Inspection on 24/01/06 for St Elizabeths Care Home with Nursing

This inspection was carried out on 24th January 2006.

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

The inspector 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.

Other inspections for this house

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St Elizabeths Care Home with... 02/06/05

St Elizabeths Care Home with... 04/11/04

St Elizabeths Care Home with... 15/07/04

St Elizabeths Care Home with... 03/12/03

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Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 St Elizabeths Care Home with Nursing South End Much Hadham Hertfordshire SG10 6EW Lead Inspector Mr Neil Fernando Unannounced Inspection 24th January 2006 10:35 St Elizabeths Care Home with Nursing DS0000019542.V282333.R01.S.doc Version 5.1 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 St Elizabeths Care Home with Nursing DS0000019542.V282333.R01.S.doc Version 5.1 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Elizabeths Care Home with Nursing DS0000019542.V282333.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Elizabeths Care Home with Nursing Address South End Much Hadham Hertfordshire SG10 6EW 01279 843451 01279 842918 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) The Congregation of the Daughters of the Cross of Liege Mrs Johanna Elizabeth Coughlan Care Home 104 Category(ies) of Learning disability (104), Learning disability registration, with number over 65 years of age (104), Physical disability of places (104), Physical disability over 65 years of age (104) St Elizabeths Care Home with Nursing DS0000019542.V282333.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. This home may accommodate 104 people (18-65 years and above 65 years) with physical disability who require personal care. This home may accommodate 104 people (18-65 years and above 65 years) with learning disabilities who require personal care. This home may accommodate 7 people (for reason of epilepsy) with learning disability and physical disability who require nursing care. 2nd June 2005 Date of last inspection 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 Cottage5 adults with moderate learning disability; St Josephs 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 Josephs Cottages are single storey building. Loretto Cottage and St Josephs 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 DS0000019542.V282333.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the second 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 26.05.05. 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. At the time of the inspection, there were 100 service users in residence. The inspection lasted for 8 hours during which time 11 service users, 8 staff including an Assistant Director and the Director were spoken to. Also records were examined and a brief tour of the premises was undertaken. Standards not assessed on this occasion were covered during the inspection that occurred on 26.05.06. What the service does well: The inspection main finding is that all of the Standards assessed on this occasion are either met or, in a number of cases, exceeded. A commendable strength of the staff and management teams is their openness and willingness to co-operate and work with the Commission, in order to further improve the quality of service delivery for service users. There is a clear audit trail that demonstrates that new service users, their families and purchasing authorities receive information to make informed decisions prior to placement agreements. The service offered is of a high standard and it is able to meet the social and health needs of people with complex needs and a range of dependency. Evidence shows that the health and personal care needs are being identified, monitored and evaluated through systematic review processes. The voice of service users is heard through the “Residents Forum” and individual meetings. Service users have been involved in some of the recent appointments of key staff, for example, Social Activities Co-ordinator. Empowering service users is a key commitment of the organisation, and this is evidenced through workshops and training received. St Elizabeth’s continues to excel at providing work, learning and leisure opportunities for its service users. Since the last inspection the Social Enterprises scheme has been granted the Investors in People Award. The ethos of the organisation is evident as you walk around and speak with staff and service users. The core values of the organisation – compassion, St Elizabeths Care Home with Nursing DS0000019542.V282333.R01.S.doc Version 5.1 Page 6 respect, trust and fairness – are embraced and integral to day to-day practices. Training continues to be given high priority in order to ensure a quality service. The Training Department has recently become an accredited NVQ centre. The environment continues to be well maintained; furnishings are comfortable and a high level of cleanliness was apparent. Staff arrangements remain satisfactory, and the organisation should be applauded for their strategies for the recruitment and retention of staff, which has reduced the use of bank and agency staff since the last inspection. Legislative requirements are complied with to ensure the safety of vulnerable adults. There have been no changes to the senior staff team since the last inspection. The Registered Manager, known as the Director of Care, is able to demonstrate that the organisation is well run under her competent leadership. The team have clear lines of accountability and work in an open and transparent manner, which provides a high degree of confidence for service users and their families. What has improved since the last inspection? What they could do better: There are 1 requirement and 2 recommendations arising from this report that need addressing. There has been some confusion in some units as staff members have been practicing fire drills when the weekly tests of break glass points were being undertaken. Some fire doors were wedged open. These practices must cease. The draft placement contract should be ratified and made available as appropriate. The frequency of formal supervision for some staff needs attention. St Elizabeths Care Home with Nursing DS0000019542.V282333.R01.S.doc Version 5.1 Page 7 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 DS0000019542.V282333.