Inspection on 27/02/08 for Etheldred House

This inspection was carried out on 27th February 2008.

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

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

Etheldred House 09/12/08

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Etheldred House Clay Street Histon Cambridge CB24 9EY Lead Inspector Janie Buchanan Unannounced Inspection 27th February 2008 09:30 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 Etheldred House DS0000070960.V360299.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. Etheldred House DS0000070960.V360299.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Etheldred House Address Clay Street Histon Cambridge CB24 9EY 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) 01223 236079 david.pointer@excelcareholdings.com Excelcare Homecare Division Ltd Caroline Goddard Care Home 80 Category(ies) of Dementia (80), Old age, not falling within any registration, with number other category (80) of places Etheldred House DS0000070960.V360299.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service: Care Home with nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Dementia - Code DE Older People, not falling within any other category - Code OP The maximum number of service users who can be accommodated is 80 Not Applicable 2. Date of last inspection Brief Description of the Service: Etheldred House is a large new purpose built care home, providing nursing and residential care to 80 older people. The home is divided into 4 units Apple, Pear, Cherry and Strawberry each with its own communal lounge, dining area bedrooms, kitchenette and bathroom facilities. The home has 3 secure garden areas that are accessible to residents. The home is situated in the village of Histon with good access to local shops and a library. Cambridge City Centre is about 4 miles away. The registered provider of the home is Etheldred Healthcare Limited, which is a subsidiary company of Excelcare Holdings Ltd. 18 of the beds are contracted to the local Primary Care Trust at their benchmark cost, with the rest being available to people self-funding their own care. Weekly charges vary between £600 and £750 per week depending upon the people’s needs Etheldred House DS0000070960.V360299.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. For this inspection we (The Commission for Social Care Inspection) looked at all the information that we have received. This included the annual quality assurance assessment (AQAA) that was sent to us by the home. The AQAA is a self-assessment that focuses on how well outcomes are being met for people living in the home. It also gave us some numerical information about the service. We also received 36 surveys from people living in the home and from other people with an interest in the home. We undertook a SOFI observation (short observational framework for inspectors). This involved observing three residents closely for a period of time and recording their experiences at regular intervals. This included their state of well-being, what tasks they engaged in and how staff interacted with them. For a summary of this observation see below. We spoke with four residents, four members of staff and the manager, and looked at a range of policies and documents. We undertook a brief tour of the home to check the environment and health and safety matters. What the service does well: We received many positive comments about the home; ‘the care workers are generally kind and helpful and treat the residents with respect’; another; ‘staff have been very responsive to specific requests e.g. cleaning dentures and arranging for a chiropodist to see my mother’; the atmosphere is always happy with lots of attention to each person’s needs, even with dementia’; good accommodation, private rooms, good service overall. Relatives told us that they were kept up to date with important issues affecting residents and that the home responded well if they raised concerns. Residents told us that they enjoyed the meals provided at the home that; that staff were easily available when needed and that they felt safe. Care plans showed us that resident’s health care is monitored closely, ensuring their well being, and that timely referrals to a range of health care professionals are made. The home’s kitchen and food service has recently been awarded four stars by the environmental health department. This is to be commended and will ensure that residents receive food that has been stored, prepared and cooked in hygienic and safe ways Etheldred House DS0000070960.V360299.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: There is much this home could do better: • The Statement of Purpose and Service User Guide must include details of how the needs of residents with dementia can be met at the home. For example; how the home’s environment will enable people with dementia to remain independent, how care planning will be person centred, what increased level of support and staffing there will be, what specific activities there will be for people with dementia, and what the security of the building will be. Residents must be more actively involved in contributing to the development and review of their care plan so that they are partners in assessing and planning their care. Also the plans must accurately reflect their needs and any health interventions that are being undertaken. The recording and storage of medication must improve so that residents receive their medication safely, and so there is a clear record of what they have