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Inspection on 02/06/05 for St Elizabeths Care Home with Nursing

Also see our care home review for St Elizabeths Care Home with Nursing for more information

This inspection was carried out on 2nd June 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The organisation including the staff team continues to embrace and deliver on the National Minimum Standards for Care Homes for Young Adults. The inspection main finding is that all of the Standards assessed on this occasion bar three, have been achieved. The arrangements to enable service users and their relatives the opportunity to visit and make an informed decision about the services offered at this establishment is managed very well. The assessment of needs carried out prior to any potential service user being offered a place is very comprehensive. The health and personal care requirements are being identified and monitored through a care planning process and review system, respectively. St Elizabeths Centre excels at providing work, learning and leisure opportunities for its service users. This can be evidenced through the review process. Information gathered from service users, staff members, records and observation made of care practice confirm the core values of the establishment as well understood, in terms of compassion, respect, trust and fairness. The complaint procedures are well publicised and service users should be able to make a complaint regarding any aspect of their care. The protection systems are robust to ensure the safety of service users. The environment is well maintained, furnished and comfortable. A high standard of cleanliness was evident. Service users are encouraged to make it their home through inclusion in the decision-making process. The staffing arrangements remain satisfactory. Staff training continues to have a high profile. The home`s robust recruitment process ensures that legislative requirements are fully met prior to any new member of staff taking up their post. The Registered Manager is known as the Director of Care. This large establishment has very experienced and sound management team under the competent leadership of the Director of Care. Another commendable strength of the management team is their openness and willingness to cooperate and work with the Commission.

What has improved since the last inspection?

Recommendations made in the last inspection report dated 4.11.04 have been addressed. The policy and procedures on fire alarm testing and evacuation have been revisited and a robust rolling programme is in place to ensure that staff members and residents respond effectively to emergency situations. A service user contract has been developed. The home has also produced video/DVD that provides an insight into day to-day life at St Elizabeth`s. There have been significant and commendable developments in the three social enterprises, which provide on and off site opportunities for work. These include art exhibitions at the National Gallery, Tate Modern and the London Art and Design Show. The enterprises offer both training and trading opportunities and the personal achievement of service users is both recognised and rewarded. Since the last inspection visit members of the management team have rigorously implemented staff supervision in line with National Minimum Standards. The training department has recently become a nationally accredited centre for NVQ courses. The home has continued to successfully improve both its recruitment and retention of staff. Overall, there is a clear strategic plan, which is being implemented by a committed and well-developed management team.

What the care home could do better:

There is one requirement and two minor recommendations arising from this report. It is essential that new staff members participate in fire drills. A system should be instituted, in order to demonstrate how the service user is being informedthat any information about them will be dealt with appropriately and their confidence, respected. In addition, it would be helpful to obtain the signature of the service user on their care plan as appropriate, so as to demonstrate their involvement in how they wish their personal needs to be addressed.

