Care Home: Eliza House

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What the care home does well The home had a relaxed and friendly atmosphere. There is a good rapport between residents and staff. People who use the service are treated with respect and their dignity and privacy is valued and upheld. Staff demonstrated a good knowledge of residents needs and consequently an individualised service is promoted. Residents have good access to health care professionals. The home makes sure that people`s needs are assessed before they move in so that people know the home will be able to meet their needs. Residents of the home feel that the staff are kind and polite and support them properly. There is a variety of activities available to residents and people have a say in how the home is run. The manager is working hard to further improve the service and encourages training for all staff. What has improved since the last inspection? People we spoke with told us that the quality of the service has improved since the manager has been working there. Six requirements were issued at the last inspection and the manager has complied with all of these. Any problems in the home are being reported to the Commission and where appropriate, are being investigated in a professional manner. A review of the catering arrangements has taken place, with the participation of residents, and as a result residents have told us they are happy with the food provided by the home. Areas affected by water damage have been redecorated. Unfortunately the cause of these leaks has not yet been established and further work needs to be done. The systems for providing petty cash have been reviewed and streamlined so that there is now more flexibility in making small purchases for the things residents might need. CARE HOMES FOR OLDER PEOPLE Eliza House 467 Baker Street Enfield Middlesex EN1 3QX Lead Inspector Mr David Hastings Unannounced Inspection 7th May 2008 10:00 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 Eliza House DS0000010670.V363180.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. Eliza House DS0000010670.V363180.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eliza House Address 467 Baker Street Enfield Middlesex EN1 3QX 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) 020 8367 8668 020 8367 2129 Peaceform Limited Post Vacant Care Home 26 Category(ies) of Dementia - over 65 years of age (26), Old age, registration, with number not falling within any other category (26) of places Eliza House DS0000010670.V363180.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home must not take people who have severe dementia with challenging behaviour or nursing needs. 19th June 2007 Date of last inspection Brief Description of the Service: Eliza House is a purpose built care home that is registered to care for up to twenty six frail elderly people, some of whom may have dementia. There are twenty six single bedrooms and service users share a large lounge, divided into two seating areas plus a dining room, bathroom, shower room and outside seating areas. The home is operated by Peaceform UK Limited who also owns other care homes in the UK. The home is located a short bus ride away from Enfield Town and is close to a park. The fees are normally £416 to £437 for each placement, and service users are expected to pay separately for hairdressing, chiropody, and some toiletries. The provider must make information available about the service, including inspection reports, to service users and other stakeholders. Eliza House DS0000010670.V363180.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 2 stars. This means the people who use this service experience good quality outcomes. This Key Unannounced inspection took place on Tuesday 6th May 2008 and was completed on the same day. The inspection lasted seven hours. We spoke with five staff on duty during the inspection. We spoke with ten residents of the home and three visitors. We observed the interactions between staff and residents. We inspected the building and examined various care records as well as a number of policies and procedures. All the residents we spoke with said they were happy with care and support they received. One resident told us, “The staff are very good, they will do anything for you”. What the service does well: What has improved since the last inspection? People we spoke with told us that the quality of the service has improved since the manager has been working there. Six requirements were issued at the last inspection and the manager has complied with all of these. Any problems in the home are being reported to the Commission and where appropriate, are being investigated in a professional manner. A review of the catering arrangements has taken place, with the participation of residents, and as a result residents have told us they are happy with the food provided by the home. Areas affected by water damage have been redecorated. Unfortunately the cause of these leaks has not yet been established and further work needs to be done. The systems for providing petty cash have been reviewed and Eliza House DS0000010670.V363180.R01.S.doc Version 5.2 Page 6 streamlined so that there is now more flexibility in making small purchases for the things residents might need. What they could do better: 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. Eliza House DS0000010670.V363180.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 Eliza House DS0000010670.V363180.