received. Staff must refrain from using language that is inappropriate and patronising to residents Long and uninteresting corridors give the home a rather institutional and hotel like feel and more could be done to make these areas more homely and attractive for residents. Better signage and orientation aids should be implemented to help residents find their way in unfamiliar surroundings, and encourage their independence. All staff should speak clear English so that residents and relatives can understand them. Staff should not be allowed to speak in their native tongues whilst on duty as this will only further confuse people with dementia. Staff’s understanding of the causes, symptoms and progression of dementia is very basic and they should undertake further training so that they have the knowledge and skills to look after residents suffering form this disease. • • • • • • Etheldred House DS0000070960.V360299.R01.S.doc Version 5.2 Page 7 • • • Residents must be helped to mobilise appropriately so that their safety is not put at risk. The use of agency staff should be reduced so that residents receive consistent care from staff that know them well. The home’s recruitment procedures must be more robust so that only the right people are employed to look after vulnerable people. Without this, residents’ safety is seriously compromised. Staff must receive supervision so they have the opportunity to discuss their working practices and identify their training needs. A permanent deputy or head of care should be appointed as soon as possible to oversee the day to day practices of staff, and ensure that standards of care are maintained and the problems highlighted in this report are addressed. • • 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. Etheldred House DS0000070960.V360299.R01.S.doc Version 5.2 Page 8 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 Etheldred House DS0000070960.V360299.R01.S.doc Version 5.2 Page 9 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): 1,2,3,5 Quality in this outcome area is adequate. Residents have information about the home to help them choose if it is the right place for them. They have their needs assessed and a contract that gives details of the service they will receive. This judgement has been made using available evidence including a visit to this service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a statement of purpose and service user guide, copies of which are made available to each resident. They contain good information about facilities of the home, its philosophy of care and arrangements for residents’ privacy and dignity. However, the home is registered to accommodate residents with dementia and more detailed information is required in these documents to show how the home can meet the specific needs of these residents. Visits to the home by prospective residents and their families are encouraged. However, two residents we spoke to told us that they came to the home straight from hospital, without visiting: they described this as confusing and unsettling for them. Each resident is issued with a contract that states the terms and conditions of Etheldred House DS0000070960.V360299.R01.S.doc Version 5.2 Page 10 their stay at the home, the fees payable, the care and support services on offer and details about termination of contract. However not all residents have been issued with these contracts as yet. The manager told us that due to the high number of admissions since the home opened, some administrative procedures had fallen behind. All residents’ health and personal needs are fully assessed before they are admitted to ensure that their needs can be met at the home and evidence of this was viewed on the files we checked. Etheldred House DS0000070960.V360299.R01.S.doc Version 5.2 Page 11 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): 7,8,9,10 Quality in this outcome area is adequate. Residents’ health needs are met at the home, however they are not involved in planning the care and support they receive. This judgement has been made using available evidence including a visit to this service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: We looked at three residents’ care plans. Residents’ needs in a number of areas including washing, dressing, mobility continence and communication were clearly recorded, as was the action to be taken by staff to meet them. Daily notes were detailed and mostly legible. However some information in the plans was confusing and inconsistent. For example one care plan stated that the resident could ‘take food and drink by mouth without assistance’. However staff told us that this resident required full assistance with eating and they had in fact been feeding him for sometime because of his Parkinson’s disease. This resident also had a food and fluid chart. There was no explanation in the care plan as to why his intake was being monitored; the chart had only been completed on 3 occasions in the period of one month; and it did not give sufficient details as to the actual amounts the residents had consumed. There was little evidence that those residents, who were able, were actively Etheldred House DS0000070960.V360299.R01.S.doc Version 5.2 Page 12 involved in planning and reviewing their care. We talked with two residents and showed them their plans of care. These residents were unaware of their plans and the plans contained no actual evidence that they had seen or signed them, despite these residents being very able to understand it. One member of staff told us that