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection St Elizabeths Care Home with Nursing DS0000019542.V282333.R01.S.doc Version 5.1 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 the following standard(s): 3 and 5. Prospective service users are given full assistance to enable them decide if they wish to live at St Elizabeths Centre. The assessment of needs is comprehensive, which ensures that identified needs are woven in the care plan. The draft placement contract should however be finalised. EVIDENCE: Staff members including the Manager reported that any prospective service user, their relatives/friends are always encouraged to visit and an overnight stay for the prospective resident will be facilitated, as appropriate. 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. A minimum of 6 weeks ‘settling in’ trial period of residence would then be offered, followed by a placement review with the service user, Social Worker, their relatives and other professionals as appropriate. Good evidence is available to demonstrate that standard 3 of the National Minimum Standards has been exceeded. A signed copy of the contract agreement is retained centrally. The current contract needs to be updated, in order to include the stated details in standard 5 of the National Minimum Standards. The Registered Manager reported that the new draft contract is available and it is expected that this would be finalised by March 2006. This is a recommendation, which remains outstanding following the implementation of the NMS from April 2002. In the meantime, an interim contract is being used for new service users. St Elizabeths Care Home with Nursing DS0000019542.V282333.R01.S.doc Version 5.1 Page 10 Considering the severe learning disabilities of some of the service users, it has not always been appropriate for some service users to sign and retain a copy of the contract. However, the signature of the relative/next of kin and/or Care Manager from the placing authority is being obtained as appropriate. St Elizabeths Care Home with Nursing DS0000019542.V282333.R01.S.doc Version 5.1 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 the following standard(s): 6 and 9. The comprehensive care planning system and established review process in place ensures that service users’ identified needs/requirements are addressed and unmet needs, closely monitored. Also this establishment is a very good example where service users are being appropriately supported to achieve a high degree of independence. EVIDENCE: Information gathered shows that the care plan is drawn up from a range of assessment of needs involving a range of professionals, including the Social Worker, the service user and relatives/advocate, and staff’s on going assessment during the trial period. Excellent details are maintained of all visits from visiting professionals. A random sample of 10 care plans was viewed and they contain comprehensive information on the cultural, religious, health, physical, social and recreational, and personal care needs of service users. Risk assessments are in place. Special factors such as nutrition and diet, and the individual levels of staff assistance required for mobility, eating and communication are considered with the actions agreed to meet the identified needs. All examples seen have been regularly updated by staff members and audited by the Unit Manager. Records St Elizabeths Care Home with Nursing DS0000019542.V282333.R01.S.doc Version 5.1 Page 12 show that the care management including health and safety of each service user is very well documented, with progress/deterioration clearly noted. Overall, evidence demonstrates that standard 6 of the NMS has been exceeded. The service users accommodated at this establishment have moderate to severe learning disabilities and therefore have varied capabilities. Individual choice and independence is one of the stated aims of the home and there is good evidence that this is being effectively promoted. Specific programme tailored to meet individual needs are well documented including assistance required from staff members. Service users spoken to were all positive about the manner their personal choice and independence is being promoted. Each service user has an individual risk assessment that is formulated with service users’ safety and welfare in mind and is not restrictive as such. The home has procedures for responding to absences without authority. Staff members interviewed demonstrated a good understanding of their responsibilities to respond promptly to unexplained absences. There have been no service users missing from the home during the previous twelve months. Good evidence is available to demonstrate that standard 9 of the NMS has been exceeded. St Elizabeths Care Home with Nursing DS0000019542.V282333.R01.S.doc Version 5.1 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 the following standard(s): 14, 15 and 17. An excellent level and variety of social and recreational activities is being facilitated and this appears to assist in the development and promote the welfare of service users. Family contacts and other personal relationships are encouraged and facilitated. Service users appear to benefit from a healthy and balanced diet. EVIDENCE: Activities programme examined and information gained from staff and service users clearly demonstrates that the staff teams actively facilitate access to indoor and outdoor activities. Seven vehicles are available for transporting service users on trips. Consistent with the last inspection report “an excellent resource” for accessing a higher level and variety of outdoor activities echoed service users and staff members, including Senior Operational Managers. 