Care Home: Elizabeth House

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What the care home does well The home has a `family` atmosphere and the emphasis is on the care of the residents with a person centred approach taken at all times. Comments were positive about the care provided and the manager and staff working within the home. The home is well supported by the local community with visitors from local schools. There are no restrictions on visiting times and visitors are encouraged to make themselves at home and have a warm drink. Children from the local school visit the home on Wednesday afternoons and help residents with arts and crafts activities. The home has sponsored a donkey named "Molly" that lives at a local sanctuary. Staff and residents also take part in reminiscence sessions with the aid of photographs. The residents all appeared very well cared for in particular with regard to their appearance and dress. Hair and beauty sessions take place regularly and foot spas. Comments from residents included: "It`s a home from home." "All the staff are lovely." Staff spoken with felt appreciated by management and well supported in their role. Through discussion with residents it was obvious that the care needs and choices of the residents come first with regard to the policies and procedures operating within the home.All staff are qualified and have a National Vocational Qualification in Care at level 2 or above. What has improved since the last inspection? The assessment that leads to the development of the care plan has been improved with a Person Centred Care Assessment ensuring that all individual needs are met and according to any religious or cultural requirements. The complaints procedure is now freely available with a copy placed in each residents bedroom. Care staff are gradually being provided with Training in Adult Protection recognition and the procedure to follow in the event of any allegation of abuse. A copy of the Bury Social Services Adult Protection Policy has been obtained and the manager has received training in how to investigate any allegation of abuse. A member of staff has been employed specifically to help with the teas and according to staff spoken with, this has given them more time to assist residents as necessary. There was evidence of staff training completed and the manager confirmed that they are now able to access a computerised system linked to Skills for Care that highlight any gaps in staff training records. A portable hoist is now available for the benefit of residents and staff. What the care home could do better: The manager and staff should familiarise themselves with the implications of the Mental Capacity Act particularly with regard to the initial assessment to ensure a correct assessment is made. Signatures should be obtained where possible from the resident, a relative or advocate when the care plan is devised or if any changes are made at review. All documents relating to the care of residents should be signed and dated by the staff member concerned. All staff should gradually be trained in Adult Protection and Abuse. The Annual Quality Assurance Assessment should be expanded upon with details of how the home is meeting the Care Homes Regulations/Standards.Informal support is good but staff would benefit from one to one formal regular supervision that provides an opportunity for `whistle blowing` and a review of residents needs within a confidential setting. CARE HOMES FOR OLDER PEOPLE Elizabeth House 147-155 Walshaw Road Bury Lancs BL8 1NH Lead Inspector Sue Dale Unannounced Inspection 4th March 2008 10:30 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 Elizabeth House DS0000008401.V359954.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. Elizabeth House DS0000008401.V359954.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elizabeth House Address 147-155 Walshaw Road Bury Lancs BL8 1NH 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) 0161 762 9394 0161 764 6700 canbra9@yahoo.co.uk Canbra Care Limited Ms Lynn Parsons Care Home 18 Category(ies) of Old age, not falling within any other category registration, with number (18) of places Elizabeth House DS0000008401.V359954.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st November 2006 Brief Description of the Service: Elizabeth House is owned and managed by Ms Lynn Parsons. The home can provide 24-hour care for up to 18 older people. The property is on Walshaw Road Bury and is about one mile from the town centre. There is a bus stop on the main road close to the home and there are shops nearby. The accommodation is provided on two levels with a lift giving access to the first floor. The home has ten single bedrooms and four rooms that are shared all of which have an en-suite toilet and hand basin. There is a well-furnished and comfortable lounge, a dining room and a conservatory that can be used all year round. Toilets and bathrooms are provided on both floors. The home has a garden area with seating that can easily be reached from the conservatory. Ample car parking is available at the back of the home and there is easy wheelchair access. A Service User Guide (Residents Information Guide) and a Statement of Purpose describing the home’s services is available and the provider gives other information about the home to new and prospective residents and their families verbally. A copy of the latest inspection report is available on request. Elizabeth House DS0000008401.V359954.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 star. This means the people who use this service experience good quality outcomes. The visit was unannounced and focused mainly on key standards. Information was also gained from the Annual Quality Assurance Assessment (AQAA) completed by the manager. The inspector was able to speak to service users and staff and examine various records. Surveys were provided to residents, staff, relatives/friends and health professionals prior to the inspection. There were no surveys returned from residents, relatives or health professionals; 3 surveys were returned from staff and they were all positive; there were no written comments. A tour of the home took place. What the service does well: The home has a ‘family’ atmosphere and the emphasis is on the care of the residents with a person centred approach taken at all times. Comments were positive about the care provided and the manager and staff working within the home. The home is well supported