Inspection on 16/04/08 for Elms Park Care Home

This is the latest available inspection report for this service, carried out on 16th April 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Elms Park Care Home 20/04/06

Elms Park Care Home 14/12/05

Elms Park Care Home 02/08/05

Elms Park Care Home 09/03/05

Elms Park Care Home 13/04/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Elms Park Care Home 11 Elms Park Ruddington Nottingham NG11 6NU Lead Inspector Karmon Hawley Unannounced Inspection 16th April 2008 14:00 Elms Park Care Home DS0000008672.V362698.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 Elms Park Care Home DS0000008672.V362698.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. Elms Park Care Home DS0000008672.V362698.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elms Park Care Home Address 11 Elms Park Ruddington Nottingham NG11 6NU 0115 945 6323 0115 945 6323 h2055@mencap.org.uk www.mencap.org.uk Royal Mencap Society 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) Wendy Cynthia Warner Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Elms Park Care Home DS0000008672.V362698.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Within the total number of beds, a maximum of 8 (eight) may be used for the category LD 24th April 2007 Date of last inspection Brief Description of the Service: Elms Park is a care home providing personal care and accommodation for up to 8 adults with a learning disability. Mencap provides care and support, though Nottingham Community Housing Association owns the building. The home is located in the village of Ruddington with easy access to the village centre. All bedrooms are single and on the ground and first floor. There is no lift, but the ground floor has level access. There is a garden to the rear of the house, which has seating for people using the service. The fees for the service range between £323.56 and £367.26 per week. Elms Park Care Home DS0000008672.V362698.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. Inspection Report Summary Care Home Adults 18-65 Elms Park 11 Elms Park Ruddington Nottingham NG11 6NU Unannounced Key Inspection Lead Inspector Karmon Hawley 16/04/08 Elms Park Care Home DS0000008672.V362698.R01.S.doc Version 5.2 Page 6 A bit about the home Elms Park supports 8 people with learning disabilities. The service is owned by the Royal Mencap Society. Although the home does not have it own minibus there is good access to local public transport. People who attend community groups are picked up by their transport. This means that the people who live at the home can get around easily. Elms Park Care Home DS0000008672.V362698.R01.S.doc Version 5.2 Page 7 Everybody who lives at the home has their own bedroom. Nobody has to share a room. This is what we did when we were at the home We talked to 5 people who live at the home. Elms Park Care Home DS0000008672.V362698.R01.S.doc Version 5.2 Page 8 We also met some of the staff who support people who live at the home. We looked at some of the policies and procedures in the office. Policies are rules about how to do things. Procedures tell people how to follow the rules. If you want to read the full report about the care home, please ask the person in charge of the home. If you want to speak to the Elms Park Care Home DS0000008672.V362698.R01.S.doc Version 5.2 Page 9 inspector please contact Karmon Hawley Telephone 01159340900. The focus of inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. This inspection involved one inspector; it was unannounced and included the tea time period. The main method of inspection used is called ‘case tracking’ which involved selecting three residents and looking at the quality of the care they receive by speaking to them, observation, reading their records and asking staff about their needs. Two members of staff and five people using the service were spoken with as part of this inspection. Documents were read as part of this visit and medication was inspected to form an opinion about the health and safety of residents at the home. A partial tour of the building was undertaken, all communal areas were seen and a sample of bedrooms to make sure that the environment is safe and homely. A review of all the information we have received about the home since the last inspection was considered in planning this visit and this helped decide what areas were looked at. The registration document was reviewed as part of this inspection to ensure it was correct. No amendments were necessary at this inspection. The Annual Quality Assurance Assessment was received in time to include information in this inspection report. Elms Park Care Home DS0000008672.V362698.R01.S.doc Version 5.2 Page 10 What the service does well: What the home does well The home is good at helping people make choices. The people who live at the home said that staff, always help them to make choices, and that staff give them the information they need to make choices. Elms Park Care Home DS0000008672.V362698.R01.S.doc Version 5.2 Page 11 The people at the home told us that they really like the staff team. The staff support people well, and we noticed that they treated people with respect. The home supports people to have interesting lives. People who live at the home have a holiday every year. Some people have work placements or attend day centres. Elms Park Care Home DS0000008672.V362698.R01.S.doc Version 5.2 Page 12 The people who live at the home told us that they really like the food. We looked at menus and could see that the home serves healthy food. The people who live at the home plan their own menu with staff every week and are then supported by staff to cook their meals. The home is very good at making information easy for people to understand. All Elms Park Care Home DS0000008672.V362698.R01.S.doc Version 5.2 Page 13 the people who live at the home have a weekly timetable of what they are doing in easy words and pictures. A warm and welcoming atmosphere was evident