Care Home: St Elizabeths Care Home with Nursing

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What the care home does well The staff teams including management continue to demonstrate their openness and positive response to requirements, recommendations and suggestions made by the Commission. They are to be commended for the way they continually strive to maintain and further improve the services offered. Prospective individuals, significant others and potential placing authorities are provided with relevant information about services and encouraged to visit the care home. The assessment and admission process is robust, which ensures that the needs of new residents are identified and care is planned accordingly. Care plans are `person centred` and reviewed on a regular basis to address the changing needs of individuals who have complex health and social care needs. The care planning approach involves the resident and significant others, in order to ensure the needs, wishes and aspiration of the individual are at the centre of service delivery. The ethos of the Organisation has a strong sense of care and compassion for people with learning disabilities giving a high profile to supporting and enabling people to learn independent living skills and participate in meaningful activities and work to reflect their wishes and needs. The environment is well maintained and all the houses are refurbished regularly. A high standard of cleanliness was evident throughout those areas viewed. The care home benefits from extensive grounds, which are well utilised by people using the service. The systems in operation including complaint and adult protection should offer adequate protection to people using the service. There is a competent and trained staff team who are knowledgeable about the individual needs of people using the service and should be commended for their professional input in enabling, empowering, supporting and caring for their residents. In relation to equality and diversity, the home has this policy in place and staff spoken to were aware of it and ensured that people were treated equally irrespective of their age, race, disability, religious beliefs, cultural background and sexual orientation. What has improved since the last inspection? The requirement and recommendations made in the last inspection were addressed. People using the service said that there are more opportunities to go out now by booking in advance to join in the daily minibus trip. What the care home could do better: The management team must revisit the areas of risks within the home and include undertaking a risk assessment for the use of electric reclining chairs. The team must also review their practice for the use of bolts and remove these from the bathroom doors. They must ensure that Fire Safety Regulations are adhered to at all times. CARE HOME ADULTS 18-65 St Elizabeths Care Home with Nursing South End Much Hadham Hertfordshire SG10 6EW Lead Inspector Bijayraj Ramkhelawon Unannounced Inspection 11 & 14th April 2008 10:00 th St Elizabeths Care Home with Nursing DS0000019542.V361750.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address St Elizabeths Care Home with Nursing DS0000019542.V361750.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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. St Elizabeths Care Home with Nursing DS0000019542.V361750.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service St Elizabeths Care Home with Nursing Address South End Much Hadham Hertfordshire SG10 6EW 01279 843451 01279 842918 jacksonj@stelizabeths.org.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) The Congregation of the Daughters of the Cross of Liege Vacant Care Home 105 Category(ies) of Learning disability (105), Learning disability registration, with number over 65 years of age (105), Physical disability of places (105), Physical disability over 65 years of age (105) St Elizabeths Care Home with Nursing DS0000019542.V361750.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th April 2006 Brief Description of the Service: St Elizabeth’s care home with Nursing is set in 68 acres of grounds in the rural village of Much Hadham. The home is a specialist provider for people with epilepsy. People using the service are accommodated in 14 buildings according to their care needs. These are: Hume House-8 adults with moderate learning disability; Vaughan House-8 adults with moderate/severe learning disability; Lewis House- has 8 elderly persons with physical disability; Vincent House-8 adults with severe learning disability and communication difficulties; Hood House-8 adults with varying degrees of learning disability and challenging behaviour; Corum Villa & St. Martins-7 adults with moderate learning disability and some with challenging behaviour; Jeanne Haze House-8 adults with varying degrees of both learning disability and mental health problems; Villa Maria-8 adults with varying degrees of learning disability, mobility problems and communication difficulties; Elena House- 8 elderly persons with high care needs; St Gabriels House-10 adults with severe learning disability and communication problems as well as varying degrees of challenging behaviour; Kelly & Kearney House-10 adults with moderate learning disability and some mobility problems; Loretto Cottage- 5 adults with moderate learning disability; St Josephs Cottage-5 adults with moderate learning disability. The Emilie Schneider Centre is a 7-bedded nursing and respite wing, where nursing care is provided on a temporary basis as and when as required. This unit offers 2 single bedrooms and a 5-bedded room with curtain dividers. The accommodation with the exception of Loretto and St Josephs Cottages are single storey building. Loretto Cottage and St Josephs Cottage are 2 semidetached double storey properties. Kelly & Kearney House is the most recent purpose built property. Each building is self-contained with assisted bathrooms and/or showers and/or assisted toilets. The current fees for this service range from £924.88 - £3153.26 per week. A copy of the ‘Service User’s Guide’ and ‘Statement of Purpose’ and the last inspection report can be obtained from the care home. St Elizabeths Care Home with Nursing DS0000019542.V361750.