by the local community with visitors from local schools. There are no restrictions on visiting times and visitors are encouraged to make themselves at home and have a warm drink. Children from the local school visit the home on Wednesday afternoons and help residents with arts and crafts activities. The home has sponsored a donkey named “Molly” that lives at a local sanctuary. Staff and residents also take part in reminiscence sessions with the aid of photographs. The residents all appeared very well cared for in particular with regard to their appearance and dress. Hair and beauty sessions take place regularly and foot spas. Comments from residents included: “It’s a home from home.” “All the staff are lovely.” Staff spoken with felt appreciated by management and well supported in their role. Through discussion with residents it was obvious that the care needs and choices of the residents come first with regard to the policies and procedures operating within the home. Elizabeth House DS0000008401.V359954.R01.S.doc Version 5.2 Page 6 All staff are qualified and have a National Vocational Qualification in Care at level 2 or above. What has improved since the last inspection? What they could do better: The manager and staff should familiarise themselves with the implications of the Mental Capacity Act particularly with regard to the initial assessment to ensure a correct assessment is made. Signatures should be obtained where possible from the resident, a relative or advocate when the care plan is devised or if any changes are made at review. All documents relating to the care of residents should be signed and dated by the staff member concerned. All staff should gradually be trained in Adult Protection and Abuse. The Annual Quality Assurance Assessment should be expanded upon with details of how the home is meeting the Care Homes Regulations/Standards. Elizabeth House DS0000008401.V359954.R01.S.doc Version 5.2 Page 7 Informal support is good but staff would benefit from one to one formal regular supervision that provides an opportunity for ‘whistle blowing’ and a review of residents needs within a confidential setting. 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. Elizabeth House DS0000008401.V359954.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 Elizabeth House DS0000008401.V359954.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): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs are properly assessed before admission so that all parties are assured that identified needs can be met by the home. The home does not provide intermediate (rehabilitative) care so Key Standard 6 does not apply. EVIDENCE: The care files of admitted residents were checked for the required preadmission needs assessment information. From this information the home is then able to assess whether needs can be met and a care plan and a range of other care delivery information is then put together. All new residents routinely have an in-house pre-admission needs assessment done irrespective of whether they are self-funding or funded by the Local Authority. The manager usually visits new residents either at home or in the hospital as a part of the pre-admission needs assessment process. There have been some inappropriate admissions within the last 12 months and the Elizabeth House DS0000008401.V359954.R01.S.doc Version 5.2 Page 10 background and reason for these admissions were discussed with the registered provider. One of the admissions had been a transfer from another home and the information from the original assessment was incorrect and the resident required a specialist dementia care setting. Changes have been made to the assessment process having devised a Person Centred Care Assessment and this has been completed for the majority of the current residents; the assessment takes into account any religious or cultural requirements. A recommendation was made that there was a need to become familiar with the Mental Capacity Act and ensure that the assessment took into account the mental capacity of the person being assessed. The manager said that new residents and their families are welcome to visit the home where they can spend some time, meet the residents and the staff, and have a meal before deciding to live there. This visiting opportunity is described in the useful and informative Service User Guide (Residents Information Guide) Elizabeth House DS0000008401.V359954.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 Quality in this outcome group was good. A comprehensive care plan is produced that meets all physical/health and emotional requirements and appropriate medication policies and procedures are in place. Care was provided with dignity and respect by staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Several residents were case tracked. A person centred care planning approach is taken and the records seen were well laid out and divided into sections covering the assessment, risk assessment and care plan. General Practitioners/District Nurses etc visits, hospital appointments and telephone calls were recorded in a separate section and were very detailed showing that good liaison was in place with all health practitioners. Every effort is being made to determine and record the background/history of residents that will assist in compiling an effective care plan. A number of risk assessments were in place. These included an up to date manual handling assessment and a nutritional assessment tool that is used at the time of the Elizabeth House DS0000008401.V359954.R01.S.doc Version 5.2 Page 12 resident’s admission to the home and then afterwards as required. Nutritional wellbeing is also assessed by direct observation and by regular and up to date weight checks. Pressure area condition is also checked by direct observation with a pressure area care plan being available if required. A recommendation was made that a signature is obtained where possible from either the resident or a relative when the care plan is devised and to ensure that signatures and dates are included on all documents connected with the care plan. All medicines are safely and securely stored. The residents’ medicines are provided in pre-filled cassettes with pre-printed prescription/recording sheets also provided. These records were found to be properly completed and to be up to date and included a photograph of the resident. The manager confirmed that they have a good relationship with the local pharmacy and the manager audits the medication records every 3 months. No resident was dealing with his or her own medicines at the time of this visit. Residents spoken with were all complimentary about how staff assisted them with personal care tasks and felt their privacy and dignity was respected at all times and this was also observed during the inspection. Residents confirmed that staff had a “kind and considerate” manner and spoke to them in a “civil and courteous” way. Elizabeth House DS0000008401.V359954.