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): 1 and 3 (6 not applicable) People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Prospective residents have accurate information about the home in order to make an informed choice about where to live. People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. EVIDENCE: We examined the home’s “Statement of purpose” and “Service user guide”. These documents describe the aims and objectives of the home and the facilities available to people coming into the home. These documents also inform social workers looking for placements for people. These documents contained clear information to prospective residents about what services are available as well as the aims and objectives of the home. Eliza House DS0000010670.V363180.R01.S.doc Version 5.2 Page 9 There was a clear statement that people from different backgrounds and cultures are encouraged by the home. The manager was able to describe how the needs of people from different backgrounds and cultures can be met at the home including appropriate diets and religious observance. Pre admission assessments were examined for five people who are now living at the home. The information was satisfactory and clearly outlined each person’ s individual needs. There were also detailed assessments from the local authority to assist the home in their own pre admission assessments. There was evidence on pre admission assessments that the person or their representative had been involved in their initial assessment. There was evidence that these identified needs were also being recorded in each person’s individual care plan. People also have a review of their placement 4-6 weeks after being in the home. This means that people have the opportunity to decide if the home is right for them. On the day of the inspection the manager was organising one of these reviews. Eliza House DS0000010670.V363180.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 and 10 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans clearly set out residents’ health, personal and social care needs so that staff know how best to support everyone at the home. Residents have good access to health care professionals and they are treated with respect. Residents get the medication they require, at the right times and by appropriately trained staff. EVIDENCE: Five care plans were examined. Each plan had a summary of the person’s care needs including their physical, emotional and social needs. Each plan gave clear instructions to staff about how best to care for each person. Care plans were generally being reviewed on a regular basis and updated where needed. Each person’s plan of care included an assessment of the risk of falling and how staff are to reduce this risk, for example, having two staff to help with personal care tasks or by supervising the resident when they walk around the home. Other risk assessments were seen including moving and handling, pressure care and nutrition. There was also a separate night care plan detailing when the person likes to get up in the morning and retire of an evening. It was Eliza House DS0000010670.V363180.R01.S.doc Version 5.2 Page 11 clear that people could get up when they wanted as there were still a number of residents having breakfast when we visited at about 10:30am. Work has been undertaken to gain a social history of people at the home so that staff can have an insight into what the person was like before they moved into the home. Visits by health care professionals such as doctors, district nurses, chiropodists, dentists and opticians were being recorded on plans we examined. These showed that people had good access to these professionals. This was also confirmed by residents we spoke with. Care plans were being reviewed but there was little evidence that residents had been involved in the review of their plans. Although all the people we spoke with said they were happy with their care, it is important that people are given an opportunity to decide if they want changes to their plan of care. A good practice recommendation has been issued that people are consulted about their care and the quality of the care they receive on a regular basis when their care plan is being reviewed. Records and procedures were examined in relation to the receipt, storage, administration and disposal of medication. These records were generally satisfactory, we saw that all medication coming into the home was being recorded accurately although some medication being carried forward to the next month was not always being added to the stock of medication. This was discussed with the deputy manager who said she would make sure this happens from now on. The temperature of the medication storage area was not being monitored to make sure the area was not too hot and so possibly affect the medication. A requirement has been issued relating to this in the relevant section of this report. A requirement was issued at the last inspection that an investigation must be carried out concerning an incident of missing medication. A satisfactory report of this investigation was sent to the CSCI and the requirement has now been complied with. Records we examined in relation to the administration of medication indicated that people were getting the right medication at the right times. Photos of residents were attached to their medication records so that staff could double check who they were giving medication to. Medication training certificates were seen for staff who are authorised to administer medication. We saw a number of examples of supportive staff interactions with people and staff were able to describe to us how they ensure the privacy of people they support. We saw staff knocking on resident’s bedroom doors before entering. People we spoke with told us that the staff were respectful and kind towards them. Eliza House DS0000010670.V363180.R01.S.doc Version 5.2 Page 12 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 and 15 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides varied activities for people who use the service in order to keep them suitably occupied and engaged. Visitors to the home are encouraged and welcomed. Residents are able to exercise choice and control over their lives. The