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. ‘The overall quality rating for this service has been judged to be 2*, GOOD.’ This unannounced key inspection was carried out on the 11th and 14th April 2008 and took two days. It included talking to people using the service, examining care plans, staff files, staff training records, fire safety procedures, maintenance records, all other records and documents and a tour of the premises. The home sent us their annual quality assurance assessment (AQAA) when we asked for it. The information in the AQAA shows that the home is still providing a good service and that they involve people using the service in decisions about the home, and they listen to and act on their views. The home works well with us and have shown us that their service continues to provide good outcomes for the people who use it. Feedback received from people using the service is very positive. They said that they are happy with their rooms, the food, activities provided and the staff. One person wrote a letter stating ‘ I would rather be at St. Elizabeth’s than the place I was at before because I really like it here. I have made lots of new friends’. What the service does well: The staff teams including management continue to demonstrate their openness and positive response to requirements, recommendations and suggestions made by the Commission. They are to be commended for the way they continually strive to maintain and further improve the services offered. Prospective individuals, significant others and potential placing authorities are provided with relevant information about services and encouraged to visit the care home. The assessment and admission process is robust, which ensures that the needs of new residents are identified and care is planned accordingly. Care plans are ‘person centred’ and reviewed on a regular basis to address the changing needs of individuals who have complex health and social care needs. The care planning approach involves the resident and significant others, in order to ensure the needs, wishes and aspiration of the individual are at the centre of service delivery. The ethos of the Organisation has a strong sense of care and compassion for people with learning disabilities giving a high profile to supporting and enabling people to learn independent living skills and participate in meaningful activities and work to reflect their wishes and needs. St Elizabeths Care Home with Nursing DS0000019542.V361750.R01.S.doc Version 5.2 Page 6 The environment is well maintained and all the houses are refurbished regularly. A high standard of cleanliness was evident throughout those areas viewed. The care home benefits from extensive grounds, which are well utilised by people using the service. The systems in operation including complaint and adult protection should offer adequate protection to people using the service. There is a competent and trained staff team who are knowledgeable about the individual needs of people using the service and should be commended for their professional input in enabling, empowering, supporting and caring for their residents. In relation to equality and diversity, the home has this policy in place and staff spoken to were aware of it and ensured that people were treated equally irrespective of their age, race, disability, religious beliefs, cultural background and sexual orientation. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. St Elizabeths Care Home with Nursing DS0000019542.V361750.R01.S.doc Version 5.2 Page 7 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. St Elizabeths Care Home with Nursing DS0000019542.V361750.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection St Elizabeths Care Home with Nursing DS0000019542.V361750.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who would like to use the service are able to make an informed choice and be sure that their needs could be met. EVIDENCE: Information about the home was available to current and prospective individuals including the ‘Statement of Purpose’ and ‘Service User’s Guide’. Care plans examined and information gained from people using the service and members of staff indicated that individuals were admitted to the home after assessment of needs has been carried out. Records examined and information gained from staff and people using the service demonstrate that normally individuals admitted to the home are under a Care Management arrangement and have a full assessment of needs carried out by their respective Social Worker, prior to admission to the home. A senior staff member from each house is involved in the pre-admission assessments, St Elizabeths Care Home with Nursing DS0000019542.V361750.R01.S.doc Version 5.2 Page 10 as well as professional