Care Home: The Elizabethan Care Home

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What the care home does well The manager ensured that she was aware of the needs of a prospective resident before offering them a place. This ensured that the home had the equipment, and the staff had the experience, to provide the necessary care.The Elizabethan Care HomeDS0000045208.V376644.R01.S.docVersion 5.2Since the last inspection the home had received the accreditation of the Local Authority to provide care for people with dementia. Care plans were clearly for all areas of care and were supported by the appropriate risk assessments. Residents or their relatives agreed care plans regularly. Residents` likes and dislikes were recoded in their care plans. Staff supported residents, in a respectful manner that recognised the resident`s skills to be as independent as possible. The complaints procedure was supplied to everyone living at the home and was on display. There was a comprehensive training plan and recruitment procedures were fully adhered to so that residents were cared for by suitable staff The manager had a clear understanding of the key principles and focus of the service. She worked closely with the staff team to continuously improve the service. What has improved since the last inspection? The manager and the staff team had worked extremely hard to raise the standard of the care provided in this home. Care plans were now written for all areas of care provided to a resident. The plans were kept under review. All medication procedures had been improved and regular auditing by the manager ensured continuity of the improvements. There had been a lot of improvements to the environment and regular redecoration plans were in place. The manager supported and encouraged staff training, which included the whole staff team including those staff who worked night duty. In the last six months formal supervision of staff had been re-introduced. The manager was reviewing all the policies to ensure staff were working to current best practise. The manager and the owner were auditing the quality of the care provided. The Elizabethan Care Home DS0000045208.V376644.R01.S.doc Version 5.2 What the care home could do better: As already stated there had been a number of improvements to this service since the last inspection. However as with any service there are always areas for more improvement both detailed in the recommendations and requirements made and identified during quality audits. The improvements include: The need for the manager to ensure that any changes to care are written in the care plans immediately. Information for residents to be produced in other formats to ensure they are meaningful to all. Remaining medications carried forward at the end of the month to be recorded and added to the new supply. Decoration to be completed as soon as possible to allow the residents to return to `normal`. Key inspection report CARE HOMES FOR OLDER PEOPLE The Elizabethan Care Home 220 Old Bedford Road Luton LU2 7HB Lead Inspector Sally Snelson Key Unannounced Inspection 20th July 2009 08:20 DS0000045208.V376644.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. The Elizabethan Care Home DS0000045208.V376644.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address The Elizabethan Care Home DS0000045208.V376644.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Elizabethan Care Home Address 220 Old Bedford Road Luton LU2 7HB Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01582 720010 elizabethan@heritagecarehomes.co.uk Heritage Care Homes Ltd Manager post vacant Care Home 21 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (23) of places The Elizabethan Care Home DS0000045208.V376644.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Service users over the age of 65 years, not falling within any other category 21(OP), 10 of whom may have dementia DE(E) (10). No one falling within the category of DE(E) may be admitted to the home when there are 10 persons in category DE(E) already accommodated in the home. The home can accommodate a maximum of 21 service users of either sex. 29th August 2008 Date of last inspection Brief Description of the Service: The Elizabethan is registered to provide services for twenty-one older people, ten of whom may also have dementia. Mr S Hussain is the proprietor. The company, Heritage Care Ltd, also operates two other care homes in the vicinity. The home is located in a pleasant residential suburb of Luton with convenient access to the towns amenities and transport links. The accommodation is distributed over three floors that are accessible via a staircase and a shaft lift. Each bedroom is for single occupancy although a few rooms are large enough to accommodate two persons who wish to share. There is a lounge and dining room on the ground floor and toilet facilities on each of the floors. The garden to the front of the property is not accessible as it had a steep slope. The front entrance to the building is similarly restricted. Service users and visitors to the home therefore mostly use the door that leads directly into the communal areas. The majority of the rear of the property is given over to a large parking area. Beyond this was a further large grassed area. The acting manager reported that the minimum fee at the time of the inspection was £460 per week and the maximum £490. These fees did not include newspapers, hairdressers, personal telephone, toiletries, or visits by private chiropodists or opticians. The Elizabethan Care Home DS0000045208.V376644.