Inspection on 29/08/08 for The Elizabethan Care Home

This inspection was carried out on 29th August 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Elizabethan Care Home 14/04/08

The Elizabethan Care Home 18/05/07

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 09/11/2008.

CARE HOMES FOR OLDER PEOPLE The Elizabethan Care Home 220 Old Bedford Road Luton LU2 7HB Lead Inspector Sally Snelson Unannounced Inspection 29th August 2008 09:20 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.V370941.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.V370941.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 No email 3/7/2007 Heritage Care Homes Ltd Vacant 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.V370941.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. 16th May 2008 Date of last inspection Brief Description of the Service: The Elizabethan is registered to provide services for twenty-one older people, ten of whom may also have dementia. Mr S Hussain is the proprietor. The company, Heritage Care Ltd, also operates two other care homes in the vicinity. The registered managers post is currently vacant. The home is located in a pleasant residential suburb of Luton with convenient access to the towns amenities and transport links. The accommodation is distributed over three floors that are accessible via a staircase and a shaft lift. Each bedroom is for single occupancy although a few rooms are large enough to accommodate two persons who wish to share. There is a lounge and dining room on the ground floor and toilet and bathing facilities on each of the floors. The garden to the front of the property is not accessible as it had a steep slope. The front entrance to the building is similarly restricted. Service users and visitors to the home therefore mostly use the door that leads directly into the communal areas. The majority of the rear of the property is given over to a large parking area. Beyond this was a further large grassed area. The acting manager reported that the minimum fee at the time of the inspection was £431 per week and the maximum £450. The Elizabethan Care Home DS0000045208.V370941.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This inspection was carried out in accordance with the Commission for Social Care Inspection’s (CSCI) policy and methodologies, which require review of the key standards for the provision of a care home for older people that takes account of service users’ views and information received about the service since the last inspection. Evidence used and judgements made within the main body of the report include information from this visit and a random inspection of 16th May 2008. This was a Key Inspection, and Regulatory Inspector Mrs Sally Snelson carried it out on The 29th of August 2008 from 09.20hrs. Since the last inspection on 14.4.08 the home had been the subject of a serious concern meeting. The home now has a new manager and the Local Authority have lifted their embargo on admissions. The home Manager was present throughout the visit to assist with any required information. Verbal feedback was given periodically throughout the inspection and at the end of the visit. During the inspection the care records of three people were case tracked. These included the most recent admission to the home, someone who had given cause for concern at the last inspection, and one other chosen randomly. This involved reading their records and comparing what was documented to the care that was, or had been provided. Documentation relating to: staff recruitment, training and supervision and medication administration were also examined as was health and safety documentation and other records. We would like to thank everyone involved for their support and assistance during this visit to the home. What the service does well: The home offers a homely place for people to live that is in a popular area of the Luton close to parks, the town centre and bus and rail links. The Elizabethan Care Home DS0000045208.V370941.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: There were still some areas that needed to improve including :All care plans must be written in the new format and monthly reviews of care plans must be documented. Whatever is needed to rid one area of the home from an offensive smell must be carried out. The Elizabethan Care Home DS0000045208.V370941.R01.S.doc Version 5.2 Page 7 Night staff must attend training the necessary training for them to provide appropriate care at night, so that medications can be spaced out regularly throughout a 24-hour period. All policies must be accurate, relate to the home and show that they have been kept under review. 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.V370941.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Elizabethan Care Home DS0000045208.V370941.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,6 People who use this service experience good quality outcomes in this area. The manager understood the importance, of people using the service, and their relatives, having enough information when choosing a care home. Admissions were not made until a full assessment of needs had been carried out, so that those involved could be sure needs would be met. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The new manager had reviewed and updated the current Statement of Purpose and the Service Users Guide and these documents now included all the required information. The manager had sent us an updated copy for the service file, and copies were available within the home. The Elizabethan Care Home DS0000045208.V370941.R01.S.doc Version 5.2 Page 10 As part of the inspection we looked in detail at the records of a person who had been admitted to the home the previous month. It was clear that staff had visited her in her previous care home and had assessed her needs, as well as relying on information from the previous home. This had resulted in a clear ‘pen picture’ which had been used to formulate care plans. Also in the file was an admission agreement, which included the fee, and had been signed and dated by the manager and the person using the service on the day they moved in. The manager told us that she encouraged people considering moving into the home to visit in advance of making the decision, but often this was not possible and a relative made the visit on the persons behalf. This home did not provide an Intermediate Care Service. The Elizabethan Care Home DS0000045208.V370941.