on entering the care home. Staff were seen to interact with people using the service in a professional and caring manner and they showed people using the service respect at all times. Staff spoken with were able to discuss the needs of people living in the home and how they support them to meet these. People using the service spoke very highly of staff, the support they receive and the life that they lead. There is a wide range of different activites on offer should people wish to join in and also a lot of people attend activites and groups within the community. People are supported to lead independent lives as able and maintain relationships that are important to them. People are supported to carry out their own shopping, cook their own meals and attend to household tasks. People using the service said that the food that they eat is always good and staff support them to make it. A clear complaints policy is in place so that people using the service knows who they can approach if they have any problems. People using the service said that staff always listen to them and act if they had any concerns. Staff training remains at a good standard and staff continue to develop in knowledge and skill in caring for the client group. What has improved since the last inspection? Elms Park Care Home DS0000008672.V362698.R01.S.doc Version 5.2 Page 14 What has got better since the last inspection? New flooring has been laid in the main entrance and lounge. This is much better for the people that live there. Staff personnel files are now available for the inspector to see, to ensure that people who use the service are protected from unsuitable people being employed. New flooring has been laid in the main entrance hall and the lounge, which gives a comfortable and homely feel to the care home. Staff personnel files are now available for inspection to ensure that people using the service are protected from unsuitable people being employed. What they could do better: Elms Park Care Home DS0000008672.V362698.R01.S.doc Version 5.2 Page 15 What the home could do better We have asked that two members of staff check handwritten entries on medication charts to ensure that these are the same as the prescription so that people get the right medication. Medication procedures in regard to handwritten entries requires attention to ensure that these are correct and that people get their medication as prescribed. Elms Park Care Home DS0000008672.V362698.R01.S.doc Version 5.2 Page 16 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. Elms Park Care Home DS0000008672.V362698.R01.S.doc Version 5.2 Page 17 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 Elms Park Care Home DS0000008672.V362698.R01.S.doc Version 5.2 Page 18 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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are assured that their needs will be assessed and that these can be met before they make a decision to move into the home. EVIDENCE: The manager visits prospective people who may wish to use the service before admission to carry out an assessment to see if the staff are able to meet their needs. The person also visits the home and is introduced to other people living there before any decisions are made. Within the case file seen of the latest person admitted to the home there was evidence of this taking place and a copy of their assessment from the social worker. People using the service spoken with said that they all have the opportunity to have a say before anyone is admitted to the home. Staff spoken with were able to discuss the process that takes place and they said that they receive enough information prior to admission to enable them to support people as needed. Elms Park Care Home DS0000008672.V362698.R01.S.doc Version 5.2 Page 19 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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff actively listen to and supports the decisions and choices of people using the service in order to improve their quality of life and promote their independence. People using the service are supported by staff to take risks as part of an independent lifestyle. EVIDENCE: Support plans examined showed that these were person centred and covered peoples needs in detail to ensure that their needs are met. Each person has a key worker who reviews the plan of care with people using the service on a monthly basis to ensure that these are up to date, thus offering appropriate support as required. All plans are written in plain English to ensure that each person using the service is able to understand their individual plan and be involved in this to ensure that their choices and preferences are documented. People using the Elms Park Care Home DS0000008672.V362698.R01.S.doc Version 5.2 Page 20 service sign their plan of care to show that they have been involved in this and that they agree with its contents. Support plans outline how staff encourage people’s independence and record in some detail the decisions that they have made, or how people are to be supported with these (e.g. menu planning, shopping, spending money, buying clothes and so on.) Each person has a “pen picture” which they write with their Keyworker and this gives clear information about their likes, dislikes, preferences and it also lets staff know about the people who are important in their lives. People using the service spoken with confirmed that they were able to make their own choices and decisions about their life. All stated that they enjoyed their independence and their social lives. They stated that staff were very good to them and supported them, as they needed. They knew staff were always there for them if needed. Appropriate risk assessments were in place within those files examined to ensure that people can balance the benefits of their particular activities, their rights as well as potential harm. One person spoken with discussed how they were able to use public transport on their own after an