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 group was good. Appropriate activities are in place according to the needs and capabilities of the service users. Contact is maintained with family, friends and the local community. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home provides a number of recreational and stimulating activities (e.g. quizzes, exercises, crafts, reminiscence sessions, shopping trips) that the residents are encouraged to join in with. A singer visits the home once or twice a month and community contact is enabled by pupils from a local school who visit the home on Wednesday afternoons when they help the residents with arts and crafts activities. The home has sponsored a donkey named “Molly” that lives at a local sanctuary. Staff spent time with the residents on a one to one or group basis in order to stimulate conversation and give them ‘quality’ time. Staff and residents also take part in reminiscence sessions with the aid of photographs. Elizabeth House DS0000008401.V359954.R01.S.doc Version 5.2 Page 14 Preparations were taking place for Easter celebrations including a buffet and the Mayor has been invited to judge an Easter Bonnet competition. At the time of the visit, a hairdresser was visiting the home and beauty sessions for the ladies are provided as well as foot spas for all residents. All the residents seen were clean and tidy and looked well cared for. One resident spoken with confirmed that he goes out on a daily basis and has been encouraged greatly by the staff to the point that he is able to walk much further than when he was first admitted to the home. His hobbies and interests are taken into account and is able to watch DVD’s and Sky Television in his own room. The resident’s social and recreational preferences are recorded in their care notes and a record is made of the activities that they have joined in with. Residents are able to choose which activities they wish to join in with and the times they wish to get up in a morning and go to bed. There have been issues in the past about residents being prepared for bed early; the registered provider confirmed that this is only done with the agreement of the service user to make them more comfortable such as after a bath. Visitors are welcome at any time and are encouraged to have a drink when they visit the home. The home has a three weekly menu that offers good nourishing food with the main meal served at lunchtime and a lighter meal at teatime. Warm food is always offered at midday and is often available at teatime. This menu provides a single choice but alternatives to the main menu are also available. Comments from residents included: “It’s a home from home.” “All the staff are lovely.” “I can’t remember how long I’ve been here but the staff look after me very well.” Elizabeth House DS0000008401.V359954.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 group was good. There is an appropriate procedure for dealing and recording any concerns about the care and facilities of the home. Polices and procedures are in place for protecting service users from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a satisfactory complaints procedure that states how a complaint is to be made, who to and that a response will be provided within 28 days. The procedure also includes how to contact the Commission for Social Care Inspection (CSCI). A record is kept of any complaints that detail the investigation and the eventual outcome; no complaints have been received since the last inspection on the 21st November 2006. A requirement was made at the last inspection for a copy of the complaints procedure to be clearly displayed within the home. The complaints procedure is now on display within each resident’s room apart from one resident who objected to it being displayed. Discussion with residents showed that they would feel comfortable about raising concerns and that they would “talk to the staff” or the manager. There are written procedures and policies covering adult protection, whistle blowing, the non-acceptance of gifts, borrowing money and legacies and the Elizabeth House DS0000008401.V359954.R01.S.doc Version 5.2 Page 16 home has a full copy of the Department of Health’s “No Secrets” document (detailed guidance on dealing with abuse). The manager has completed training from the point of view of ‘investigating’ any allegation of abuse and 3 staff have received Adult Protection Training with a further 2 due to attend the course in April 2008. All staff will gradually attend the training. The home is now part of the local Adult Protection Partnership and has obtained a copy of the procedures from the local authority as recommended at the last inspection. Staff spoken with during the site visit had some knowledge of Adult Protection procedures but had not yet attended any training. Elizabeth House DS0000008401.V359954.R01.S.doc Version 5.2 Page 17 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 & 26 Quality in this outcome group was good. The home provides pleasant and well looked after accommodation. All areas of the home including service users’ personal accommodation are safe, clean and comfortable. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home and grounds are safe, accessible, and well designed for the needs of the service users. There is a well-kept garden area at the rear of the home that is provided with seating, which is easily accessible from the conservatory. The building complies with the requirements of the fire service and environmental health department. A tour of the premises took place and the home was found to be warm, clean and free from any obvious hazards. Elizabeth House DS0000008401.V359954.R01.S.doc Version 5.2 Page 18 The home employs domestic help and staff help to ensure that personal items belonging to residents are kept tidy and according to the individual wishes of residents. As recommended at the last inspection, a copy of the certificate verifying the servicing of the home’s fire alarm system has been sent to CSCI. Elizabeth House DS0000008401.V359954.R01.S.doc Version 5.2 Page 19 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 group was good. Suitable numbers of competent, well trained and properly recruited staff ensures they are able to meet the needs of the service users safely. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager and the staff described a largely stable staff group some of whom have worked at the home for a considerable time, which ensures that residents are cared for by people they know and are familiar with. On the day of this inspection enough staff were on duty to meet residents care needs. Staff spoken with confirmed that there was sufficient time for them to carry out their duties and that it was helped by the fact that there was now additional help at tea times. The home is required to have 50 of the care staff with NVQ level 2 qualifications or above by the end of 2005. All care staff employed at the home have a National Vocational Qualification (NVQ) in Care at Level 2; 100 of the staff are therefore trained to the required level so the above target is exceeded. The home has a suitable recruitment policy and procedure and the files of staff recruited since the last inspection were examined. All appropriate checks have been undertaken prior to the commencement of new staff. Two written Elizabeth House DS0000008401.V359954.R01.S.doc Version 5.2 Page 20 references had been received prior to commencement and clearance had been obtained from the Criminal Records Bureau (CRB) and a check undertaken of the Protection of Vulnerable Adults Register (POVA). A volunteer employed by the home who at the last inspection had not been cleared by the CRB has since left the home. Staff spoken with confirmed that they had received training including, medication, safe moving and handling, fire safety, food hygiene and first aid. At the last inspection a recommendation was made that a training matrix was devised to help show any gaps in staff training. The manager confirmed that they have access to a computerised system linked to Skills for Care, which would highlight any gaps. Elizabeth House DS0000008401.V359954.R01.S.doc Version 5.2 Page 21 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 group was good. The home is well run and service users are protected and benefit from the policies and procedures operating within the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager has been registered by CSCI and has over 20 years experience of working in care settings both in residential and community situations and has successfully completed the required NVQ Level 4 Registered Managers Award. There are systems in place to check whether the home is meeting the needs of the current residents with questionnaires issued to the families of residents and health care workers. According to the manager, the residents do not wish to complete any questionnaires. Questionnaires were sent to residents, Elizabeth House DS0000008401.V359954.R01.S.doc Version 5.2 Page 22 relatives and staff by CSCI as part of the inspection but none were returned other than those completed by staff. The questionnaires seen issued by the home indicated that relatives are happy with the quality of care provided. The home has Investors in People Status. When service users cannot look after their own finances, assistance is provided with the best interests of the service users in mind. Staff and residents commented that the support they receive from the manager was very good and that she was willing to take into account any concerns they may have in the running of the home. One of the staff gave the example of how additional staff support at teatime was provided following discussions with staff. Comments included: “I am much happier here than at my previous employment.” “Its like being part of a big family.” Staff spoken with did not receive one to one formal supervision but very good informal support from the manager. A recommendation was made that regular formal supervision would benefit the staff and provide an opportunity for any ‘whistle blowing’ if required and to discuss individual residents or personal matters within a confidential setting. Risk assessments are carried out at every stage of the care planning process and staff are provided with training in Health and Safety. A recommendation was made at the last inspection for a portable hoist to assist in moving any residents; the manager confirmed that a portable hoist is now available. Prior to the inspection the manager of the home had to complete an AQAA. This is to give information about how the home is meeting the standards required for a care home. The AQAA provided information about the maintenance of equipment and important policies and procedures. There is a need to expand on the information contained within the AQAA stating how the home is meeting the Care Homes Regulations/Standards to inform any future inspections or reviews of the home. Elizabeth House DS0000008401.V359954.R01.S.doc Version 5.2 Page 23 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X 2 X 3 Elizabeth House DS0000008401.V359954.R01.S.doc Version 5.2 Page 24 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. Standard Regulation Requirement Timescale for action 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. 3. 4. 5. Refer to Standard OP3 OP7 OP18 OP31 OP36 Good Practice Recommendations The assessment process should take into consideration the legislation contained in the Mental Capacity Act in order to ensure a correct assessment is provided. Signatures should be obtained from the resident, relative or advocate following the recording of a care plan to show they have been involved in the process. Staff should continue to be provided with training on Adult Abuse and Protection issues for the protection of vulnerable people. The AQAA should include more detail about how the home is meeting the Care Homes Regulations/Standards in order to inform any future inspections or reviews. Consideration should be given to providing formal, regular one to one supervision of staff to support and improve the overall effectiveness of staff. DS0000008401.V359954.R01.S.doc Version 5.2 Page 25 Elizabeth House Elizabeth House DS0000008401.V359954.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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. 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