CARE HOME ADULTS 18-65 St Elizabeths Care Home with Nursing South End Much Hadham Hertfordshire SG10 6EW Lead Inspector Neil Fernando Unannounced 02 June 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. St Elizabeths Care Home with Nursing I52-I02 s19542 St Elizabeths v230298 260505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service St Elizabeths Care Home with Nursing Address South End, Much Hadham, Hertfordshire, SG10 6EW Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01279 843451 01279 842918 enquiries@stelizabeths.org.uk The Congregation of the Daughters of the Cross of Leige Mrs Johanna Elizabeth Coughlan CRH N 104 places Category(ies) of LD - Learning Disability - 104 places registration, with number LD(E) - Learning Disability over 65 - 104 places of places PD - Physical Disability - 104 places PD(E) - Physical Disability over 65 - 104 places St Elizabeths Care Home with Nursing I52-I02 s19542 St Elizabeths v230298 260505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 This home may accommodate 104 people (18-65 years and above 65 years) with physical disability who require personal care. 2 This home may accommodate 104 people (18-65 years and above 65 years) with learning disabilities who require personal care. 3. This home may accommodate 7 people (for reason of epilepsy) with learning disability and physical disability who require nursing care. Date of last inspection 4 November 2004 Brief Description of the Service: St Elizabeth Centre for adults is set in acres of grounds in the rural village of Much Hadham. Service users are accommodated in 15 buildings according to their care needs. These are: Hume House-8 adults with moderate learning disability; Vaughan House-8 adults with moderate learning disability; Lewis House-8 elderly persons with physical disability, Vincent House-8 adults with special needs and profound communication difficulties; Hood House-8 adults, some with challenging behaviour; Corum Villa & extension-7 adults with moderate learning disability and some with challenging behaviour; Jeanne Haze House-8 adults with moderate learning disability; Villa Maria-8 adults with physical and communication difficulties; Elena House–9 elderly persons with high care needs; St Gabriels House-10 adults with challenging behaviour; Kelly & Kearney House-10 adults with moderate learning disability; Loretto Cottage– 5 adults with moderate learning disability; St Joseph’s Cottage-5 adults with moderate learning disability. The Emilie Schneider Centre is a 7-bedded nursing wing, where nursing care is provided on a temporary basis for the service users as required. This unit offers 2 single bedrooms and a 5-bedded room with curtain dividers. The accommodation with the exception of Loretto and St Joseph’s Cottages are single storey building. Loretto Cottage and St Joseph’s Cottage are 2 semi-detached double storey properties. Kelly & Kearney House is the most recent purpose built property. Each building is selfcontained with assisted bathrooms and/or showers and/or assisted toilets. St Elizabeths Care Home with Nursing I52-I02 s19542 St Elizabeths v230298 260505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first inspection for the year 2005/06 under the National Minimum Standards for Care Homes for Younger Adults and the Care Homes Regulations 2001. The last inspection was undertaken on 4.11.04. St Elizabeths is a residential care home, which is registered to accommodate a maximum of 104 younger and older people with learning disabilities, of both genders, that may have an associated physical disability. It also offers 7 nursing care places to its service users when and as required. St Elizabeths is managed by the Congregation of the Daughters of the Cross of Liege. At the time of the inspection, there were 104 service users accommodated. The inspection took place over one afternoon/evening in early June 2005. It found that almost all of the standards assessed during this visit meet the stated National Minimum Standards. 10 service users and a visiting parent, and 8 staff members including the Registered Manager/Director were spoken to, in order to seek their views regarding the quality of service offered at this establishment. In the main, evidence available suggests that the care for service users has been maintained to a very good standard. What the service does well: The organisation including the staff team continues to embrace and deliver on the National Minimum Standards for Care Homes for Young Adults. The inspection main finding is that all of the Standards assessed on this occasion bar three, have been achieved. The arrangements to enable service users and their relatives the opportunity to visit and make an informed decision about the services offered at this establishment is managed very well. The assessment of needs carried out prior to any potential service user being offered a place is very comprehensive. The health and personal care requirements are being identified and monitored through a care planning process and review system, respectively. St Elizabeths Centre excels at providing work, learning and leisure opportunities for its service users. This can be evidenced through the review process. Information gathered from service users, staff members, records and observation made of care practice confirm the core values of the establishment as well understood, in terms of compassion, respect, trust and fairness. The complaint procedures are well publicised and service users should be able to make a complaint regarding any aspect of their care. The protection systems are robust to ensure the safety of service users. St Elizabeths Care Home with Nursing I52-I02 s19542 St Elizabeths v230298 260505 Stage 4.doc Version 1.30 Page 6 The