assessment, which made them feel really good. Staff spoken with were able to discuss potential risks in activites and how they ensure that these are balanced against the rights and wishes of each person to ensure that they enjoy their lives and are as independent as possible. Staff were observed throughout the visit to treat people with respect and enable them to make their own choices and decisions wherever able. Elms Park Care Home DS0000008672.V362698.R01.S.doc Version 5.2 Page 21 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 excellent. This judgement has been made using available evidence including a visit to this service. The choices and support that people experience offer them a flexible and supportive lifestyle that exceeds the minimum standards. People using the service have individual and flexible lifestyles, which meet their needs, preferences and are in line with their choices providing them with a positive quality of life. EVIDENCE: Staff spoken with stated that people attend day services and have at least one day a week off to do chores, menu planning, shopping and paying bills. One person has paid employment and others carry out work experience programmes with support from the Pathways scheme, supported by MENCAP. One person spoken with said that they enjoyed their job. They said that they worked hard and looked forward to having a little treat when they had finished so they were going to go to the chip shop to get their tea that night. This person was seen to leave the home and fetch their tea and return safely. Several other people spoken with discussed the groups and clubs that they Elms Park Care Home DS0000008672.V362698.R01.S.doc Version 5.2 Page 22 attend in the week and they said that they enjoy the things that they do there. Several peoples were also looking forward to going out that evening to the quiz night. Staff spoken with said that they try to ensure that people go out if, and when they want and they said that on occasion they would join together with staff from other homes to facilitate this, (e.g. staff and service users from a MENCAP home who are going to the pictures may meet service users from Elms Park from their taxis and ensure they get back into their taxis at the end of the night.) People using the service spoken with said that they enjoyed life within the home and everyone generally got on well together, they could have their own space if they wanted and spend time alone. They also enjoyed activites such as going to the cinema, bowling, the pub, church and being with their partners and friends. They all said they can do what they want with their time and that there was always enough for them to do. People living at the home were seen to move freely about the home, converse with each other in a friendly manner and spend their time as they pleased. Two people spoken with said that they enjoyed going shopping in Ruddington with staff support when needed. One person was seen to be supported by a member if staff to carry out their weekly shop on the day of the visit. People are supported to have personal relationships with others outside of the home and see them regularly if they wish. If this is the case Community nurse’s are available to provide appropriate support and advice to them about protection from pregnancy and infection. One person spoken with said they have their boyfriend over to the house once a week and she sometimes stays over with him at his home. People said that they see their family and friends regularly and there are no restrictions on when they can visit. One member of staff spoken with confirmed this. Staff confirmed that people are encouraged to be in relationships if that is their wish and they make sure they are properly protected from pregnancy, infection and abuse by liaising with health professionals. The routines during the week can be governed by the times of day services, however people spoken with also confirmed that otherwise they could spend their time as they wish. They said that they do what they want when they want. They confirmed that they have their own routines, when they ate and when they did their household chores, which suited them. Each person is given a weekly food budget, to supplement the main items provided by the service. They use this to plan their menu and do their shopping for the ingredients they will need. People spoken with said that they prepare their meals with support from staff. There was information within people’s support plans to show that staff encourage and support healthy eating, some people also have assistance with this from a nutritionist who visits the home. People spoken with discussed healthy eating and the meals Elms Park Care Home DS0000008672.V362698.R01.S.doc Version 5.2 Page 23 that they had planned for that night. Service users help themselves to hot and cold drinks when they want. Elms Park Care Home DS0000008672.V362698.R01.S.doc Version 5.2 Page 24 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’s health needs are properly assessed and monitored to ensure they are well and healthy. There is a risk that people may not receive their medication as prescribed due to the medication charts and boxed medication not corresponding. EVIDENCE: People using the service are currently independent in bathing and showering and see to their own personal care needs. People using the service and staff spoken with confirmed this. This standard is not applicable at the present time. The arrangements made for health care were checked to make sure that people’s wellbeing is protected and promoted. There is good evidence in the support plans seen to indicate that staff are vigilant, in regard to health care and that people using the service are supported to attend appointments they need to keep. There are good records of visits to the GP, Optician, Chiropodist, Dentist and Nurses. Where appropriate there was evidence of people accessing age appropriate appointments such as the well woman clinic. One person spoken