Inspection on 10/09/08 for Elmstone, The

This is the latest available inspection report for this service, carried out on 10th September 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Elmstone, The 04/04/06

Elmstone, The 16/11/05

Elmstone, The 01/03/05

Elmstone, The 21/06/04

Elmstone, The 27/03/04

Elmstone, The 13/01/04

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Chatsworth Care - Tudor Lodge

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Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOME ADULTS 18-65 Elmstone, The 17 Norwood High Street West Norwood London SE27 9JU Lead Inspector Sonia McKay Key Unannounced Inspection 10th September 2008 08:15 Elmstone, The DS0000022763.V370841.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 Elmstone, The DS0000022763.V370841.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. Elmstone, The DS0000022763.V370841.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elmstone, The Address 17 Norwood High Street West Norwood London SE27 9JU 0208 655 9631 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) elmstone.lambeth@larche.org.uk www.larche.org.uk L`Arche Lambeth Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Elmstone, The DS0000022763.V370841.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is: 5 10th September 2007 Date of last inspection Brief Description of the Service: The Elmstone is a home for five adults who have a learning disability. It is one of five residential care homes in the area that are part of the Lambeth LArche community. The home is a large Victorian house. Residents have their own bedroom and access to a communal living room, dining room, kitchen and courtyard garden. The home is adjacent to the LArche Lambeth head office and workshops. The LArche community aims to provide a strong sense of belonging and value for residents and their assistants. There is on street parking available nearby. There is good access to West Norwood train station, bus links and shops. Elmstone, The DS0000022763.V370841.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. This inspection was carried out in one day. The methods used to assess the quality of service being provided were: • • • • • • • • • Talking with the newly appointed home manager Looking at the ‘Annual Quality Assurance Audit’ completed by the home manager (this document is sometimes called an ‘AQAA’ and it provides the Commission with information about the service) Talking to staff on duty during the inspection Talking to two residents A tour of the communal areas of the premises Looking at records about the care provided to three of the residents Looking at records relating to recent staff recruitment and training Looking at the way medicines are handled by staff in the home Looking at issues that the Commission has been notified about since the last inspection and how they were handled The Commission would like to thank all who kindly contributed their time, views and experiences to the inspection process. What the service does well: There is a good booklet about the home. It tells people who are thinking about moving there what it is like to live there. There are lots of pictures and photographs and this makes it easy to understand. The home is clean and comfortable and residents have their own bedrooms. People get a good chance to see what it is like to live in the home before they have to make a decision to move in. Residents can make decisions and contribute their ideas to the way the home is run. Residents have lots to do. Some go to work and some go to college or attend a workshop. There are lots of holidays and evening activities. Residents are supported to attend the places of worship that they wish to attend. Elmstone, The DS0000022763.V370841.R01.S.doc Version 5.2 Page 6 Staff listen if residents have a concern or want to complain about something and they try and sort it out make things better Confidential information is stored securely. Staff help residents to be as independent as possible and to make decisions about their day-to-day lives. Staff help residents to stay healthy and to see a doctor if they become unwell. Residents enjoy the meals and there are lots of fresh fruit and vegetables available. Residents are supported to have diets that suit their medical needs. What has improved since the last inspection? What they could do better: Staff should write down important things about people’s cultures so that staff that don’t know much about that culture have better information about how to support people to meet their cultural needs. Staff should think about safety often, especially when people are becoming more or less independent. This is because staff need to know how to keep people safe and still support them to take risks and be as independent as possible. Staff should write down what the risks are so that all staff know what to do. Staff do not stay long as many are from overseas. This means it is hard for the home to retain a qualified team. Staff must keep a better record of people who visit the home and of things that belong to residents. The registered provider must visit the home more often (each month) to talk to residents and to staff and to check that records are being kept properly. They should look around the house and make sure that everything is all right. The manager must think about each member of staff and what training they need to do this year. She must then make a plan for when the training will Elmstone, The DS0000022763.V370841.R01.S.doc Version 5.2 Page 7 happen. This will make sure that staff know how to support the residents properly. 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. Elmstone, The DS0000022763.V370841.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 Elmstone, The DS0000022763.V370841.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 & 4. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There is accessible information about the services provided. This is useful to prospective residents who may find text only documents difficult to understand. There is also ample opportunity for residents to experience life in the home before making a decision to move in for a trial period. EVIDENCE: The statement of purpose contains adequate information and was reviewed in January 2008. . There is an informative guide about the service provided in the home. Emphasis is placed on making the guide accessible to residents with a learning disability and it contains many colour photographs, symbols and clear language. The ‘Resident’s guide and associated individual contracts have greater detail relating to the standard package of services provided and fees. L’Arche offers long-term placements and there is a lengthy placement process. This is tailored to meet the needs of the individual and involves at least two brief visits to the home and three longer visits, including overnight stays. This provides an opportunity to experience life in the home before making a positive choice to move in for a trial period. Elmstone, The DS0000022763.V370841.R01.S.doc Version 5.2 Page 10 There are no new resident since the last inspection visit. There are currently four residents and one vacant placement. There is no resettlement work underway at this time. Elmstone, The DS0000022763.V370841.