residents never saw their plans. One relative commented ‘I am not involved in my mother’s care plan and would like to be’ All residents are registered with a local GP under a formal contract of service and a doctor from this practice visits the home every Wednesday and more often if residents need. Care plans showed that residents’ health needs were monitored closely. Their weights are taken at least monthly and their nutrition, dependency level and continence management are regularly reviewed. One resident had recently experienced a number of falls and staff had made an appropriate referral to the falls co-ordinator. We checked medication storage and records in one of the home’s care units. The following shortfalls were noted: • • • • • Handwritten additions to the MAR sheets had not been signed or dated Medical creams that were administered to residents in their bedrooms were not signed for on the MAR sheets The recording of ‘variable dose’ medication was erratic and it was not always possible to tell if a resident had received one or two tablets. The number of paracetamol in stock did not actually tally with the number of paracetamol recorded as having been administered. One resident appeared only to get her Fortisip nutritional drink when a particular member of staff was on duty, at other times she did not receive it. Residents and their relatives told us that staff treated them respectfully. However we overheard one member of staff calling a resident a ‘good boy’: this language is inappropriate and patronising. When we entered one unit, a resident was having her nails cut in the communal lounge; ideally this personal care task should have been done in the privacy of her bedroom or the bathroom. Etheldred House DS0000070960.V360299.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): 12,13,14,15 Quality in this outcome area is good. The home provides a range of activities to help keep residents entertained and stimulated and also provides good information to relatives about their loved ones. This judgement has been made using available evidence including a visit to this service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home employs a specific activities co-ordinator in the home for two days a week, and there is a weekly schedule, with activities planned both in the morning and afternoon. There are regular movies, bingo, quizzes and ball games, and trips out are planned in the warmer weather, although the home does not have its own minibus. The activities co-ordinator has recently introduced a 6-week SONAS programme with residents. This programme is consists of sessions to heighten residents’ sensations and involves activities around music, touch and taste. Relatives told us that the home was good at keeping them up with important issues affecting their relative. Comments included ‘staff are very caring and also regularly check with me that my mother’s needs are being met’; ‘my uncle now has his own phone but before it was arranged they enabled him to phone me whenever he wanted.’ Etheldred House DS0000070960.V360299.R01.S.doc Version 5.2 Page 14 One relative commented; ‘the food is excellent and my mother has gained weight’; another ‘the food provided is varied and of a good standard’. However another commented; ‘we feel the food at teatime could vary, almost every day it’s sandwiches and when we mentioned this to staff we were told the cook finishes at 4 o’clock’. We had lunch with the residents: this consisted of fish, chips and mushy peas, followed by sponge and custard: it was satisfactory. The meals were served fully plated up thereby denying residents choice of how much and what they ate, and no salt and pepper was available on any of the tables for residents to season their food with. However the mealtime was relaxed and pleasant and those residents requiring help with eating received it sensitively. Etheldred House DS0000070960.V360299.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. Residents and their relatives are able to express their concerns and know that the home will take then seriously. This judgement has been made using available evidence including a visit to this service.This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents and relatives told us that their concerns are taken seriously. One commented: ‘recently my mother changed her room to a room on the ground floor. I asked if she could be allocated a room near to the lounge/dining area, this was done and I was very impressed to see that all her needs and my concerns were considered and catered for’. Another said ‘any complaint or suggestion has always been addressed by the staff’. One commented ‘I have never been advised specifically about the complaints procedure although this is apparently displayed in the reception area. I do think residents should be fully informed about how to complain if they need to, more information is needed. However another reported: ‘there is an information notice about the complaints procedure in the lift that I see each time I visit’. Thehome has not received any formal compalints since it opened. Records showed that staff have received training in protecting vulnerable adults so that they are aware of the different types of abuse and reporting procedures. Etheldred House DS0000070960.V360299.