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 People who use this service experience adequate quality outcomes in this area. A new care planning system had been introduced and as a consequence care needs were being delivered, but the documentation supporting reviews was not always precisely up-to-date. People using this service appeared happy with they way staff delivered their care and respected their dignity. Medication records were generally up to date and accurate. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: We looked at the care documentation for three people using the service. Since the new manager had been appointed she had introduced new care planning documentation that she had used in the past and was confident with. She had The Elizabethan Care Home DS0000045208.V370941.R01.S.doc Version 5.2 Page 12 re-written the majority of the care plans, and in doing so had ensured that all aspects of a persons care needs were included. However because of the amount of work this had generated, plus her on-going work towards meeting other requirements made at the last inspection, some of the plans had not been reviewed every month. The manager was aware of this and the need to delegate the responsibility for writing and reviewing care plans to some of the senior staff. Throughout the care tracking process we were not aware of any needs not being acted upon, but in order for this standard to be met there must be evidence of regular reviews. There was also a need for all information to be transferred to the individual care plans. For example, people had been weighed every month and their weights recorded in a notebook, but not always written in their care files in order to influence the reviewing process. Those care files that had been re-written were very neat, and because of the addition of a content sheet they were easy to work through. They had been written with care and gave detailed instructions to the staff. For example a plan for personal care explained that the person needed assistance from one member of staff to wash and dress, and then went on to describe what that staff member needed to do. Plans had also been written for short term and individual needs For example a person who was prone to wandering at night had a care plan to support how night staff should deal with this. He had also been provided with an alarm mat to alert staff to his movements. It was clear that his family had been involved in his care planning and have been invited to attend reviews in the home. A community nurse who was visiting, told us that the manager made appropriate referrals and acted correctly on any instructions given. The home had good relationships with most of the GP’s in the area and ensured people were visited regularly, and when necessary, by their GP of choice. At the last inspection on 14/04/08 an immediate requirements was made relating to medication storage and records. A compliance visit to check this immediate requirement was made 16/05/08 when it noted that the new manager, although only just in post had addressed many of the problems. During this inspection we checked the Medication Administration Record (MAR) sheets and the blister packs. These all corresponded correctly. We picked five resident’s ‘as required’ medication at random to reconcile. All reconciled correctly with the exception of one, where recent omissions on the MAR chart made it impossible to reconcile. However this was a minor shortfall and we were aware that staff had received additional training and the manager and deputy were auditing medications regularly. We were concerned that as the night staff had not been trained to give medication, routine medications were spaced over a 12-hour period rather than a 24-hour period. The Elizabethan Care Home DS0000045208.V370941.R01.S.doc Version 5.2 Page 13 The home has recently changed their pharmacy supplier and had purchased new medication storage equipment, particularly a controlled drug cupboard and a medication fridge. We were however disappointed to note this cupboard had been placed in an unlit area and meant staff had to move away from the area when administering the medications. Throughout the inspection people were observed being treated with dignity and respect. Staff made conversation with people when providing care and when going about other tasks. There was a natural rapport between the people living and working in the home, which made it feel like an extended family situation. Care plans included information about how a person wished to be cared for at the time of sudden death or illness. The information included details about any relatives that should be informed and how and when they wished to be called. The Elizabethan Care Home DS0000045208.V370941.R01.S.doc Version 5.2 Page 14 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 People who use this service experience good quality outcomes in this area. There were a variety of activities provided for people to join in with if they wished. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The new manager encouraged staff to spend time talking to people and stimulating them whenever possible, and as a consequence staff sat with people in between providing care whenever they had time. A new activity programme had been introduced which was much more realistic, and did not rely on the home having its own transport which had not been operational for sometime. Displayed throughout the home were cards and crafts that had been made by those living at the Elizabethan. People spoke of decorating plant pots and The Elizabethan Care Home DS0000045208.V370941.R01.S.doc Version 5.2 Page 15 baking cakes in addition to the usual activities, such as quizzes and games. Staff were also now recoding how an activity was received by a person, and how they were able to participate. Following some additional dementia training the home had purchase some particular equipment for those people with dementia, in addition to large jigsaws and playing cards. We noted that visitors were welcomed into the home at anytime and had been invited to join in some activities. Staff were planning a surprise birthday party for one person who did not have visitors. Throughout the day people were offered regular hot and cold drinks and biscuits. A bowl of fruit was available for people to help themselves from. The inspection spanned lunchtime. During the morning people using the service had made the choice between fish, sausage or egg with chips and beans, and alternatives were available for those who wanted something different. The manager had collected a variety of pictures of meals from magazines to make picture menus in order to help people with communication problems choose what they wanted to eat. The Elizabethan Care Home DS0000045208.V370941.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 People who use this service experience good quality outcomes in this area. The complaints procedure was displayed and the manager was aware of her responsibility when dealing with a complaint. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: A new complaints procedure had been written and was displayed; it now included more realistic timescales for investigation of a complaint and advising the complainant of the outcome. The manager was aware of her responsibility to investigate a complaint and keep any supporting documentation on file in the home. We discussed encouraging staff to document concerns raised with them in the same way so that an audit trail was available if a concern became a complaint. There was clear evidence from reading care files that the manager and the staff were aware of their responsibility to report incidents under safeguarding (SOVA) to us and to the local authority. The home reported all unexplained injuries using this procedure. We had been informed of an allegation of missing medication, which had also been reported to the police. This incident was under investigation. The Elizabethan Care Home DS0000045208.V370941.R01.S.doc Version 5.2 Page 17 All staff had undertaken some training on safeguarding vulnerable adults and the manager ensured that staff regularly updated the training and that new staff did not start work until they understood SOVA. The Elizabethan Care Home DS0000045208.V370941.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21,24, 26 People who use this service experience adequate quality outcomes in this area. This home provided a clean, comfortable and homely environment for most people, although an unpleasant smell was still apparent in one area. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Since the last inspection the home appeared much tidier, as equipment not in use was now being stored correctly and away from communal areas, and a bicycle had been removed from the hallway. We also believed the home was safer as areas that could pose a safety risk, such as the boiler room, were kept The Elizabethan Care Home DS0000045208.V370941.R01.S.doc Version 5.2 Page 19 locked. There was a marked improvement in the presentation of manager’s office, which although small was now organised. The manager had worked with the fire authority to ensure compliance with recommendations made as part of a recent fire service inspection. The past manager had not acknowledged the recommendations and could have put people’s lives at risk. The lawns at the back of the house had been cut and the car parking area was tidy. Some people using the service would still find it difficult to access the lawns as it is necessary to cross the gravelled car parking area, but staff confirmed that on summer’s days the garden was used. There was still a smell in one area of the home that appeared to be associated with continence problems. Regular shampooing of carpets had not addressed this completely and some carpets were to be replaced by alternative flooring. Toilet and bathing / shower facilities were sufficient in this home, and individual rooms had been decorated and furnished to personal taste. Some rooms contained furniture that individuals had brought into the home with them, making each bedroom individual. Photographs and personal assets reflecting individuals’ life history also enhanced a homely atmosphere. Laundry facilities were adequate and we did not witness dirty laundry being bought through communal areas of the home, as we had done at previous inspections. The Elizabethan Care Home DS0000045208.V370941.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): People who use this service experience adequate quality outcomes in this area. The manager recognised the importance of training and planned to provide a varied programme that met the requirements of the home. Staff recruitment was done safely to ensure that people were protected and only cared for by those checked as satisfactory to provide care. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: At the time of the inspection there were no staff vacancies at the home. On the day of the inspection the manager, a team leader and 2 carers in addition to a cook and cleaner were on duty to provide care for 18 people. Staff told us that they were happy to do additional shifts to cover sickness and holidays and would cover for the cleaner at weekends and the cook on her days off. The staff team were keen to learn and have training, and seniors spoke about the additional training they had undertaken since the last inspection. For example all those administering medication had now had some training to do so. The manager kept a matrix of the training and ensured that this was kept up-to-date so that she could identify who needed what training. The training matrix was discussed with individuals during supervision. The Elizabethan Care Home DS0000045208.V370941.R01.S.doc Version 5.2 Page 21 All new staff were now undertaking a period of induction and were working supervised initially. The manager was encouraging and supporting