Inspection on 18/05/07 for The Elizabethan Care Home

This inspection was carried out on 18th May 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Elizabethan Care Home 29/08/08

The Elizabethan Care Home 14/04/08

The Elizabethan Care Home 07/06/06

The Elizabethan Care Home 30/11/05

The Elizabethan Care Home 21/04/05

The Elizabethan Care Home 28/10/04

The Elizabethan Care Home 22/04/04

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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Elizabethan Care Home 220 Old Bedford Road Luton LU2 7HB Lead Inspector Mr Pursotamraj Hirekar Unannounced Inspection 18th May 2007 12:00 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 The Elizabethan Care Home DS0000045208.V337664.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. The Elizabethan Care Home DS0000045208.V337664.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Elizabethan Care Home Address 220 Old Bedford Road Luton LU2 7HB 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) 01582 720010 Heritage Care Homes Ltd Miss Erin Bermingham Care Home 21 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (23) of places The Elizabethan Care Home DS0000045208.V337664.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Service users over the age of 65 years, not falling within any other category 21(OP), 10 of whom may have dementia DE(E) (10). No one falling within the category of DE(E) may be admitted to the home when there are 10 persons in category DE(E) already accommodated in the home. The home can accommodate a maximum of 21 service users of either sex. 7th June 2006 Date of last inspection Brief Description of the Service: The Elizabethan was registered to provide services for twenty-one older people, ten of whom who may also have dementia. Mr S Hussain had been the proprietor a number of years. He had changed the registered status to a company, Heritage Care Homes, two years ago. The company also operates two other care homes in the vicinity. The manager Miss Bermingham had been appointed several months ago. The service had improved significantly under her direction. The home was located in a pleasant residential suburb of Luton with convenient access to the towns amenities and transport links. The accommodation was distributed over three floors that were accessible via a staircase and a shaft lift. Each bedroom was for single occupancy although a few rooms were large enough to accommodate two persons who wished to share. A lounge and dining room were located on the ground floor. Toilet and bathing facilities were located on each of the floors. However, only two of the bathing facilities were in use. The garden to the front of the property was not accessible as it had a steep slope. The front entrance to the building was similarly restricted. Service users and visitors to the home therefore mostly used the door that led directly into the laundry from the side of the property. Service users could also use the patio doors that lead out from the rear lounge onto a paved area. The majority of the rear of the property was given over to a large parking area. Beyond this was a further large grassed area that was not in use. The minimum fee was £395/- and £420/- per week. The Elizabethan Care Home DS0000045208.V337664.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the report of the unannounced key inspection carried out on 18/05/07 over 5 hours 20 minutes by pursotamraj hirekar. The method of inspection included review of outstanding requirements and recommendations, study of a sample of care plans, risk assessments, discussion with the service users’, staff on duty, manager and observations of staff and service users interaction. The manager coordinated the entire inspection. The information from the preinspection questionnaire and service users’ survey is considered for this report as well. What the service does well: What has improved since the last inspection? What they could do better: The service user’s plan is reviewed, updated to reflect changing needs and current objectives for health and personal care. The home must ensure that all hot water points’ temperature is taken at regular intervals to prevent risks of scalding. The home must ensure to operate a through recruitment procedure. The home must ensure staffs receive training appropriate to the work they are to perform, and from accredited trainers. The home must ensure that the care staffs receive formal supervision at least 6 times a year. This would include recording the supervision and judgement making about an individual’s performance in a descriptive way. The Elizabethan Care Home DS0000045208.V337664.R01.S.doc Version 5.2 Page 6 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. The Elizabethan Care Home DS0000045208.V337664.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Elizabethan Care Home DS0000045208.V337664.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had ensured a comprehensive need assessment prior to the admissions of potential service users’. EVIDENCE: The home had updated the statement of purpose and the service user guide that enabled potential service users’ to make an informed decision. On this inspection 5 service users care records were seen and found that the home had carried out needs and risk assessment of the service users’ prior to their admission to the home. The needs assessments covered areas such as personal history, respiratory problems, digestive problems, current pressure sore, allergies, degenerative disorders, strokes, thyroid problem, epilepsy, diabetes, alcohol abuse, previous operations, mobility, MRSA, sensory, medication, dental, elimination/continence, communication, dementia, feeding, and personal hygiene. The risk assessment covered areas such as pressure sore, falls, mobility, bathing, toileting, in pain location, sight, eating, self- The Elizabethan Care Home DS0000045208.V337664.R01.S.doc Version 5.2 Page 9 medication and smoking. The assessments also covered social and recreational preferences. The home did not have service user for intermediate care. The Elizabethan Care Home DS0000045208.V337664.