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 inspection was carried out in accordance with the Care Quality Commission (CQC) policy and methodologies, which requires review of the key standards for the provision of a care home for older people, that takes account of residents’ views and information received about the service since the last inspection. Information from the home, through written evidence in the form of an Annual Quality Assurance Assessment (AQAA) has also been used to assess the outcomes within each standard. Evidence used and judgements made within the main body of the report include information from this visit. Sally Snelson undertook this inspection of The Elizabethan. It was a key inspection, was unannounced, and took place from 08.20am on 20th July 2009. Jane Roe, the acting manager, was present for the majority of the inspection. Feedback was given throughout the inspection and at the end. During the inspection the care of three people who use the service (residents) was case tracked in detail. This involved reading their records and comparing what was documented to what was provided. In addition to sampling files, people who lived at the home, visitors, and staff were spoken to, and their opinions sought. During the inspection we also had a tour of the premises and spent some time in the communal areas of the home, observing the care practices and interventions that were carried out. Any comments received from staff or residents about their views of the home, plus all the information gathered on the day was used to form a judgement about the service. The inspector would like to thank all those involved in the inspection for their input and support. What the service does well: The manager ensured that she was aware of the needs of a prospective resident before offering them a place. This ensured that the home had the equipment, and the staff had the experience, to provide the necessary care. The Elizabethan Care Home DS0000045208.V376644.R01.S.doc Version 5.2 Page 6 Since the last inspection the home had received the accreditation of the Local Authority to provide care for people with dementia. Care plans were clearly for all areas of care and were supported by the appropriate risk assessments. Residents or their relatives agreed care plans regularly. Residents’ likes and dislikes were recoded in their care plans. Staff supported residents, in a respectful manner that recognised the resident’s skills to be as independent as possible. The complaints procedure was supplied to everyone living at the home and was on display. There was a comprehensive training plan and recruitment procedures were fully adhered to so that residents were cared for by suitable staff The manager had a clear understanding of the key principles and focus of the service. She worked closely with the staff team to continuously improve the service. What has improved since the last inspection? The manager and the staff team had worked extremely hard to raise the standard of the care provided in this home. Care plans were now written for all areas of care provided to a resident. The plans were kept under review. All medication procedures had been improved and regular auditing by the manager ensured continuity of the improvements. There had been a lot of improvements to the environment and regular redecoration plans were in place. The manager supported and encouraged staff training, which included the whole staff team including those staff who worked night duty. In the last six months formal supervision of staff had been re-introduced. The manager was reviewing all the policies to ensure staff were working to current best practise. The manager and the owner were auditing the quality of the care provided. The Elizabethan Care Home DS0000045208.V376644.R01.S.doc Version 5.2 Page 7 What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. The Elizabethan Care Home DS0000045208.V376644.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Elizabethan Care Home DS0000045208.V376644.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,5,6 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager ensured that she was aware of the needs of a prospective resident before offering them a place. This ensured that the home had the equipment, and the staff had the experience, to provide the necessary care. EVIDENCE: The Statement of Purpose had been reviewed and remained unchanged. Each of the residents had been given a copy of a Service Users Guide. The documents also included the required contractual information with the exception of the number of the room that the residents occupied. This is essential to ensure people using the service are not moved from one bedroom The Elizabethan Care Home DS0000045208.V376644.R01.S.doc Version 5.2 Page 10 to another without their agreement. We did not see any evidence that the Service Users Guide or the contract were produced in any other format. Since the last inspection the home had received the accreditation of the Local Authority to provide care for people with dementia. As part of the inspection we looked in detail at the records of a person who had been recently admitted to the home. Documentation included the assessment of need from the Local Authority and a pre-admission assessment by the manager. This had resulted in clear information about the resident which had been used to formulate care plans. The manager told us that she encouraged people considering moving into the home to visit in advance of making the decision, but often this was not possible and a relative made the visit on the person’s behalf. This home did not offer intermediate care. The Elizabethan Care Home DS0000045208.V376644.