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,26 Quality in this outcome area is adequate. Residents live in a new, comfortable and safe environment. This judgement has been made using available evidence including a visit to this service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has been purpose built to meet the needs of older people. It is spacious and has fixtures and fittings of a high standard. There is a comfortable reception area, visitor’s toilet and a reception desk that is staffed. Facilities include a hairdressing and treatment room, a movie theatre, smoking room and relatives’ meeting room. One room is currently being turned into a reminiscence room for residents, with items and memorabilia from the past. All bedrooms have ensuite facilities (with a level access shower), a TV and telephone point and fully profiling beds. There are a number of secure garden areas, giving residents safe access to fresh air and sunlight. Residents and relatives were generally impressed with the premises: ‘It is light, airy and has nice rooms and gardens’; ‘the facilities are superb’ and ‘the rooms are always clean’. Etheldred House DS0000070960.V360299.R01.S.doc Version 5.2 Page 17 Three of the home’s units are for residents with dementia. These are rather large (18,20,22 beds respectively) for such residents. Corridors in these units are long, devoid of natural light and very similar looking in beige paint. This is potentially confusing for residents with cognitive impairments. There are some orientation aids but not enough to help residents who maybe unfamiliar with their environment to find their way about. Pictures of residents have been put on their bedroom doors but it unlikely that residents with dementia would actually recognise themselves currently. It would be much better to place a picture of the resident in their younger days, or have items on the door that the resident would recognise to help them find their bedroom. In one unit we visited, both the radio and television were on loudly together in the main sitting room. This can only have been confusing for residents with cognitive and hearing difficulties. Although we did not check the home’s main kitchen it has recently been awarded four stars following a visit from the environmental health officer. This is to be commended. Etheldred House DS0000070960.V360299.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is poor. Although the number of staff on duty is sufficient to meet residents’ needs, the home’s recruitment practices seriously compromise residents’ safety. This judgement has been made using available evidence including a visit to this service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People who completed questionnaires told us that staff looked after them properly and treated them well. Comments included: ‘staff are attentive’; ‘staff are friendly and work hard; ‘I really enjoy chats with the chap who cleans my room’. Residents told us that staff were available when needed and they didn’t wait too long for help. However, the home has been having some difficulty recruiting permanent staff and therefore relying heavily on agency staff to fill the gaps. Relatives had concerns about this: ‘A higher proportion of full-time to agency staff is desirable. Most agency staff appear to be adequately trained but there is obviously less continuity and knowledge of each resident’s problems. Another: ‘Unfortunately there are an awful lot of agency staff who are very good, but when they do occasional shifts they fail to get to know the residents personally’ The home employs a number of oversees staff, whose first language is not English. Although their care practices were observed to be good, it is of concern that they might have difficulty in communicating effectively with residents, as we struggled to understand, and be understood, by some of these staff. We observed two staff talking quickly in an eastern European language in the corridor of one of the dementia care units: this can only add Etheldred House DS0000070960.V360299.R01.S.doc Version 5.2 Page 19 confusion to the residents living there. Relatives too were concerned about this: one told us ‘when calling on the phone I often don’t get someone who speaks well to report (i.e. speaks English clearly)’. Another said: ‘I had trouble understanding many of the staff (even the nursing staff) as their accent (foreign) was so pronounced. I found difficulty in understandings what they were trying to communicate to me’; another ‘whilst not racist we feel there are too many foreign carers, who do not speak very good English. Even we have problems to understand, and as our mother is rather deaf, it’s impossible for her’. Most staff had some received training in dementia care. However their knowledge of the different types of dementia, its common symptoms and the disease’s progression was very basic. One staff member commented ‘I watched a very short video about dementia but can’t really remember much about it’. The home’s senior nursing staff are registered general nurses rather than mental health nurses and therefore don’t have the specialist knowledge and training to look after residents with dementia. Despite this lack of formal training, however, interactions observed between staff and residents on the dementia units were respectful and enabling. Relatives also praised staff; ‘I would say that the staff are very good at dealing with dementia sufferers. They are extremely patient, kind and caring. When they have to be firm they do it in a nice way. The three residents we observed at length were in a positive state of well being for the much of the time and engaged well in tasks and the people around them. Training files viewed showed that staff received a range of training, including moving and handling. Despite