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, & 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home had carried out comprehensive need assessments and developed individual care plans. The care plans needed regular review and update. EVIDENCE: The home had developed care plans for the service users on the basis of the needs and risk assessments carried out prior to their admission to the home. Service users do not take their own medication; the home had trained staffs to administer medication. The home’s annual review process ensures the privacy and dignity of the service users’. On this inspection 5 service users’ were case tracked on a random sample, their details are as follows: Service user – 1 the preadmission assessments was carried out on the 25/08/05 and the care plan covered areas such as family tree, personal care: dressing, washing, bathing, toileting, walking, transporting, dementia, medication, night safety, meals, mobility, incidents of falls, incidence of pressure sores, nutrition screening and pressure sore risk assessment The Elizabethan Care Home DS0000045208.V337664.R01.S.doc Version 5.2 Page 11 reviewed every month. GP and district nurse appointments records were maintained. The care plan covered medication dated 13/01/06 which did not coincide with the current mars sheet for example salbutomol – inhaler, metoclopramide – anti sickness tablet, ciprofloxine – antibiotic and fluccloxacitin – antibiotic were not on the current mar sheet. The manager informed on this inspection that the care plan was not updated when the medication was changed. The home needs to update care plan as and when the needs and services undergo change as well as, the medication section of the care plan regularly. The mar sheet and the medicine seen on this inspection correlated. Service user – 2 preadmission assessments was carried out on the 23/03/06. The care plan dated 29/03/06 covered areas such as personal care: dressing, washing, bathing, toileting, walking, transporting, dementia, medication, night safety, meals, mobility, incidence of falls, pressure sore, lifting, aggression, nutrition, weight, feet, GP visit of 14/03/07, 20/03/07 and 03/05/07 change of medication prescribed. The service user being physically and verbally aggressive incidences were recorded when personal care and medication was given. The service user had refused medication as prescribed in the mar sheet from 07/05/07 to 17/05/07 except for application of cream. The manager informed, that the home was coordinating with the social worker and taking the route of ‘independent mental capacity advocate’ and plan to review the risk assessment and update the care plan. In response to the feedback on inspection, the commission had received a letter from the manager on the 24/05/07 regarding medication that ‘Dr Schoeman from Lime trees (MHOP) has written to the service user’s GP stating that he thinks it will be beneficial to her to have her medication administered covertly. The home was now awaiting reply. The home was also going through the process of getting an advocate for her with regards to the home no longer being able to meet the service user’s needs and the lack of mental capacity. Service user – 3 care plan was developed on the basis of the preadmission assessment that covered personal care: dressing, washing, bathing, toileting, walking, transporting, dementia, medication, night safety, meals, mobility, incidence of falls, nutrition, pressure sore risk assessment was carried out every month, feet and weight checks carried out every month. GP and hospital visit were undertaken as required. The mar sheet and the medicine was seen for the dates from 7/05/07 to 17/05/07 and found both coincided with each other. The care plan was reviewed on the 30/03/06 in which the service user, service user’s son, carer, and the manager participated. Service user – 4 care plan was developed on the basis of the preadmission assessment that covered personal care: dressing, washing, bathing, toileting, walking, transporting, dementia, medication, night safety, meals, mobility, incidence of falls, nutrition, pressure sore, personal risk assessment was carried out every month. The care plan was not updated to cover the additional medication that was recorded on the mar sheet, which includes adcal – calcium The Elizabethan Care Home DS0000045208.V337664.R01.S.doc Version 5.2 Page 12 chewable and Latanoprost – eye drop. However, the mar sheet and the medicine was seen for the dates from 7/05/07 to 17/05/07 and found both coincided with each other. Service user – 5, preadmission assessment was carried out on the 08/03/07. Care plan was developed on the basis of the preadmission assessment that covered personal care: dressing, washing, bathing, toileting, walking, transporting, dementia, medication, night safety, meals, mobility, incidence of falls, nutrition, pressure sore, personal risk assessment was carried out every month. The care plan, current medication, mar sheet and the medicines was compared on this inspection for the dates 01/05/07 to 18/05/07 and found that the 3 medicines namely paxazosin, omepazole and perindapril recorded as the current medication in the care plan did not match with the current prescription on the mar sheet. The manager informed on this inspection that the care plan was not updated when the medication was changed. The home needs to update care plan as and when the needs and services undergo change as well as, the medication section of the care plan regularly. The mar sheet and the medicine seen on this inspection correlated. In response to the feedback on inspection, the commission had received information from the manager on the 24/05/07 regarding medication said that the information on the MAR sheets now coincide with what is documented in the care plans. This has now been actioned. Regarding the 6 monthly care plan reviews; of the 20 service users’ 10 service users’ whose 6 monthly care plan reviews were outstanding are now planned for completion by the 31/05/07. A separate list of every service user with the date was received at the commission. The Elizabethan Care Home DS0000045208.V337664.