home provides people with a wholesome appealing balanced diet. EVIDENCE: People’s interests and social and cultural needs are recorded on their plan of care. There are some residents from different backgrounds and cultures living at the home. The manager said that the cultural needs of these residents’ are being met by the home and appropriate food can be provided by the kitchen if needed. One resident was going to church on the day of the inspection. There appeared to be enough staff on duty to make sure that residents were suitably engaged and occupied. Staff were observed sitting and chatting with residents and residents were clearly benefiting from the staff contact. The home employs an activities worker who was carrying out a discussion group in the afternoon which included listening to music. There were lots of Eliza House DS0000010670.V363180.R01.S.doc Version 5.2 Page 13 activity equipment and books around the lounge which residents had easy access to. Visitors to the home told us that they could visit at any reasonable time and that they were made welcome by the management and staff. Residents we spoke with confirmed this. One visitor told us, “I come most days” and “I can come in whenever”. One visitor said they would like to be more involved in the care of their relative. The manager told us that family contact is encouraged. There is a regular and separate relatives meeting held at the home. Minutes of these meetings indicated that relatives and friends were encouraged to take part in the day to day activities of the home. There are regular residents’ meetings and people told us they have a say in how the home is run. For example we saw that people are consulted about activities and the menus in the home. One resident said, “They don’t tell you what to do”. Another person told us that they were never, “Bossed about” at the home. Staff we interviewed were able to give us practical examples of how they offer choice to people living at the home. The kitchen was inspected. Fridge and freezer temperatures were being recorded and there were sufficient amounts of fresh fruit and vegetables available. The cook was interviewed and had a good knowledge of individual resident’s dietary needs and preferences. Currently the home is trying out frozen, pre-cooked food at lunchtimes throughout the week. The manager said that residents have a cooked breakfast and evening meals and food at weekends in freshly prepared by the cook. The manager said she would be discussing the success or otherwise of these frozen meals at the next residents’ meeting. The meals we saw on the day of the inspection looked and smelt appetising. People who use the service confirmed that the food was good at the home and that they always get enough to eat. One person commented that the food was, “Lovely”. Another person said the food was, “Worth eating”. There appear to have been some problems in the past with catering at the home and a requirement was made at the last inspection that the catering structure is reviewed. This requirement has now been complied with. Eliza House DS0000010670.V363180.R01.S.doc Version 5.2 Page 14 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 and 18 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Complaints are taken seriously and responded to in a professional manner. People at the home are protected from abuse by clear policies and procedures and by an appropriately trained staff team. EVIDENCE: The home has satisfactory policies and procedures in relation to complaints and the protection of residents from abuse. No complaints have been received by the home since the last inspection. Previous complaints recorded, had been dealt with appropriately and in line with the home’s complaints procedure. All the residents and visitors we spoke with said they had no complaints about the service but were clear that they would say something if they had a concern. One resident said, “I’ve got no complaints about anybody”. Another resident said that if she had any problems, “I’d go and see the supervisor”. Staff were able to describe how vulnerable people could be at risk of abuse in a residential care setting. All staff interviewed were clear of their responsibility to report any suspicions of abuse to the appropriate authorities. Residents that we spoke to said they felt safe and well supported at the home. One resident said, “I’m treated very well, I’m respected, I feel safe here”. Records indicated that staff have undertaken training in the protection of vulnerable people in September 2007. Eliza House DS0000010670.V363180.R01.S.doc Version 5.2 Page 15 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 and 26 People using the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is clean and furnished and decorated to a satisfactory standard. Further work needs to be undertaken to ensure that people who use the service live in a secure environment. EVIDENCE: We toured the home and met with a number of residents in their rooms. The general maintenance and decoration of the home is satisfactory. There appears to have been a lack of investment in the fabric of the home and although the manager is working very hard to address this, there are still some areas that need improvement. There appears to be a chronic problem with the plumbing in the home and requirements have been made at previous inspections concerning water damage. The manager is well aware of this issue and has tried to have this investigated on a number of occasions. Areas that have sustained water damage in the past have been redecorated but in some cases this damage has Eliza House DS0000010670.V363180.R01.S.doc Version 5.2 Page 16 returned. A new requirement has been issued that the cause of these leaks is further investigated by a registered plumber. This requirement supersedes the two requirements issued at the last inspection. The