staff to attend additional training and complete NVQ’s. Care must be taken that the training covers all the needs of people living at the home to provide the evidence that the staff team can meet the assessed needs of individuals. The provider had agreed at a staff meeting to pay staff to attend up to two days training a year; this must be increased to three to be in line with standard 30 of the National Minimum Standards. We were concerned that the staff on night duty had not been given medication training, so night medications were routinely given before the day staff went off duty. At the last inspection recruitment processes had been satisfactory. At this inspection we looked at the file of a member of staff who had been employed by the new manager and noted that all the required checks had been undertaken and references taken up before she had been advised that she could start work. The Elizabethan Care Home DS0000045208.V370941.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37,38 People who use this service experience adequate quality outcomes in this area. The manager was developing systems that monitored practice and compliance with the plans, policies and procedures in the home. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: A new manager, Mrs Jane Roe, had been appointed following the last inspection. She took up the post on the 8th May 2008 and by the time of a random inspection to the home on 16th May 2008 she had identified what The Elizabethan Care Home DS0000045208.V370941.R01.S.doc Version 5.2 Page 23 needed to be done and started to produce an action plan. Mrs Roe had worked in the home before and had managed another home for the provider in the past. She had also been registered with us in the past. Staff spoke very highly of her management style and spoke of improvements she had made to the home that benefited them and the people living there. Since the last inspection we had required the provider to take responsibility for Regulation 26 visits. These are visits done by the provider, or by someone on the provider’s behalf, which audit how the home is being managed. The provider has identified someone within his family to do these and they are now being completed to a satisfactory standard. The manager stated that the visits and the resulting report were useful. In addition she was auditing different areas such as the kitchen, an audit of falls and an audit of medication. She told us she had sent out questionnaires to all relatives as soon as she started at the home and incorporated the findings of the questionnaires into her action plan. Accidents and incidents are being appropriately reported to The Commission for Social Care Inspection (CSCI) and other agencies as required. The home managed ‘personal allowance money’ for some of the people who lived there. A selection was sampled, as none of the people being tracked had money held by the home; all were found to be correct. Staff had not been used to being supervised the required six times a year. Since taking up her post the manager had supervised all the staff and had a plan to continue to supervise two monthly. The manager favoured task supervision but was aware she was required to have one to one time with a staff member as well. The manager was reviewing all the policies and procedures in the home and was aware that some were out-of-date and needed reviewing, she was also aware that the company may have updated some of the policies but that they had not been filed at the home. We looked at safety checks that had been carried out and noted that they were completed regularly and when an issue was identified a solution was sought. The Elizabethan Care Home DS0000045208.V370941.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 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 2 X X 3 X 3 x 2 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X 3 2 2 3 The Elizabethan Care Home DS0000045208.V370941.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement Care plans must be written for all areas of care provided to a resident to ensure that all staff are aware of the care needs, and these plans must be kept under review. This was almost met so the dated has been extended All medication procedures must be clearly recorded to ensure people receive the correct medication in a safe way and medication practices can be audited. There was a minor shortfall to this requirement so it has been extended. Medications must be spaced out regularly throughout a 24-hour period. Whatever is needed to rid one area of the home from an offensive smell must be carried out. This requirement now only relates to one area of the The Elizabethan Care Home DS0000045208.V370941.R01.S.doc Version 5.2 Page 26 Timescale for action 31/10/08 2 OP9 13(2) 12(1)(a) 31/10/08 3 4 OP9 OP19 OP26 13 (2) 12(1), 23(d) 30/09/08 30/11/08 5 OP28 18(1) 6 OP36 18(2) 7 OP37 17 home Night staff must attend training the necessary training for them to provide appropriate care at night. 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. Some work had been done towards addressing this requirement, so the date is extended. All policies must be accurate, relate to the home and show that they have been kept under review. 30/11/08 01/01/09 01/01/09 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 OP9 OP28 Good Practice Recommendations Consideration should be given to the lighting in the area that the controlled medication is stored. The manager should continue to ensure that the training programme meets the needs of the staff team to ensure that they can meet the needs of the people using the service. The manager should consider starting the process to become the registered manager. The manager should continue to audit the home and ensure that results of the audit reflect the home’s planning processes. 3 4 OP31 OP33 The Elizabethan Care Home DS0000045208.V370941.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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.V370941.R01.S.doc Version 5.2 Page 28 - 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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