with said that they can see the doctor whenever the needed to. Elms Park Care Home DS0000008672.V362698.R01.S.doc Version 5.2 Page 25 The arrangements for medication were checked to ensure that people using the service received their medicines as prescribed by their GP. These are stored appropriately and securely. The home is registered with a pharmacist who supplies medicines in individually sealed packs and also provides a pharmacy audit, to ensure safe working practices within the home. Evidence of staff being trained in the safe handling of medicines was seen on files. One service user self medicates and is risk assessed to make sure they can do this safely. Medication Administration Records were inspected to make sure there are accurate records of the medication given. There were no gaps in signing for medication to demonstrate that medication as been administered as required. Handwritten entries are not currently signed by two members of staff to show that these have been checked as correct. In one instance where this had occurred when checking the boxed medication there were no instructions on the box to correspond with the instructions on the medication record, which could lead to the incorrect dose being administered. Elms Park Care Home DS0000008672.V362698.R01.S.doc Version 5.2 Page 26 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 and 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 are assured that their views are listened to an acted upon. People using the service are protected from abuse. EVIDENCE: The arrangements for making a complaint were checked to make sure that people using the service know how to complain and that these views were heard and responded to. The complaints procedure was displayed on the notice board in the dining room and was also held on each persons support plan. There have been no complaints made since the previous inspection. On speaking with people using the service they stated that they knew who to talk with if they were unhappy and that they felt confident that any problems they had would be listened to and resolved. Opportunities are also given to people to express their views and opinions before they may need to complain at monthly house meetings. There was evidence within one case file that showed evidence where individual worries and concerns had been dealt with. Staff spoken with were able to discuss how they would deal with any complaints received. To ensure that people are safe from abuse the majority of staff have undertaken training in safeguarding vulnerable adults. Staff spoken with were able to discuss the relevant issues in regard to this and how they would report poor working practices. People using the service spoken with stated that they felt safe living at the home and that staff were there to support them when Elms Park Care Home DS0000008672.V362698.R01.S.doc Version 5.2 Page 27 they needed. There was information that had been issued by the local police on the notice board in the dining room about safe practices when out and about. People using the service collect their own benefits and hold their own money in secure storage. One person using the service was observed to go out shopping with the support of a member of staff. On their return they were able to discuss how they had done their shopping and the support staff had given them whilst dealing with their money. General accounts for shopping and stationary are kept on the computer as this money is facilitated from petty cash. Each person is allocated £25 per week for personal food shopping to supplement that, which is already provided by the service. There were receipts available for all transactions. Other people spoken with said that they look after their own money and are responsible for paying their bills; one person also discussed how they had brought some new clothes with the support of staff. Elms Park Care Home DS0000008672.V362698.R01.S.doc Version 5.2 Page 28 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 and 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 live in a well maintained and comfortable environment. EVIDENCE: The accommodation was checked to make sure it provides a safe, comfortable and homely environment for people to live in. The communal space comprises a dining room and a lounge; both spaces are comfortable, clean and well used by people using the service. They can access the garden by either room and this area is also well maintained and pleasant. To enable people to do some work in the garden a mini green house has been purchased so that they may plant some seedlings. One person using the service was seen to access the garden to hang out their washing. The kitchen is fully accessible for people to use and is well equipped having lots of work surfaces and two cookers for service users to prepare and cook food. Each person using the service has designated storage for their weekly food and they take it in turns to do communal household chores. Elms Park Care Home DS0000008672.V362698.R01.S.doc Version 5.2 Page 29 Three bedrooms were seen with the person’s permission and these were personalised and comfortable. Two people said that they were responsible for keeping their room clean and tidy. They also said that they had been able to bring in their own things to make their rooms more comfortable. There is a daily chore list for people to ensure that the home is kept clean and tidy. People spoken with were aware of their chores for that day. Several people were seen to carry out their chores when they returned to the home after attending various community activites. The staff said they work hard to make sure the home is clean, comfortable and homely for people living in the home and that they support them with these tasks as needed. Elms Park Care Home DS0000008672.V362698.R01.S.doc Version 5.2 Page 30 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 and 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 are supported by a well trained