carpets in the entrance and lounge areas are being almost constantly steam cleaned but may be coming to the end of their useful function. There was a musty smell apparent which could indicate the carpets are becoming harder to keep clean. A good practice recommendation has been issued that the carpets in the entrance and lounge areas are replaced. A good practice recommendation was issued at the last inspection that the general repair and refurbishment of the building continues including the redecoration of the corridors. This recommendation remains. The building has very little storage space and as such some areas have become cluttered and may present a risk to people moving about. A good practice recommendation has been issued that the registered provider explore ways to increase the storage areas in the home possibly but providing a shed in the courtyard area to store equipment safely. We noted that some window restrictors on the ground floor were broken. This could present an increased risk of intruders entering the home. A requirement has been issued that all windows on the ground floor are fitted with fully functioning window restrictors. On the day of the inspection the lounge areas were quite warm and could become uncomfortable for residents in the summer months. A good practice recommendation has been issued that the registered providers investigate cooling systems for the lounge areas that can be deployed during hot weather. The laundry was inspected and although it was untidy the equipment was functioning properly and the area was clean and infection control measures were being followed appropriately. People we spoke with said the home was clean and, apart from the slightly musty smell in the entrance hall, there were no offensive odours present on the day of the inspection. Eliza House DS0000010670.V363180.R01.S.doc Version 5.2 Page 17 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 and 30 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The staff at the home work very hard to meet the needs of the residents and are provided with good training opportunities to further enhance their knowledge and skills. Recruitment practices are sufficiently detailed in order to protect residents at the home. EVIDENCE: The staffing rota was examined and indicated that there are four care staff on duty in the morning, three care staff on duty in the evening and two waking night staff on duty during the night. Both residents and staff that we spoke to said they thought the staffing numbers were sufficient. Staff did not appear rushed and seemed to have time to sit and chat with residents and meet their personal care needs. One resident commented. “Everyone is very friendly”. According to information received from the home prior to the inspection, most staff have completed their NVQ level 2 or are undertaking this qualification at present. A number of staff are also undertaking the NVQ level 3 in care. Staff were very positive about the training offered by the home and records and certificates seen indicated that staff are attending the appropriate training they need to support people properly and safely. This training included Eliza House DS0000010670.V363180.R01.S.doc Version 5.2 Page 18 medication, moving and handling, adult protection and infection control. The manager told us that most staff have also undertaken an NVQ in dementia care. One staff member commented that, “The manager updates us with training all the time” Three staff files were examined from staff recently employed by the home. We checked these files to see if the home’s recruitment procedures were being followed so that residents are protected from unsuitable staff working at the home. The files examined contained all the information needed to protect residents including two written references, proof of identity and criminal record checks. The manager said she checks references by confirming information over the phone with the referee. Eliza House DS0000010670.V363180.R01.S.doc Version 5.2 Page 19 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, 34, 35, 37 and 38 People using the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The manager of the home knows the residents very well and understands their needs. Residents have opportunities to have a say in how the home is run. Residents’ financial interests are being safeguarded. The health and safety of residents and staff are generally being promoted and protected. EVIDENCE: The manager has been running the home for about two years and residents, staff and visitors we spoke to were very positive about the improvements she has made. One relative commented that since the change of manager the home has, “very much improved”. A member of staff said the manager, “Tells it to you straight”. One resident told us, “She listens”. Eliza House DS0000010670.V363180.R01.S.doc Version 5.2 Page 20 The manager will need to be registered with the Commission and a requirement relating to her registration has been made in the relevant section of this report. The home has regular residents and relatives meetings to give people the opportunity to comment on the way the home is run and to make suggestions for improvements. Minutes seen indicated that changes have been made as a result of these meetings. For example residents are very involved in the choosing of menus at the home. Residents have also requested more outings and the manager is planning these trips out. Through discussion with the manager it was evident that she is aware of the improvements needed at the home and is working towards these. Residents and their representatives are given regular quality questionnaires. To fully meet this standard the manager will need to collate the information received and make this information available to all interested parties. A requirement has been issued relating to quality assurance within