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans were clearly written although care needed to be taken that they were altered immediately care needs changed. Medication records were in order, and had been signed appropriately by staff. EVIDENCE: Each of the people using the service had plans of care which described what and how care was to be provided. Care plans were reviewed monthly and a summary of the review was recoded. Staff must be careful that when a care need alters this is reflected immediately in the care plan in addition to it being The Elizabethan Care Home DS0000045208.V376644.R01.S.doc Version 5.2 Page 12 recorded in the review section. For example, we saw a review that recorded that a resident should have a period of bed rest, to prevent pressure areas developing. The daily log confirmed this was being carried out, but the instruction had yet to be included in the care plan. We were therefore confident that the outcome for the residents was good, but with a staff team unfamiliar with the resident’s continuity could be compromised. The manager had recently started to produce the care plans electronically. This meant changes could be made easily, but it would still be expected that hand written changes to the plans would be made between reviews or the construction of new plans. Residents’ likes and dislikes were recoded in the plan and the manager told us that where possible residents were made aware of their care plan. The manager told us that where possible she explained the care plans to the resident and they signed the plan as a form of agreement and were given a copy. Where this was not possible a relative was asked for their agreement to the plan of care. The community nurses recorded their activity in their own records and the care plan listed the community nurses visits and any treatment changes. All aspects of the individual care of a resident was incorporated within the care plans. Where problems had been identified risk assessments had been carried out. We saw risk assessment for moving and handling and developing pressure sores. Each resident was weighed monthly and more frequently if needed. It was apparent that staff were acting on deviations to recorded weights appropriately. The AQAA told us that the home intended to introduce the Malnutrition Universal Screening Tool (MUST) to the home. Any restrictions considered necessary for the safety of the individual, or others, was recorded within the care plans and risk assessments, and where necessary an agreement for a restriction was in place, such as for the use of bed rails. Staff supported residents, in a respectful manner that recognised the resident’s skills to be as independent as possible. There was a homely atmosphere within the home, the residents were relaxed and friendly with each other and the staff. Moving and handling equipment was provided and used correctly and health professionals, such as community nurses were frequent visitors to the home and the staff had a good relationship with them. Specialist equipment such as hospital beds, alarm mats and larger commodes had been provided as necessary. Since the last inspection the dark cupboard used to store the controlled drugs (C.D’s) had been removed and a regulation cupboard purchased. We checked the Medication Administration Record (MAR) sheets for the three residents we case tracked, plus three more. Medications were appropriately stored in a locked trolley that was secured to the wall. The Elizabethan Care Home DS0000045208.V376644.R01.S.doc Version 5.2 Page 13 All the medication dispensed in blister packs, and the medication prescribed on a regular basis and dispensed in boxes reconciled correctly. Monthly deliveries had been correctly signed in. However there were some instances where medication remaining from the previous month, had not been carried forward so reconciliation was not possible for these. On the whole charts had been accurately completed with signatures and omission codes where appropriate. The back of the MAR sheet had also been completed when an omission code had been used. There were cases where staff had used omission code G, which is ‘other’ but as they had not detailed what ‘other’ meant, we did not know why the medication had been omitted. CD’s were stored appropriately and all administrations had been recorded accurately with two signatures in the CD register. The manager carried out regular audits of medication which ensured any problems were identified early. Staff were supporting one resident to self medicate, in line with their policy. The manager was asking the resident and/or their relatives about any end of life wishes and ensuring that where possible these were carried through. The Elizabethan Care Home DS0000045208.V376644.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff provided a variety of different activities in an effort to stimulate the residents. EVIDENCE: There was no specific member of staff responsible for activities in the home, but all staff would spend time with groups or individuals. A visitor confirmed that there was always something organised although a number of the residents were reluctant to participate. We were pleased to note that the activity plan covered weekends as well as week days. The manager told us that it was hoped that more residents could spend time out of the home and visit shops or have a day trip. Residents were currently using taxis to have The Elizabethan Care Home DS0000045208.V376644.R01.S.doc Version 5.2 Page 15 trips out but the manager was in the process of signing all the residents up with the local transport system ‘dial-a-ride’. Following some additional dementia training the home had purchased some particular equipment for those people with dementia, in addition to large jigsaws and playing cards. There were examples of resident’s creative work throughout the home. Residents were also involved in planning any social events such as a summer Bar-B-Q or parties. A report was written of residents