environment is well maintained, furnished and comfortable. A high standard of cleanliness was evident. Service users are encouraged to make it their home through inclusion in the decision-making process. The staffing arrangements remain satisfactory. Staff training continues to have a high profile. The home’s robust recruitment process ensures that legislative requirements are fully met prior to any new member of staff taking up their post. The Registered Manager is known as the Director of Care. This large establishment has very experienced and sound management team under the competent leadership of the Director of Care. Another commendable strength of the management team is their openness and willingness to cooperate and work with the Commission. What has improved since the last inspection? What they could do better: There is one requirement and two minor recommendations arising from this report. It is essential that new staff members participate in fire drills. A system should be instituted, in order to demonstrate how the service user is being informed St Elizabeths Care Home with Nursing I52-I02 s19542 St Elizabeths v230298 260505 Stage 4.doc Version 1.30 Page 7 that any information about them will be dealt with appropriately and their confidence, respected. In addition, it would be helpful to obtain the signature of the service user on their care plan as appropriate, so as to demonstrate their involvement in how they wish their personal needs to be 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. St Elizabeths Care Home with Nursing I52-I02 s19542 St Elizabeths v230298 260505 Stage 4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection St Elizabeths Care Home with Nursing I52-I02 s19542 St Elizabeths v230298 260505 Stage 4.doc Version 1.30 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2 and4. The arrangements to enable service users, their relatives and significant others to make an informed decision regarding the facilities offered and suitability of the home are satisfactory. The offer of a trial period wherever necessary, on going assessment followed by a review process is indicative that identifying needs and individual aspirations during the initial stage are central to ensuring the right choice of home and a successful placement. EVIDENCE: The home has an up-to-date statement of purpose and a service user’s guide to the home. Evidence available indicates that a copy of the guide is made available to every service user, their representative and professionals, as appropriate. The Registered Manager/Director is very clear that any prospective service User and their family will be fully supported by the care staff team, in order to enable them decide if the home is suitable to meet their needs. Records examined and information gained from staff members and service users demonstrate that normally service users admitted to the home are under a Care Management arrangement and have a full assessment of needs by their respective Social Worker, prior to admission to the home. A senior staff member from each unit is involved in the pre-admission assessments, as well as professional assessments from referring agencies. Self-funding service users also have a pre-admission assessment. The establishment considers it to be “very essential” that the involvement of the prospective resident, St Elizabeths Care Home with Nursing I52-I02 s19542 St Elizabeths v230298 260505 Stage 4.doc Version 1.30 Page 10 family/relatives and significant others is central to the assessment process. Assessment records are noted to be very comprehensive. Members of staff reported and service users and a visiting parent confirmed that prospective residents, their relatives/friends are always encouraged to visit. The opportunity to meet with residents and staff members, have a meal, overnight stay and seek clarification, appear to be a routine part of the admission process. If a placement is offered and accepted, the initial visits to the home is followed by a trial period to allow for staff to carry out a full assessment of needs. At the end of the trial period, a review meeting is held with all concerned, in order to consider if a long term placement is appropriate or not. Overall, evidence indicates that standard 4 of the National Minimum Standards has been exceeded. St Elizabeths Care Home with Nursing I52-I02 s19542 St Elizabeths v230298 260505 Stage 4.doc Version 1.30 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 and 10. The comprehensive care planning system and established review process in place ensure that service users’ identified needs/requirements are addressed and unmet needs, closely monitored. This is beneficial to service users and evidently promotes their welfare. The organisation’s stated principle to support service users to make choices about their lifestyles and to be treated as individuals, is being translated in practice hence service users achieving a high degree of independence. EVIDENCE: Information gathered shows the service user’s care plan is drawn up from a range of assessment of needs including Social Worker’s reports, input from family representatives, staff’s on going assessment during the trial period and contributions from any other professional as appropriate. Very good details are maintained of all visits from visiting professionals. A random sample of care plans for ten service users, including recently admitted residents were viewed. These are very well written and reflect the identified needs/requirements of each service user. Good evidence is available to demonstrate that standard 6 of the National Minimum Standards has been exceeded. St Elizabeths Care Home with Nursing I52-I02 s19542 St Elizabeths v230298 260505 Stage 4.doc Version 1.30 Page 12 