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. In addition, the home has good links with other organisation that offer various activities such as digital photography, life drawing/water colour etc. Overall, good evidence is available to indicate that an excellent level and variety of social and recreational St Elizabeths Care Home with Nursing DS0000019542.V282333.R01.S.doc Version 5.1 Page 14 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. Four staff members including the Manager/Director confirmed that service users are encouraged to maintain contact with their family and friends. Visiting times are flexible and visitors are welcomed. Residents are able to entertain their visitors in the communal areas or their own room, if they so wish. Service users’ wishes regarding whom they wish to see and whom they do not wish to see are respected. Staff reported that none of the residents are involved in any intimate personal relationship. They are however clear that the wishes and feelings of service users would be respected and promoted. Discussion with staff and examination of care plans indicates that service users and their relatives are consulted regarding residents’ culinary likes and dislikes. Service users are involved in menus planning, in order to reflect their taste and preference. Some service users are able to prepare snacks and hot drinks for themselves and others, with staff assistance. Menus lists viewed suggest that the variety and quality of food offered at this home is of a good standard. Service users expressed a good deal of satisfaction with respect to food available to them. A Dietician is available for advice on any specific dietary requirement of residents. There are neither religious nor cultural dietary requirements at present. St Elizabeths Care Home with Nursing DS0000019542.V282333.R01.S.doc Version 5.1 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 the following standard(s): 19 and 20. 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. Sound procedures are in place for the safe handling and administration of medication that ensure the protection of service users. EVIDENCE: Information available from service users, staff members and the Manager indicates that intimate personal physical care is offered in a sensitive and dignified manner. Bathroom and toilet doors are kept closed by staff members, when residents use these facilities. Bed, bath and meal times are flexible. The Manager confirmed that all staff members are aware that any restriction must first be discussed with the service user, their Social Worker, family and significant other professionals, before enforcing any restriction. She was also clear that any restriction imposed would be reflected in the resident’s care plan. Documentary evidence is available to indicate that service users are registered with a General Practitioner. Service users are able to see their doctor at their surgery but the doctor may visit a resident at the home in an emergency. Other professionals, residents have some contact with include Psychiatrist, Psychologist, Optician, Podiatrist, Hairdresser, Occupational and Speech St Elizabeths Care Home with Nursing DS0000019542.V282333.R01.S.doc Version 5.1 Page 16 Therapist, Dentist and Social Workers. A private Consultant Neurologist and a Consultant Psychiatrist for Learning Disability are also available. When a service user becomes ill they are 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. Sound medication systems are operated to protect the interests of service users. Medication is stored securely in each unit, with receipt, administration and disposal accurately recorded. A medication management working party is in operation that oversees the administration and control of medicines. St Elizabeths Care Home with Nursing DS0000019542.V282333.R01.S.doc Version 5.1 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 the following standard(s): 22 and 23. There are a number of systems including complaint that should offer adequate protection to service users from harm. Staff training on the Protection of Vulnerable Adults continues to be given a high profile, thus highlighting the organisation’s commitment to the welfare of its service users. EVIDENCE: The policy and procedures on comments, compliments and complaints have been reviewed in 2006. Information on how to make a complaint is included in the statement of purpose and the service user’s guides. Service users consulted said that they are aware of how to make a complaint and expressed confidence in the likely positive response of the Unit Manager and staff, to any complaint. Staff members reported and service users confirmed that staff would routinely inform them about the home’s complaint procedures. The home maintains a record of complaints. Records examined indicate that the home has received a total of 5 complaints since the last inspection May 2005. Evidence shows that the complaints have been dealt with speedily and satisfactorily. The home has a copy of the Hertfordshire procedures on Adult Protection. Staff confirmed that they are familiar with the above procedures and they have received training on the Protection of Vulnerable Adults. This is a subject also included in the induction programme for all new staff members and those people undertaking the NVQ assessment. There is currently an adult protection matter, which is being dealt with by the appropriate Adult Protection Team in Hertfordshire. The staff team appeared St Elizabeths Care Home with Nursing DS0000019542.V282333.R01.S.doc Version 5.1 Page 18 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 DS0000019542.V282333.R01.S.doc Version 5.1 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 the following standard(s): 24 and 30. The premises provide a safe, comfortable and homely environment suitable for the needs of service users. The standard of cleanliness was high. EVIDENCE: The physical environment continues to be maintained to a high standard. It is decorated and furnished in domestic style and provides a very homely, comfortable and safe environment. All bedrooms seen are painted different colours chosen by the residents and are thoroughly personalised to reflect the tastes and interests of the occupants, with gadgets, pictures and hobby materials. 