involvements in any activities, and this was used to influence future events and activities. We noted that visitors were welcomed into the home at anytime and staff had a good relationship with them. The manager had built up some relationships with the local community, including churches. The inspection spanned breakfast and lunch. Breakfast was served to people as they got up and we noted the last breakfast was served at 10.40am and the first had been served before the inspection started. Throughout the day people were offered regular hot and cold drinks and biscuits and other snacks. Lunch was a sociable occasion and residents were encouraged to have their meal at dining tables. Prior to lunch the cook asked residents for their preferences for the meal. The choice was ham or cheese salad or pork casserole served with potatoes cabbage and carrots and fruit and ice cream or pudding and cream. Asking each resident for their choice took time, but we were told that the home had picture menus but usually staff enjoyed describing the meals to the residents and used the time to talk about other things and find out their likes and dislikes. On the day of the inspection the permanent cook was on leave and one of the care staff, (not allocated that week to provide care) was deputising for her. The Elizabethan Care Home DS0000045208.V376644.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The complaints procedure was supplied to everyone living at the home and was on display. EVIDENCE: In addition to the Service Users Guide this homes’ complaints policy was displayed in the entrance and was easily accessible to residents and visitors to the home. It confirmed the expected timescales for responses, and advised people of the process if they were dissatisfied with the outcome. The home had not received complaints since the previous inspection. The manager advised us that she was available for residents or relatives if they had a concern, which she believed prevented concerns becoming complaints. Safeguarding issues had been clearly recorded and reported appropriately to the Local Authority. We had been made aware of the referrals made since the previous inspection, and all had been managed correctly. Documentation The Elizabethan Care Home DS0000045208.V376644.R01.S.doc Version 5.2 Page 17 indicated that the manager liaised with the safeguarding (SOVA) team as and when necessary. The manager and the deputy had attended training about the Mental Capacity Act including the Deprivation of Liberty This training was to be made available to all staff. All staff underwent SOVA training as part of their induction and it was updated regularly. We saw evidence of the home working with solicitors and advocates where residents did not have families to manage their affairs. The Elizabethan Care Home DS0000045208.V376644.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,22,26. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Current changes to the environment and a lift that was out of action meant that some residents felt that the home was not meeting their needs. However the improvements would make the home a comfortable place in which to live. EVIDENCE: Since the last inspection there had been some major improvements to the environment of the home. Including, removing some cupboards, moving the office downstairs, and upgrading and replacing the fire detection system. As a The Elizabethan Care Home DS0000045208.V376644.R01.S.doc Version 5.2 Page 19 result, at the time of the inspection, one of the communal lounges was out of action and there was electrical work on-going. The improvement work highlighted the need for some decoration which we were told would take place as soon as possible after the completion of the work. It was expected that the new fire detection system would be commissioned later in the week. Residents, staff and the workmen said that although there had been some upheaval their time together had been enjoyable and they would all miss each other. A maintenance man was employed between the heritage homes and any faults were reported to him for repair. The manager told us that he had made a big difference to the home. The gardens were tidy and residents had been involved in producing pots of flowers for the patio at the back of the building. A recent purchase of garden furniture was encouraging the residents to use the patio when the weather permitted. The rest of the back garden was across a car park and not accessible to most of the residents but it was now kept tidy. At the time of the inspection there was an on-going problem with the lift. It had broken down some weeks previously. The home had a ‘gold’ maintenance contract and therefore did not expect the necessary repairs to take so long. Engineers had visited immediately and had replaced parts systematically, but as each part had to be ordered it was taking sometime. The manager had explained the situation to all the residents and their families, reported it to ourselves and the commissioners and kept everyone updated. A spare bedroom on the first floor had been converted to a seating area for those residents who were ‘trapped’ on the first floor. The home had also purchased an ambulance chair that could, and had, been used to ensure hospital appointments were kept. There were five residents who could not use the stairs, but not all of these were concerned about not being able to access the communal areas. Staff were ensuring that they spent time on the first floor and additional activities were provided. The Elizabethan Care Home DS0000045208.V376644.