An established system is in operation, in order to ensure that each service user has a formal review undertaken by the placing authorities every six months. An internal monthly review for each resident is also carried out and details of the changing needs/requirements made, is of a commendable standard. Service users spoken with expressed a high level of satisfaction regarding the assistance they receive. It was not possible to gain any accurate view of some of the service users on the subject of care planning and review systems, given their level of learning disabilities. They however, appeared to be aware of who their key worker is and generally what is happening in their lives. One of the stated principles underpinning this organisation is that service users would be given the opportunity to make choices about their lifestyles and to be treated as individuals. Staff members interviewed demonstrated a good knowledge of individual service user’s needs. Care practice observed appear to empower service users and their rights to decision-making are also being proactively encouraged and upheld, as appropriate. Evidence gathered suggests that staff respect information given by service users in confidence. Records regarding the resident is compiled and stored in accordance with the establishment written procedures. A system should however be instituted, in order to demonstrate how the service user is being informed that any information about them will be dealt with appropriately and their confidence, respected. St Elizabeths Care Home with Nursing I52-I02 s19542 St Elizabeths v230298 260505 Stage 4.doc Version 1.30 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 16. The excellent level and variety of social and recreational activities facilitated appear to assist the development and promote the welfare of service users. Whilst being treated with dignity and respect, service users continue to receive very good support and they appear to enjoy a full and meaningful life at St Elizabeth Centre. EVIDENCE: Leisure interests clearly take into account religious and cultural needs as well as individual preferences and the pattern followed in the service user’s own family own home. Information on the above issues is woven in service user’s care plan. There continues to be an excellent range of social and recreational activities in place, based on the identified needs and abilities of the individual service user. Details of social history, previous interest and hobbies are clearly reflected in each person’s care plan. Those who are able are actively encouraged to continue with any activity or hobby they were involved in, prior to their admission to the home. This includes community based activities as well as St Elizabeths Care Home with Nursing I52-I02 s19542 St Elizabeths v230298 260505 Stage 4.doc Version 1.30 Page 14 support for service users attending the very effective on-site day centre. A significant majority of service users attend the day centre. Many residents were seen coming and going from and to various activities during the visit. Information gained from service users indicates that staff members proactively facilitate access to indoor and outdoor activities. Seven vehicles are available for transporting service users on trips – “an excellent resource” for accessing a higher level and variety of outdoor activities reported service users and staff members. A full time activities co-ordinator is available and activities programme is organised on a monthly basis and a copy made accessible to each unit. Outside entertainers are brought in frequently. Overall, good evidence is available to indicate that an excellent level and variety of social and recreational activities is facilitated to the satisfaction of the service users. The staff team are to be commended for their hard work and achievement in this area. Information gained indicates that promoting the rights of the service user is central to the philosophy of this establishment. Residents’ rights appear to be upheld through staff following the home’s written procedures, on going staff training and supervision, and monitoring of care practice. Risk assessment for each service user is in place and regularly updated, with a view to minimise any potential hazard. Observation made in the course of the visit indicates that staff members treat service users with dignity and respect. St Elizabeths Care Home with Nursing I52-I02 s19542 St Elizabeths v230298 260505 Stage 4.doc Version 1.30 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 and 19. The registered person ensures that the physical and health care requirements of service users are assessed and recognised, and procedures and effective management support enable staff members to address them. Close monitoring from the staff team means that any potential difficulty or complication is identified and dealt with early and quickly by an appropriate professional. EVIDENCE: The dependency levels of service users vary significantly; some live quite independently with staff available for just part of the day whilst others need ‘one to one’ attention during the day in order to achieve daily living tasks or to monitor their challenging behaviour. The needs/requirements of the wheelchair bound service users also appear to be well addressed. Evidence suggests that the service user receives assistance in the way they prefer and require, as reflected in their care plan. A minor but important improvement is to obtain the signature of the resident on their care plan thus demonstrating their involvement in how they wish their personal needs to be addressed, as appropriate. Staff members are aware that any restriction must first be discussed with the resident, their Care Manager/Social Worker, family