assessments from referring agencies. Self-funding service users also have a pre-admission assessment. The establishment considers it to be “very essential” that the involvement of the prospective resident, family/relatives and significant others is central to the assessment process. People using the service and staff spoken to confirmed that prospective residents, their relatives/friends are always encouraged to visit and to “test drive the home. The opportunity to meet with residents and staff members, have a meal, overnight stay if necessary and seek clarification, appear to be a routine part of the admission process at St Elizabeths. If a placement is offered and accepted, the initial visits to the home is followed by a trial period to allow for staff to carry out a full assessment of needs. At the end of the trial period, a review meeting is held with all concerned, in order to consider if a long term placement is appropriate or not. Overall, evidence indicates that standard 4 has been exceeded. St Elizabeths Care Home with Nursing DS0000019542.V361750.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7, 9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service can be confident that their identified needs would be met appropriately and that they would be enabled to live the lifestyle they chose. EVIDENCE: Care plans examined show that these were drawn up from a range of sources including individual’s assessment of needs, reports from Social Workers, input from family representatives, staff’s on going assessment during the trial period and contributions from other professional as appropriate. Care plans were detailed and comprehensive which reflected the identified needs of people using the service and how these needs were being met. People using the service have a formal review undertaken by their placing authorities on a six monthly basis. Regular review of individual’s care needs St Elizabeths Care Home with Nursing DS0000019542.V361750.R01.S.doc Version 5.2 Page 12 was also carried out and details of their changing needs were reflected in their care plans. One of the stated principles underpinning this organisation is that people using the service would be given the opportunity to make choices about their lifestyles and to be treated as individuals. Staff members spoken to demonstrated a good knowledge of the needs of individuals. Care practice observed appeared to empower people using the service and their rights to decision-making were also being proactively encouraged and upheld, as appropriate. Up to date risk assessments were in place covering a wide range of activities. However, it was noted that the electric reclining chairs used for residents did not have a risk assessment carried out so that risks are identified, minimised and managed to prevent residents being put at risk of injury or harm. Evidence gathered suggests that staff treated information given by people using the service and significant others in confidence. Records regarding the residents are compiled and stored in accordance with the organisation’s written procedures and the Data Protection Act 1998, and in their best interests. People using the service said that they are involved in their care planning and reviews which they or their family representatives sign. St Elizabeths Care Home with Nursing DS0000019542.V361750.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service can be assured that they would have opportunities for personal development and enhanced their daily living skills so that they would be enabled to lead as near normal a life as possible. St Elizabeths Care Home with Nursing DS0000019542.V361750.R01.S.doc Version 5.2 Page 14 EVIDENCE: A wide range of social and recreational activities was being provided (horticultural project, making jewellery, learning how to use the computer, doing wood work, arts and crafts, needlecraft, music and drama, physical activities etc for people using the service, based on the identified needs and abilities of the individual. Details of social history, previous interest and hobbies were reflected in each person’s care plan. Those who are able were actively encouraged to continue with any activity or hobby they were involved in, prior to their admission to the home. This includes both community based activities as well as attending the on site day centre and the use of other resources available for them during the evenings and weekends. Individuals spoken to said that they received excellent support from members of staff in facilitating to access indoors and outdoor activities. One person said ‘I can book the coach from the main reception so that I could go shopping’. Others said that they go to restaurants, swimming, cinema etc. The home has a number of vehicles that are used for outdoor activities. A variety of social and recreational activities are facilitated to people using the service including leisure interests and taking into account religious and cultural factors. People using the service are encouraged to develop and maintain social, emotional, communication and independent living skills where appropriate. Staff actively promote the rights of individuals to make informed choices e.g. staff asking residents ‘what would you like for lunch, choices given? What activities would you like to do in the evening? Staff also provide links to specialist support when needed. This includes developing and maintaining family and personal relationships. Information gained from staff, residents and examination of care plans and menus indicates that people using the service and their relatives are consulted regarding residents’ culinary likes and dislikes. Residents expressed satisfaction with respect to food available to them. St Elizabeths Care Home with Nursing DS0000019542.V361750.