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There was a comprehensive training plan and recruitment procedures were fully adhered to so that residents were cared for by suitable staff. EVIDENCE: This home was staffed by a small team that appeared dedicated to the service users. Agency staff were rarely used. Staff spoken to were happy to cover each others absences where possible. During the daytime there were currently three care staff on duty, supported by the manager, and at night there were two staff on duty. Separate staff were employed for the cooking (but not all the kitchen duties) and cleaning but not laundry. Three staff files were picked at random during the inspection and examined. One of these had been very recently recruited. All files contained the appropriate recruitment documentation, which included; fully completed application forms, two appropriate references, a Criminal The Elizabethan Care Home DS0000045208.V376644.R01.S.doc Version 5.2 Page 21 Records Bureau (CRB) check, photograph identification, passport and home office documentation where appropriate. Contracts and terms and conditions of employment were clearly signed and dated. This home manager supported training and sourced a variety of training from different providers. Training records indicated that nine of the 16 staff had achieved NVQ certificates in care at varying levels, and a further six were currently working towards this qualification. Additional training included dementia awareness, administration of medication and death and bereavement. The manager kept a training matrix that showed that most of the staff had attended mandatory training and refresher courses as required. All new staff had a period of induction and accessed the training programme as and when. Observations of staff and residents interactions indicated that there was a happy atmosphere, and generally the staff were confident and competent in their roles. The Elizabethan Care Home DS0000045208.V376644.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37,38. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager had a clear understanding of the key principles and focus of the service. She worked closely with the staff team to continuously improve the service. EVIDENCE: The Elizabethan Care Home DS0000045208.V376644.R01.S.doc Version 5.2 Page 23 The manager had settled into her role and had started the process to become the registered manager of the home. She had recently completed her NVQ level 5 in management. One resident’s annual review recorded ‘the family are very pleased with the care in last 12 months since the manager took over’. Staff also spoke of the support and the confidence they received from the manager. The manager had had a lot of work to do to raise the standard of the home and she had shown that she was organised and could prioritise her work. Staff reported that staff meetings were held, although during the building work space had prevented some of these. This home addressed quality assurance on an annual basis via questionnaires to residents and relatives. The last questionnaires were reviewed during May and June of this year and covered topics such as nutrition and mealtimes, communication, the home, the care provided and any additional comments. Ten of the 19 questionnaires sent out had been returned and all were very positive, with the exception of a comment about furniture being moved and people sitting in different places because of the building work. Since the last inspection the provider had ensured that regular independent inspections (Regulation 26 visits) of the home were carried out. These were meaningful and helped the manager ensure quality. We checked the accounts of the ‘pocket money’ held by the home on behalf of the residents whose care we tracked. These were all correct and we saw receipts to support any expenditure. Staff supervision records did not provide evidence that all staff had received six supervision sessions over the past year, but they did show that this standard was on track to be met next year as supervision had been happening regularly for the last six months. The was an example of how the manager had prioritised her workload. Files were tidy and well maintained and stored securely, but available to staff. The manager understood and followed the reporting processes for accidents and injuries in this home, and liaised with both CQC and the local safeguarding team appropriately. During this inspection we examined the health and safety file. These had been kept up-to-date. The Elizabethan Care Home DS0000045208.V376644.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 X 2 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 3 3 3 X 3 2 3 3 The Elizabethan Care Home DS0000045208.V376644.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 OP7 Regulation 15 Requirement The manager must ensure that any changes to care are written in the care plans immediately, to ensure continuity of care. Timescale for action 10/09/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP1 Good Practice Recommendations Information for residents should be produced in other formats to ensure they are meaningful to all. I.e large print, easy read or even pictorial for the resident with a learning disability. Any medications carried forward at the end of the month should be recorded and added to the new supply to ensure that medication can be reconciled at any time. Decoration should be completed as soon as possible to allow the residents to return to ‘normal’. The future service contract for the lift should be considered. The manager should ensure that the supervision programme is kept up-to-date. 2 3 4 5 OP9 OP19 OP22 OP36 The Elizabethan Care Home DS0000045208.V376644.R01.S.doc Version 5.2 Page 26 Care Quality Commission Care Quality Commission East Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). 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