staff team who are aware of their roles and responsibilities. EVIDENCE: To ascertain if sufficient staff are available to support people living at the home, the duty rota was examined. This showed that sufficient staff are available. As it had been indicated that extra staff would be beneficial at the weekend to enable people to carry out more activites, this was discussed with the manager, she stated that this was currently being looked at in this year’s budget. Staff spoken with said that sufficient staff were available, however extra staff would be beneficial when people go out and to ensure that sufficient staff are left at the home to support the remaining people and also at weekend to give greater freedom to people using the service. People using the service all felt that sufficient staff are available to support them as needed. Four staff personnel files were examined to ensure that they contained all the required documentation by law to make sure that people are protected from unsuitable people being employed. All files observed contained the required documentation such as an application form, two references and a criminal Elms Park Care Home DS0000008672.V362698.R01.S.doc Version 5.2 Page 31 record bureau check (a police check to see if an individual has a police caution or criminal record). Staff spoken with confirmed that they had undertaken a criminal record bureau check before commencing employment. Staff training files were inspected to make sure that staff have had the training they need to work positively and safely with people using the service. The files observed showed that staff continue to undertake compulsory training such as fire, manual handling, first aid and person centred care. Staff spoken with said that they were supported in their development and training offered was at a good standard. They were able to discuss the individual needs of people using the service to a good standard. To ensure that all new employees are aware of their roles and responsibilities when commencing employment they undertake an induction, this was confirmed by the information provided on the annual quality assurance assessment. There was evidence of two new members of staff undertaking an induction at present. The annual quality assurance assessment states that three members of staff have undertaken the National Vocational Qualification (a nationally recognised work and theory based qualification) level two in care and one person is working towards this qualification, which ensure that staff have the necessary skills and knowledge in regard to caring for the client group. Elms Park Care Home DS0000008672.V362698.R01.S.doc Version 5.2 Page 32 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 live in a home that is well managed and run in their best interests. EVIDENCE: The manager has been in post for three years, she ensures that she remains up to date with training and development and has now completed the National Vocational Qualification level 3 (a nationally recognised work and theory based qualification. Staff spoken with said that the manager was very fair at all times and listened to staff if they had any concerns. They felt that the home was well run and managed. People using the service spoken with also spoke highly of the manager and said that she helped to support them. Staff said that they received supervision sessions every six weeks; two separate records were available to confirm that these take place. Elms Park Care Home DS0000008672.V362698.R01.S.doc Version 5.2 Page 33 The manager and regional manager, to ensure that a quality service is on offer for people living at the home, undertake monthly audits such as the services and facilities, support plans, medication and finances. There was evidence of action plans being in place to address any issues and to ensure an ongoing auditing system takes place. Although at present people living at the home do not fill in questionnaire forms, their views and opinions are fully documented and considered during monthly house meeting and the monthly reviews of their support plan. People using the service spoken with said that they felt that their views were fully considered in the running of the service and there was evidence of this within the auditing documentation. The information in the annual quality assurance assessment provided to the Commission prior to the visit demonstrated that relevant servicing such as the mains electrics and fire systems take place as required to ensure that these remain serviceable and safe. Staff have received training in health and safety issues and were able to discuss relevant issues. There were no hazards observed during the tour of the home. Elms Park Care Home DS0000008672.V362698.R01.S.doc Version 5.2 Page 34 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 X 2 3 3 X 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 X 33 3 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 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 N/A 2 X 3 X 3 X X 3 X Elms Park Care Home DS0000008672.V362698.R01.S.doc Version 5.2 Page 35 No Are there any outstanding requirements from the last inspection? 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 YA20 Regulation 13(2) Requirement Handwritten entries on the medication administration chart must correspond with the prescription on boxed medication to ensure the people using the service receive the correct medication. Timescale for action 20/05/08 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 YA20 Good Practice Recommendations Handwritten entries on the medication chart should be signed by two members of staff to show that these have been checked as correct. Elms Park Care Home DS0000008672.V362698.R01.S.doc Version 5.2 Page 36 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 Elms Park Care Home DS0000008672.V362698.R01.S.doc Version 5.2 Page 37 - 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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