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. This judgement has been made using available evidence including a visit to this service. The service users’ were engaged in appropriate activities and relationships with their family and friends. The dietary needs of the service users’ were taken care. EVIDENCE: The home’s annual review and the monthly review mechanisms were in place to ensure the socio-cultural needs of the service users’ were met, the quality assurance action plan for 2007 was seen on this inspection. The home had an activity schedule that included videos, TV, reading, exercise with ball, coffee morning, visit to dominos, sing along, music, colouring and painting, skittles, visit to park and bingo. However, not all the service users actively take part in all of these activities and there were few who enjoy. The service users’ family members and their representatives were encouraged to participate in the annual review; few service users’ do visit their families as well. Service users’ were encouraged to have their own choice of time for going to bed, food menu, maintaining their own money, what they would like to wear. The home had carried out a nutritional assessment of all service users and their food menu was customised based on the outcomes of the nutritional assessments. Nutritional assessments were carried out as part of the needs The Elizabethan Care Home DS0000045208.V337664.R01.S.doc Version 5.2 Page 14 assessment and care planning process and then followed up by every six months review. The home would carry out nutritional assessment as and when required for service users when observed that the service user’s weight was reducing. The Elizabethan Care Home DS0000045208.V337664.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. This judgement has been made using available evidence including a visit to this service. The home had a complaints policy and procedure that ensured the service users’ were protected from abuse. EVIDENCE: The home had a robust complaint policy and procedure, which was available to all the service users’ and their representatives. The service users’ are protected from abuse. For example: Service user – 2 was being physically and verbally aggressive incidences were recorded when personal care and medication was given. The service user had refused medication as prescribed in the mar sheet from 07/05/07 to 17/05/07 except for application of cream. The manager informed, that the home was coordinating with the social worker and taking the route of ‘independent mental capacity advocate’ and plan to review the risk assessment and update the care plan. In response to the feedback on inspection, the commission had received information from the manager on the 24/05/07 regarding medication that ‘Dr Schoeman from Lime trees (MHOP) has written to the service user’s GP stating that he thinks it will be beneficial to her to have her medication administered covertly. The home was now awaiting reply. The home was also going through the process of getting an advocate for her with regards to the home no longer being able to meet the service user’s needs and the lack of mental capacity. The Elizabethan Care Home DS0000045208.V337664.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, 22, 24, 25 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was clean and tidy. The home need to take appropriate measures to ensure that the hot water temeperatures are taken at regular intervals of all water points. EVIDENCE: On a partial tour of the premises, the home was found clean and tidy. The kitchen cupboard door, service users rooms’ furniture cupboard and wardrobes broken locks have been fixed. Maintenance person services have been regularasied and were improved. Water temperatures were recorded as top on the 28/01/07, bottom on the 19/02/07 middle on the 20/03/07, and then again bottom on 24/04/07 and top bath 01/05/07. There was no clarity with the regard to the frequency and whether all water point temperature checks were carried out. In response to the feedback on inspection, the commission had received letter from the manager on the 24/05/07 regarding hot water temperature checks that the maintenance person had taken temperatures from every water point, and will be done every week hereafter. The Elizabethan Care Home DS0000045208.V337664.R01.S.doc Version 5.2 Page 17 It was reported in the previous inspection report that the entrance to the home was inappropriate as the service users use the entrance that takes you through the laundry. A requirement was made to this effect to provide a suitable ramp. There was no evidence provided on this inspection that the registerd provider had made any attempts to make an application to the authorities concerened for the construction of ramp. However, the provider and the manager stated that the service users’ do not use the door leading to the laundry which is now accessible only to the staff. The service users now use the drive way and the door leading to the patio and lounge. The Elizabethan Care Home DS0000045208.V337664.