and other professionals, in order to seek their approval prior to enforcing any restriction. Any restriction imposed will be also reflected in the service user’s St Elizabeths Care Home with Nursing I52-I02 s19542 St Elizabeths v230298 260505 Stage 4.doc Version 1.30 Page 16 care plan. Technical aids and equipment needed to maximise the independence of service users are available as required. Any service user who becomes ill is transferred to the Emilie Schneider Centre - nursing unit, where appropriate. A three monthly medical review is also carried out involving the GP, service user, key worker/link nurse and relatives, whenever possible. Service users are registered with a General Practitioner. Residents are able to see their doctor at the surgery by appointments but he is able to visit the resident at the home, in case of an emergency. A private Consultant Neurologist and a Consultant Psychiatrist for Learning Disability are also available. Other professionals, residents have some contact with include Psychiatrist, Psychologist, Optician, Podiatrist, Hairdresser, Occupational and Speech Therapist, Dentist and Social Workers. Overall, information gathered from service users and staff members, and records examined indicate that the health care needs of service users are being addressed well. St Elizabeths Care Home with Nursing I52-I02 s19542 St Elizabeths v230298 260505 Stage 4.doc Version 1.30 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23. The complaint procedures are well-publicised and service users, relatives and significant others should be able to make a complaint. Equally, systems in operation should offer adequate protection to service users from harm. Providing essential training on the Protection of Vulnerable Adults for all staff members is a positive indication of the organisation’s commitment to effectively protect and promote the welfare of service users. EVIDENCE: Information regarding how to make a complaint is included in the home’s statement of purpose and service user’s guide. Staff members interviewed including the Registered Manager/Director reported that the procedures on complaints are available and accessible to the staff team, relatives and professionals as appropriate. Members of staff demonstrated a good understanding of the need to investigate and record all complaints, including remedial action taken, if any. Staff members reported and service users confirmed that staff members routinely inform residents about the home’s complaint procedures. A record of complaints is maintained. A total of three complaints have been received by the home since the last inspection dated 4.11.04. These have been responded to within 28 days. Evidence gathered indicates that complaints are being managed sensitively and satisfactorily. The home has its own procedures on adult protection, which reflects the Hertfordshire policy and procedures on the subject. Staff members interviewed confirmed that the procedures on adult protection are available and accessible them. Staff members have received training on the Protection of Vulnerable Adults, a subject also included in the induction programme for all new staff members and those people undertaking the NVQ assessment. St Elizabeths Care Home with Nursing I52-I02 s19542 St Elizabeths v230298 260505 Stage 4.doc Version 1.30 Page 18 There is currently an adult protection matter, which is being dealt with by the appropriate Adult Protection Team in Hertfordshire. The staff team appeared to have responded well to the alleged incident. There are a number of systems in place, which should adequately protect service users from harm. St Elizabeths Care Home with Nursing I52-I02 s19542 St Elizabeths v230298 260505 Stage 4.doc Version 1.30 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 and 30. The home appears to continue to provide good and safe living conditions to service users. The accommodation is bright and comfortable. The standard of cleanliness was high and furnishings are suitable for the individual and collective needs of the service users. EVIDENCE: The physical environment has been maintained to a high standard. Rooms have been individually decorated and reflected the service users taste and preference. Good evidence is available to show that service users are able to personalise their own bedrooms. Individualised bedrooms generated a domestic and homely atmosphere. Staff members reported and service users confirmed that they are routinely consulted about the décor and have keys to their rooms, as appropriate. Service users expressed a high level of satisfaction with regards to their bedrooms and furnishings. A high standard of cleanliness was evident throughout those areas viewed. There were no mal-odours present. The laundry facilities are suitable and adequate for the resident accommodated. The management of clinical waste is very good. St Elizabeths Care Home with Nursing I52-I02 s19542 St Elizabeths v230298 260505 Stage 4.doc Version 1.30 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 34 and 36. The establishment continues to provide the staffing levels required by day and night, and service users’ needs are being well met. The recruitment process for staff is robust, which means that service users are in safe hands. Staff training including NVQ assessment is an indication of the organisation’s commitment to improve staff’s knowledge and skills to enable them to deliver an improved quality of service delivery to residents. EVIDENCE: Staff duty roster for a period of one month was scrutinised and discussion with staff members including the Registered Manager/Director indicate that staffing levels are adequate to meet the needs of service users. Information gained suggests that staff members