the home. A requirement was issued at the last inspection that the home maintains appropriate amounts of petty cash in order to provide more flexibility in making small purchases. The manager said that petty cash systems have improved and that she is now able to buy any small items that residents may need. The home holds small amounts of money on behalf of residents so that they can pay for minor expenses such as toiletries and hairdressing. A sample of these accounts were checked and found to be accurate. A requirement was made at the last inspection that the home must notify the Commission of any incidents that affect the well being of residents at the home. This is now taking place and so the Commission is being kept up to date with any possible issues at the home. During a tour of the building we noticed that some bedroom doors were being wedged open. The manager said that this only happened during the day and that all doors were shut at night. The manager also told us that risk assessments had been completed for all residents who wanted their door to be open. It would be safer for residents if door guards were fitted to any door that a person wanted to remain open. This is because if there was a fire the door guard would automatically close and reduce the risk of smoke inhalation. Although the home had an inspection from the fire officer in February 2008 this issue was not picked up. We spoke with the fire officer after the inspection and he told us that bedroom doors should not be wedged open and it was good practice to install door guards. We spoke with the manager about this and she told us she would ensure that all doors are kept closed until door guards have been fitted as requested by residents. We asked her to confirm this in writing to the Commission. Fire doors have been fitted in the corridors and these Eliza House DS0000010670.V363180.R01.S.doc Version 5.2 Page 21 automatically close when the fire alarm goes off. A requirement has been issued relating to door guards in the relevant section of this report. On the day of the inspection the fire alarm and emergency lighting was being checked and found to be working properly. Records seen indicated that staff have undertaken regular fire drills. It is important that these drills sometimes happen at night as there are less staff on duty. The manager said that those staff working at night have worked day shifts when the fire drills took place. However a good practice recommendation has been issued that night time fire drills take place on a regular basis so that the staff know what to do in the event of a fire. Records seen on the day of the inspection and information provided by the home prior to the inspection indicated that other health and safety matters were being properly managed at the home. These included electrical and gas safety as well as appropriate risk assessments. Training records examined indicated that staff have undertaken the relevant health and safety training to make sure that residents are cared for in a safe way. Eliza House DS0000010670.V363180.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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 3 3 X 3 2 Eliza House DS0000010670.V363180.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 OP9 Regulation 13(2) Requirement The registered person must ensure that the temperature of the medication storage area is checked and recorded daily. This is required as high temperatures can affect some medication. The registered person must ensure that the cause of the leaks in the home are investigated by a registered plumber and action taken to repair these leaks. The registered person must ensure that all window restrictors are functioning properly so that the security of the building is maintained. The registered person must ensure that the manager applies to the Commission to be registered as the home’s manager. The registered person must ensure that the results of quality monitoring surveys are collated and made available to all interested parties. This should ensure that residents and other stakeholders know DS0000010670.V363180.R01.S.doc Timescale for action 01/07/08 2. OP19 23(2) b 01/09/08 3. OP19 13(4) a 01/07/08 4. OP31 8(1) 01/07/08 5. OP33 24(2) 01/09/08 Eliza House Version 5.2 Page 24 6. OP38 13(4)a how well the home is doing to meet the aims and objectives of the service. The registered person must ensure that door guards are fitted to any bedroom doors that residents wish to remain open. This is to ensure that all bedroom doors are closed in the event of a fire. 01/07/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP19 Good Practice Recommendations It is recommended that the registered persons continue with the schedule of repair and refurbishment of the building to include the re-decoration of the corridors, and in particular the corridor of Beech wing. The registered person should ensure that residents are consulted about their care and the quality of this care when staff are reviewing care plans with them. The registered person should ensure that the carpets in the reception and lounge are replaced with either new carpet or a similar floor covering that is easier to keep clean. The registered person should ensure that more storage areas are provided in the home so that equipment can be stored out of the way. The registered person should explore ways of maintaining the lounge area at a comfortable temperature during the summer months. The registered person should ensure that night time fire drills take place so that staff working at night are confident about what to do in the event of a fire. 2. 3. OP7 OP19 4. 5. 6. OP19 OP19 OP38 Eliza House DS0000010670.V363180.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Eliza House DS0000010670.V363180.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. 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