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service can be confident that their personal and healthcare needs would be met appropriately. EVIDENCE: The dependency levels of people using the service vary considerably. Some live quite independently with minimal staff assistance whereas others have physical and learning disabilities with challenging behaviour that necessitate continuous one to one attention with the tasks of daily living or to deal with their behavioural difficulties. Individuals receive personal and healthcare support using the ‘person centred approach’ with support provided based upon identified needs including the rights of dignity, privacy, choices and respect. Care plans examined show that people using the service are registered with a General Practitioner. They are able to see their doctor at their surgery but the doctor may visit a resident at the home in an emergency. Other professionals residents have contact with include Psychiatrist, Psychologist, Optician, St Elizabeths Care Home with Nursing DS0000019542.V361750.R01.S.doc Version 5.2 Page 16 Podiatrist, Hairdresser, Occupational and Speech Therapist, Physiotherapist, Art Therapist, Dentist and Social Workers. A private Consultant Neurologist and a Consultant Psychiatrist for Learning Disability are also available. Any resident who becomes ill is transferred to the Emilie Schneider Centre nursing unit, where appropriate. A three monthly medical review is also carried out involving the GP, resident, key worker/link nurse and relatives, whenever possible. The ordering, storage, administration and disposal of medication remain satisfactory. St Elizabeths Care Home with Nursing DS0000019542.V361750.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service can be assured that their concerns and complaints would be listened to and acted upon and that they would be safeguarded from abuse, neglect and harm. EVIDENCE: The policy and procedures on complaints include an ‘easy read version’ with pictographs. Information on complaints is also included in the ‘Service Users’ Guide and ‘Statement of Purpose’. Residents spoken to said they are aware of how to go about making a complaint and expressed confidence that their concerns and complaints will be listened to and acted upon. The home maintains a record of complaints. 7 complaints have been recorded since the last inspection in April 2006. 5 have been dealt with and 2 are still pending. 76 compliments have been received during the same period. The home has a copy of the Hertfordshire procedures on safeguarding adults. Staff spoken to confirmed that they are familiar with the procedures and staff records showed that they have received training on the safeguarding adults. An element of adult protection is also covered in the induction programme for all new staff members and those people undertaking the NVQ assessment. St Elizabeths Care Home with Nursing DS0000019542.V361750.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are cared for in an environment that is homely, comfortable and safe. EVIDENCE: All the houses were well maintained and furnished in a domestic style to provide a very homely, comfortable and safe environment. All bedrooms viewed were painted in different colours chosen by individual residents and personalised to reflect the tastes and interests of the occupants, with pictures and hobby materials displayed in their individual room. Staff members reported and residents spoken with confirmed that they are consulted about the décor and have keys to their rooms, as appropriate. Overall, all three houses and gardens are well maintained, which service users appear to appreciate very much. A high standard of cleanliness was evident throughout those areas viewed. Food items were appropriately stored in fridges and temperatures, recorded St Elizabeths Care Home with Nursing DS0000019542.V361750.R01.S.doc Version 5.2 Page 19 daily. The home has an infection control policy and procedures in place and staff encourage residents to follow good hygiene practice. Arrangements for the storage and disposal of domestic and clinical waste remain satisfactory. Staff members spoken to are conversant with infection control procedures. People using the service said that they liked their individual rooms, and the house they lived in. They also commented that they ‘feel safe and it is homely here’. St Elizabeths Care Home with Nursing DS0000019542.V361750.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service do benefit from the care and support they receive from a competent and qualified staff team and that they feel protected by the home’s recruitment policy and practices. EVIDENCE: Information gained from duty roster, staff members including the senior management team provides evidence that the day and night staffing levels remain adequate to meet the needs of the resident group in each of the houses. In addition to the care staff team, the home has administration, maintenance, catering and ancillary staff members, and these arrangements are satisfactory. Staff members have the necessary skills and they receive appropriate training to meet the varying needs of the service users. Staff spoken with indicated that they have excellent opportunities for relevant training and this gives them greater confidence to do their jobs. Staff were very knowledgeable about the St Elizabeths Care Home with Nursing DS0000019542.V361750.R01.S.doc Version 5.2 Page 21 needs of individuals whom they were supporting and caring for. Currently, 80 care staff have completed their NVQ Level 2 and 4 Level 3. This represents 68 of the care staff have successfully completed the required NVQ Level and above. The procedures for the recruitment of staff were found to be robust. The recruitment files for 6 members who have been recently employed including registered nurses were examined. These were found to be in good order. 