have adequate experience and skills to enable them deliver a good quality service to residents. In terms of NVQ assessment 55 care staff members (33.5 ) have achieved an NVQ Level 2 or equivalent, 53 members (32.3 ) are currently working towards it and a further 46 people (27.8 ) are scheduled to start the same course in September 2005. This in effect means that by September 2005, 65.8 of care staff members would have achieved an NVQ Level 2 or equivalent. The organisation is to be commended for giving NVQ assessment for care staff such high profile. St Elizabeths Care Home with Nursing I52-I02 s19542 St Elizabeths v230298 260505 Stage 4.doc Version 1.30 Page 21 The home follows the organisation’s procedures for the recruitment and selection of staff members. The recruitment files for 5 new staff members were examined these were found to be in order. Agency staff members used have similar rigorous checks, prior to them starting work at St Elizabeth Centre. It is evident from recruitment files scrutinised and staff members interviewed, including 2 Assistant Directors and the Director that the recruitment process is robust. Staff interviewed confirmed that they are well supported and receive formal supervision within the required frequency. Staff meetings are held monthly and members have good opportunity to raise any care and staff management issue for discussion. St Elizabeths Care Home with Nursing I52-I02 s19542 St Elizabeths v230298 260505 Stage 4.doc Version 1.30 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 and 42. St Elizabeths Centre continues to be managed well, which therefore means that care and staff management systems including health and safety matters are being implemented to very good effect. The health, safety and welfare of service users are being safeguarded and promoted. St Elizabeths Centre remains a safe home for service users to live in. EVIDENCE: The Registered Manager is known as the Director of Care. She is a professionally qualified first level nurse, of long standing experience. She has a BA Honours in Health Studies and a Post Graduate Certificate and Diploma in Management and Research. She has also successfully completed the Registered Manager Award in April 2004. Her management qualifications would therefore not warrant her undertaking NVQ level 4. The Manager has continued to undertake periodic training to update her knowledge, skills and competence, while managing the establishment. The Director of Care has the overall management responsibility and accountability for the home. A team of senior Managers including 2 Assistant St Elizabeths Care Home with Nursing I52-I02 s19542 St Elizabeths v230298 260505 Stage 4.doc Version 1.30 Page 23 Directors very ably support the Manager. There continues to be excellent evidence to indicate that the Director of Care is competent and experienced to manage this large establishment and meet its stated purpose, aims and objectives. There is good evidence to show that care practice is monitored closely and a formal supervision system is in operation. Staff members interviewed confirmed that they receive formal one to one supervision every two months and that they are very satisfied with management support they receive. The home has robust and detailed procedures to ensure the health and safety and welfare of service users and staff. The Training Centre Manager has arranged for all staff to receive on going mandatory training that ensures safe working practice. The fire alarm system and extinguishers are serviced as appropriate. Fire drills and weekly test of break glass points have been carried out within the required frequency and a record maintained. However, some care staff members stated that they had not participated in any fire drill since starting work about 8/9 months ago. Hot water temperature is monitored regularly, in order to ensure a safe limit of 43 degrees Centigrade at the point of outlet. Windows have been fitted with restrictors for the safety of service users and security of the building. Portable electrical appliances are checked, tagged and a record maintained. St Elizabeths Care Home with Nursing I52-I02 s19542 St Elizabeths v230298 260505 Stage 4.doc Version 1.30 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x 4 x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 4 3 x x 2 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 4 x 3 x Standard No 31 32 33 34 35 36 Score x 3 x 3 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 St Elizabeths Care Home with Nursing Score 2 3 x x Standard No 37 38 39 40 41 42 43 Score x 4 x x x 2 x I52-I02 s19542 St Elizabeths v230298 260505 Stage 4.doc Version 1.30 Page 25 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA42 Regulation 23 (4) Requirement The Registered Person must ensure that new staff members participate in fire drills. Timescale for action 31.07.05 & on going 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 YA10 Good Practice Recommendations A system should be instituted, in order to demonstrate how the service user is being informed that any information about them will be dealt with appropriately and their confidence, respected. Obtain the signature of the resident on their care plan, in order to demonstrate their involvement in how they wish their personal needs to be addressed, as appropriate. 2. YA18 St Elizabeths Care Home with Nursing I52-I02 s19542 St Elizabeths v230298 260505 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire Al7 3BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI St Elizabeths Care Home with Nursing I52-I02 s19542 St Elizabeths v230298 260505 Stage 4.doc Version 1.30 Page 27 - 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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