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 adequate. This judgement has been made using available evidence including a visit to this service. The staff had good working relations with the service users’. The home must provide evidence on inspection that all statutory checks of staff have been carried prior to their employment. EVIDENCE: On this inspection 4 staff members’ files were seen. 3 staff members had application, interview record, 2 references, CRB, contract of employment, induction, appraisal, and supervision record. However, 1 staff member did not have a professional reference, employment history and the salary indicated on the work permit and the contract did not match. The staffs have undergone mandatory training that includes moving and handling, POVA, dementia, first aid, food and hygiene, health and safety and pressure care. However, there was no information available about the trainer with regard to their accreditation for training staff. At present, the manager was developing staffs training plans in response to the training needs of the staffs. It was observed during the inspection that the staff have good working relations with the service user and the service users have confirmed the same when spoken too. In response to the feedback on inspection, the commission had received a letter from the manager on the 24/05/07 regarding staff records the manager had spoken to the responsible individual and the home will arrange information about one staff employment history, reference from a professional and details The Elizabethan Care Home DS0000045208.V337664.R01.S.doc Version 5.2 Page 19 of qualification as soon as possible. Regarding staff training the commission had received information about 15 staff members trainings required and time plan for imparting training for each staff member, and with regard to the accreditation of training provider, the manager said that they will update the commission when they have more information. The Elizabethan Care Home DS0000045208.V337664.R01.S.doc Version 5.2 Page 20 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. This judgement has been made using available evidence including a visit to this service. The home manager was competent and ensured the service delivery to meet the assessed needs of the service users’. However, some aspects of management that cover review and update of care plan, staff supervision, staff statutory checks and staff training needed improvement in the best interest of the service users’. EVIDENCE: The manager and the staff have good working relation with the service users’. 6 Staff supervision records have been seen on this inspection and found that the supervisions have been carried out regularly. However, the tool used for supervision was a tick box tool without providing scope for narrative and proposed plan of action recording and specific job of the staff member. In response to the feedback on inspection, the commission had received information from the manager on the 24/05/07 regarding supervision that May 2007 supervisions have started today and used the written supervisions during The Elizabethan Care Home DS0000045208.V337664.R01.S.doc Version 5.2 Page 21 discussion with staff and incorporated areas of action, instead of the tick sheets. The home had developed an in-house financial management system with regard to the monies of service users’ and followed the same. The home manages the monies of 3 service users’, reported in the pre-inspection questionnaire. As part of the annual quality assurance system the home had sent out questionnaire to relatives and family members of the service users’ for their comments about the service provision and any suggestions for improvements. The home had analysed the information provided by the family members and acted upon their suggestions. The action plan for the year 2007 covered; large print books for the service users’, curtain rail, bubble bath and curtains in the lounge, clothes of service users’ not to be put in the dryer and towels and flannels are brought back to the service user’s room after the wash, memory boxes as an activity to be introduced and flowerbeds to be arranged in the patio. The commission had undertaken service users’ survey prior to this inspection, to get the feedback from the service users’ and their family members about the care and services they get from the home. A pre-inspection questionnaire was also used for the responsible individual/manager to provide information to the commission with regard to various aspects of care provision and delivery they undertake. Some quotes in the words of the service users’: Service user – 1 said that ‘I have lived here for nearly six months and I have been well looked after, no complaints at all, I feel safe here’. Service user – 2 said that ‘I have no complaints. I feel that the staff at the Elizabethan look after my mother extremely well’. Currently, the home had a registered manager, who will be on maternity leave beginning August 2007. In the absence of the registered manager, the current deputy manager was asked to take on the manager’s responsibilities. There was no information available on this inspection about the staff recruitment plan to take over the responsibilities of deputy manager. The capacity of the current deputy manger to perform the role of a manager was not inspected on this inspection. The Elizabethan Care Home DS0000045208.V337664.R01.S.doc Version 5.2 Page 22 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 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 3 X 3 2 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 The Elizabethan Care Home DS0000045208.V337664.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 (2) (b) (c ) Requirement The service user’s plan is reviewed, updated to reflect changing needs and current objectives for health and personal care. The home must ensure that all hot water points’ temperature is taken at regular intervals to prevent risks of scalding. The home must ensure to operate a through recruitment procedure. The home must ensure staffs receive training appropriate to the work they are to perform, and from accredited trainers. The home must ensure that the care staffs receive formal supervision at least 6 times a year. This would include recording the supervision and judgement making about an individual’s performance in a descriptive way. Timescale for action 15/07/07 2. OP25 13(4) 31/05/07 3. 4. OP29 OP30 19 (4) (c) 18 (1) (c) 30/06/07 31/07/07 5. OP36 18 (2) 30/06/07 The Elizabethan Care Home DS0000045208.V337664.R01.S.doc Version 5.2 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Elizabethan Care Home DS0000045208.V337664.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Bedfordshire & Luton Area Office Clifton House 4a Goldington Road Bedford MK40 3NF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Elizabethan Care Home DS0000045208.V337664.R01.S.doc Version 5.2 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!