11 care staff were spoken to and they all confirmed that they had their CRB checks carried out prior to an offer of employment was made. Staff spoken to confirmed that they received one to one formal supervision on a regular basis. Supervision records were maintained. Staff also confirmed that they received support from the management team and that senior members of staff were approachable and available for advice as and when needed. St Elizabeths Care Home with Nursing DS0000019542.V361750.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service can be assured that their health, safety and welfare are protected by the systems and practices in place and the support they receive from an open and transparent management team. EVIDENCE: The management communicate a clear sense of leadership within the home and has an open-door policy where staff could see them at any time with any issues or concerns they may have. People using the service and their relatives have commented positively on the good practices and quality of service provision. St Elizabeths Care Home with Nursing DS0000019542.V361750.R01.S.doc Version 5.2 Page 23 The effective implementation of a number of systems including assessment and admission process, care planning and review, consultation and communication, recruitment, induction, training, supervision and appraisal of staff ensures that the home operates in an efficient manner; this clearly benefits people using the service and the staff teams. The risk assessment systems are thorough and tailored to the needs of the individuals. The home has a quality assurance system in place and seek the views of people using the service, relatives, staff and other interested parties. It was noted that some of the bathroom doors were fitted with a bolt as well as locked with a key. Staff explained that this practice was to stop residents going in without supervision. However, senior management team agreed that the bolts would be removed. It was also noted that some fire doors were wedged open. The management team explained that this practice was agreed by the Fire Safety Officer after a risk assessment was carried out. During discussion, the management team agreed to consider other means of holding these fire doors open and have since fitted automatic ‘Fire Door Closers’ (written confirmation via E-mail has been received by CSCI from the Chief Executive of St. Elizabeth’s Care Home). All statutory records were available for inspection and maintained in accordance with legislation. Records inspected were up-to-date and accurate and were held securely. Staff spoken to were aware that people using the service can access their records and information held about them in accordance with the Data Protection Act 1998. There were policies and procedures in place to ensure that the health, safety and welfare of people using the service and staff are promoted and protected. These records were accessible to all staff. All accidents and injuries are recorded in the accident book and RIDDOR forms have been completed where applicable. CSCI has been kept informed of all accidents and admissions to hospital. Regular checks on hot water temperatures and moving and handling equipment were recorded. A valid insurance certificate was displayed in the reception area and this offered cover of no less than £5 million. St Elizabeths Care Home with Nursing DS0000019542.V361750.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 Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 4 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 4 X X 2 X St Elizabeths Care Home with Nursing DS0000019542.V361750.R01.S.doc Version 5.2 Page 25 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 YA9 Regulation 13 (4) (c) Requirement Electric reclining chairs used for residents must have a risk assessment undertaken so the people are not put at risk. Fire doors must only be held by means approved by the Fire Safety Regulations and not wedged open. (This requirement has been complied with). Bolts fitted to bathroom doors must be removed so that people using the service are not put at risk. Timescale for action 06/06/08 2. YA42 23 (4) (c) (i) 14/04/08 3. YA42 13 (4) (a) 06/06/08 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 YA6 Good Practice Recommendations The format used for obtaining the signatures of relatives and other professionals at care plan reviews should be identified with their occupation or relationship to the resident. DS0000019542.V361750.R01.S.doc Version 5.2 Page 26 St Elizabeths Care Home with Nursing St Elizabeths Care Home with Nursing DS0000019542.V361750.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 St Elizabeths Care Home with Nursing DS0000019542.V361750.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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