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. There are infection control policies and procedures in place. The arrangements for the storage and collection of domestic and clinical waste are very good. St Elizabeths Care Home with Nursing DS0000019542.V282333.R01.S.doc Version 5.1 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32 and 36. Staffing levels are adequate to meet the needs of the current service users. The training requirements of staff are being addressed appropriately and this enables them to deliver a good quality service. EVIDENCE: Staff duty roster for a period of one month was scrutinised and discussion with staff members including the Registered Manager/Director demonstrates that staffing levels are adequate to meet the needs of service users. Information gathered indicates that staff members have adequate experience and skills to enable them deliver a good quality care and service to the resident groups. Staff members spoken with indicate that they have excellent opportunities for relevant training and this give them greater confidence to do their jobs. It was evident during the inspection that staff members understand the different requirements and approaches appropriate for individuals accommodated. The home has not yet achieved the 50 NVQ Level 2 for its staff. 59 care staff members (33.7 ) have completed their assessment and 36 (17.7 ) are currently working towards it. Therefore the home is working towards meeting the stated Standard. St Elizabeths Care Home with Nursing DS0000019542.V282333.R01.S.doc Version 5.1 Page 21 Staff interviewed reported that they are well supported and have received formal one to one supervision. However, the frequency of supervision needs improving in a few cases. St Elizabeths Care Home with Nursing DS0000019542.V282333.R01.S.doc Version 5.1 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38 and 42. This establishment is managed well. The health, safety and welfare of service users, and staff are being safeguarded. Records are maintained as required. EVIDENCE: The Registered Manager is known as the Director of Care. She has the overall management responsibility and accountability for the home. A team of senior Managers including 2 Assistant Directors very ably support the Manager. There continues to be excellent evidence to indicate that the Director of Care is well qualified and experienced, and competently manages this large establishment to meet its stated purpose, aims and objectives. Staff members spoken to stated that they are very happy working at St Elizabeths Centre, under the leadership of the Director of Care. Observation of staff interaction with service users clearly demonstrates that the ethos of the home is put into practice. Action plans are drawn up for any shortcoming. All staff members have received mandatory training in order to ensure safe working practice. There are lockable cupboards for the storage of disinfectant St Elizabeths Care Home with Nursing DS0000019542.V282333.R01.S.doc Version 5.1 Page 23 and other cleaning materials, and care is taken by staff to ensure that service users are not exposed to hazards. The home’s policies and procedures cover compliance with relevant legislation and this is reinforced though training. Risk assessments have been undertaken on moving and handling, fire safety, the building and equipment used at the home. Fire equipment and the fire alarm system including smoke detectors and emergency lighting are serviced within the required frequency. Hot water temperature is tested regularly. However, there are 2 observations made: a) There has been some confusion in some units as staff members have been practicing fire drills when the weekly tests of break glass points were being undertaken; b) Some fire doors were wedged open. Remedial actions must be taken. St Elizabeths Care Home with Nursing DS0000019542.V282333.R01.S.doc Version 5.1 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 Standard No Score 1 x 2 x 3 4 4 x 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 3 32 3 33 x 34 x 35 x 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 x x 4 x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 4 15 3 16 x 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x 3 3 x x 4 x x x 2 x St Elizabeths Care Home with Nursing DS0000019542.V282333.R01.S.doc Version 5.1 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 Requirement The Registered Person must ensure that: a) The current practice on some of the units to undertake fire drills during weekly tests of break glass points is stopped; a) Fire doors are not wedged open. Timescale for action 28/02/06 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 YA5 YA36 Good Practice Recommendations The draft placement contract should be finalised and used for new service users. The frequency of formal supervision for staff members needs attention in a few cases. St Elizabeths Care Home with Nursing DS0000019542.V282333.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Hertfordshire Area Office 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 DS0000019542.V282333.R01.S.doc Version 5.1 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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