeguarding and Fire Safety. We saw that good records of training are kept and refresher courses arranged to keep people up to date. Additional training around dementia has been arranged with a local college as part of the dementia care strategy in place. We have strongly recommended that the activity co-ordinators have more specialist training to make sure of their own good practice. The managers and senior staff need to look at how staff are working and how the routines could be changed to help staff to be less task orientated. Care staff may need more support to put training into practice especially where this means a real culture change in how they work. Leadership and role modelling are crucial to make this happen. We looked at a daily routine for care staff displayed in the office of one unit. This was a list of tasks such as toileting, drinks or snacks, shower or baths with times allocated for these activities. Staff did say that this was no longer followed but perhaps it should be removed from the wall to underline this. As said previously, all staff need to be much more involved in supporting people in activities within each unit. We looked at the recruitment records for three staff members and saw that good records are kept of these. Eltandia Hall Care Centre DS0000019089.V364819.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 and 38. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A new manager is in post and work is underway to look at the care culture and practice in the service. Staff make regular checks to ensure the health and safety of people who use the service. EVIDENCE: The previous manager left the service in early 2008 and a new manager started work by the second day of this inspection. We saw that he had already started to meet with staff on each unit and explore specific issues with them - for example, staff were looking at what ‘resident centred care’ meant to them. It’s important that the home has a period of stable management to Eltandia Hall Care Centre DS0000019089.V364819.R01.S.doc Version 5.2 Page 23 embed this in practice. Care staff will need to have clear leadership and role modelling from senior staff in developing the culture to be person centred and to encourage purposeful daily activity on every unit. Comments from staff included “the managers are supportive but we need more resources”, “it’s good but we can do more” and “we need to be less formal”. A system for staff supervision is in place. This means that staff meet with their manager to discuss their work but the new manager needs to make sure that these sessions take place more regularly with better records kept. We were unable to see records to show that staff have had at least six supervision sessions over the past year. We saw that resident and relative meetings have been held and topics discussed included activities, menus and the decoration of the home. A surgery day has been held once a month where relatives can either phone or call in for one-one chat with the home manager. The organisation has put a dementia strategy in place in November 2007 to address shortfalls in arears such as mealtimes, activities in daily lives and staff training. As stated within the September 2007 inspection report, staff wearing uniforms should be looked at again. It may be worth trying some mufti days to see how this works within different units. Health and Safety is managed well by the service. We saw that good records are kept for areas such as hot water, fire alarms and equipment checks. Eltandia Hall Care Centre DS0000019089.V364819.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 2 3 X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 3 X 3 2 X 3 Eltandia Hall Care Centre DS0000019089.V364819.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 15 Requirement All Care plans must be reviewed on a monthly basis. This includes people who are at the home for longer periods of respite care. This will help top make sure that the changing needs of individuals continue to be met. 2. OP19 23 (2)(b) In order to make sure that people are able to bathe or shower in pleasant surroundings, the bathrooms need to be repaired and renovated. This is with reference to communal bathrooms on Ivy and Irving units. 3. OP36 18 (2) In order to make sure that staff are provided with regular support and guidance, the home must ensure that each staff member has supervision at least six times a year with full records kept. 01/08/08 01/09/08 Timescale for action 01/07/08 Eltandia Hall Care Centre DS0000019089.V364819.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 OP3 Good Practice Recommendations The user guide should be updated and be made available in user friendly formats such as large print or pictures. The assessment format should be reviewed to make sure that good quality person centred information is captured. This can then be used to inform the care plan from when the individual moves in. Relatives, friends or advocates could be asked to contribute information if the person cannot give this himself or herself. 3. 4. 5. OP3 OP7 OP3 OP7 Negative language recorded about individuals should be looked at by care staff. Assessments and care plans should focus on positives and avoid labelling people. More consideration needs to be given around how respite care is accommodated within the service. The home should continue to look at ways to make the care plans more person centred and better reflect the individual’s life and preferences. The plan in place should direct the care to be person orientated and less task based. Care plans need to give specific information about how the person likes the care and support to be delivered. Better background information about the person and their life should be recorded. 6. OP7 More life story books should be developed with the individual and their family or friends. These books should be available and regularly used to help communication and engagement. Staff should also think about developing their own life story books to share. Care staff should look at the daily notes and monthly evaluations they keep to make sure that good quality and DS0000019089.V364819.R01.S.doc Version 5.2 Page 27 7. OP7 Eltandia Hall Care Centre 8. 9. OP8 OP12 useful information is being captured. Cot side assessments should be looked at to make sure that this equipment is only being used as necessary. Care staff should see the provision of social and emotional care as important parts of their work. Care staff could look at how people could be more involved in the daily life of the home. This could be helping with preparation of meals, serving food and drink, helping with laundry or cleaning. 10. 11. OP12 OP12 12. OP15 It is strongly recommended that a suitable vehicle be purchased for use by the home. The communal lounges and hallways should contain lots of occupational items such as rummage boxes, soft toys and dolls, hats, dressing tables, typewriters, dolls houses, wedding dresses, glasses, keys and other sensory items. The mealtime experience needs to be further improved. Practices such as staff eating with people who live there, more use of serving bowls and varying times / numbers / types of mealtimes should be considered. The menus should be produced in accessible formats for the people who live there. Ideas such as recipes from the past, individual favourites and international days could be looked at. Protected mealtimes need to mean that all staff go to the dining rooms to be part of the mealtime. Relatives and friends should be encouraged to be part of the mealtime. 13. 14. 15. OP16 OP30 OP32 The complaints procedure needs to be produced in user friendly formats. Activity co-ordinators should have access to specialist training to make sure of their own good practice. It is recommended that the home look at the issues around staff wearing uniforms. Eltandia Hall Care Centre DS0000019089.V364819.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Eltandia Hall Care Centre DS0000019089.V364819.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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