this, one member of staff was observed moving one resident clumsily, putting both her and the resident at risk of falling. We looked at the personnel files for three recently employed staff. It was of concern that CRB disclosures had not yet been received in respect of any of these employees before they started work at the home. Although DOH guidance states that staff can be employed whilst awaiting full CRB disclosures in ‘exceptional circumstances only’ it is not best practice to do so, and puts residents at unnecessary risk. More worryingly, records indicated that one member of staff had started work before the home had received a POVA first check for her. Interviews for prospective employees were very basic; only 3-4 questions were asked, none of which were very pertinent to the role. No questions were asked about people’s experience of working with older people, of their previous caring roles, of team working, of their people skills, of what areas of the job they might find difficult or the different ways they might communicate with someone. One person had worked for seven years in a care home, but no questions were asked about her experience there, or why she left. It was of great concern that a reference from this home had not been obtained in relation to this prospective employee. These shortfalls seriously compromise residents’ safety. Etheldred House DS0000070960.V360299.R01.S.doc Version 5.2 Page 20 Etheldred House DS0000070960.V360299.R01.S.doc Version 5.2 Page 21 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): 31,33,35,36,38 Quality in this outcome area is adequate. Residents are protected by the home’s health and safety practices. However, management arrangements at the home are still uncertain. This judgement has been made using available evidence including a visit to this service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registered manager is Caroline Goddard, however she is also currently the manager of another home owned by Excel Care. The acting manager is David Pointon, who is yet to be registered with the CSCI. The home is currently without a ‘Head of Care’ as the previous employee left before Christmas. Staff reported that they felt supported as workers and enjoyed their jobs. However, two members off staff told us they had never received any formal supervision despite having worked at the home since it opened. No supervision records were available for these staff when we checked. Etheldred House DS0000070960.V360299.R01.S.doc Version 5.2 Page 22 The home has well developed quality procedures, based on seeking the views of residents and their relatives, in place. These are yet to be implemented, as the home has not long been open. Many records (including health and safety) where fully checked as part of the home’s registration including insurance, employer’s liability, fire safety certificates, electrical and gas installation certificates, hoists, financial statements and business plans. Training records showed that staff had received training in health and safety, infection control, moving and handling and fire safety. No health and safety hazards were viewed during our visit. Etheldred House DS0000070960.V360299.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 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 1 3 3 x 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 3 3 x x x x 3 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x N/A 2 x 3 Etheldred House DS0000070960.V360299.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Not applicable 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 OP1 Regulation 4 and 5 Requirement The Statement of Purpose and Service User’s Guide must fully reflect the service that is to be provided to those residents with dementia. Residents must be actively involved in planning their care and developing their care plan where possible. Their care plans must also accurately reflect their needs. All records of medication administered (or not administered) to residents must be accurate and up to date. Recruitment procedures must improve significantly so that residents are protected Staff must receive good training in dementia care so they can meet the needs of residents with this disease. Residents must be helped to mobilise appropriately so that their safety is not put at risk. Staff must receive supervision of their working practices Timescale for action 01/05/08 2. OP7 15 01/05/08 3 OP9 17 (1)(a) 01/05/08 4 5 OP29 7,9,19 18(1)(c) and (i) 18(1)(a) 18(2) 01/05/08 01/05/08 OP30 6 7 OP30 01/05/08 01/05/08 OP36 Etheldred House DS0000070960.V360299.R01.S.doc Version 5.2 Page 25 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 OP9 Good Practice Recommendations When handwritten additions or alterations are made to the computer printed medication administration record charts, supplied by the pharmacy, these should be signed by the person making the entry and checked for accuracy by a second person. Long corridors should be made more interesting and homely, and orientation aids should be provided to help residents find their way about the home. CRB Disclosures should be obtained for prospective employees before the person is employed at the home so that residents are protected. 2. 3 OP19 OP29 Etheldred House DS0000070960.V360299.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Aylesbury Office Cambridge House 8 Bell Business Park Smeaton Close Aylesbury Buckinghamshire HP19 8JR 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. 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