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, 8, 9 & 10. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Changing needs and goals are written down and reviewed often with residents. Residents are given good support to enable them to keep the plans centred on their own goals in life. Residents are consulted and contribute ideas to how the home and wider L’Arche community is run. People are supported to take risks as part of developing greater independence although risk review processes have slipped. The cultural needs of residents are not adequately assessed and there are no specific plans for how these needs are to be addressed. Confidential information is stored securely. EVIDENCE: Each resident has three files of written information for staff reference. One file contains detailed information about current care needs and risks and personal life history information, another file contains medical and health records and a third is used to safely store older information. Elmstone, The DS0000022763.V370841.R01.S.doc Version 5.2 Page 12 There is a written plan for each resident describing the type of support that each person needs in areas if daily living. There are also goals for each resident to achieve. These goals are decided during annual review meetings with the resident and key people in their lives. Progress in achieving these goals is monitored well. The outcomes of placing authority review meetings are also held on file. Information included in the plans is comprehensive, written in plain English and focuses on the needs and goals of the resident themselves. Although residents have not signed the plans, there is evidence in the minutes of the review meetings that residents are consulted about how they want to be cared for and what things are important to them. There is detailed information about how each person communicates and how to interpret some things that are often said. The new manager has developed an easy read summary of needs for new staff to refer to whilst on duty and busy. This makes essential information more accessible. One area of improvement is still required. One resident is African-Caribbean, none of the staff or other residents are. The resident is in contact with family who live in the area. Although some cultural needs relating to food are mentioned in care plans, there are no specific plans for meeting wider cultural needs. An assessment of the cultural needs of all of the residents would be of benefit to them as staff, who are not of the same cultural background as the residents may not have sufficient knowledge to adequately support residents to address and meet their cultural needs, and staff turnover is high. (See requirement 1) Risk assessments are in place in a range of appropriate areas. There is evidence that the risks have been reviewed, as there are pencil additions. These amendments must be added properly and the date of review established so that staff have clear information to follow. (See requirement 2) L’Arche aims to provide each resident with a ‘reference person’ in the home to act as a key worker. Residents have a key member of staff to work with who has special responsibility for assisting with decision-making, planning and dayto-day arrangements. L’Arche uses a semi-independent advocacy system with people who know the resident well. This ensures that someone from outside the home is involved. Elmstone, The DS0000022763.V370841.R01.S.doc Version 5.2 Page 13 When major decisions need to be made L’Arche aims to provide the services of fully independent advocates. Residents are encouraged to participate in the day-to-day running of the home and in community planning. They take part in weekly house meetings, ‘talking group’ meetings with the Community leader and they are able to vote in community council elections. Residents are involved in the assessment of new staff during their probationary period and increased involvement in staff appraisal is being developed. There was resident involvement in setting the priorities for the Community as a whole and in the review of the day services that are also provided. Residents make day-to-day decisions about what to wear, how to spend their leisure time, who to invite to dinner and what to cook. All need assistance from staff to manage their own finances. Confidential information is stored securely. Elmstone, The DS0000022763.V370841.R01.S.doc Version 5.2 Page 14 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): 11, 12, 13, 14, 15, 16 & 17. Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Residents have opportunities for personal development and are encouraged to be responsible in their daily lives. They take part in a wide range of leisure activities and therapeutic employment and they are offered a healthy diet. Residents are supported to maintain and develop relationships with family and friends. Residents are part of their community. EVIDENCE: L’Arche is a faith-based community and offers active support to each resident to develop their faith and spiritual lives. Residents who choose not to attend religious activities of any particular denomination are offered opportunities to engage in art, music and nature instead. On the morning of the inspection residents were observed to getting ready for their day. Each has a place in the L’Arche supported employment workshops Elmstone, The DS0000022763.V370841.R01.S.doc Version 5.2 Page 15 (weaving, stone work, gardening and candle-making). Two residents also attend college. One resident has recently started work and is reported to be enjoying the experience. He sails regularly in the summer and swims each week. He attends workshops in gardening and candle making. One resident started college the week of the inspection and also attends workshops in weaving and candle making. She also attends regular keep-fit sessions. One resident swims, attends workshops and visits his family without staff support. One resident attends workshops in weaving and candle-making. She also attends a music class and swims. The close proximity of the other L’Arche homes provides an opportunity for residents visit each other and goes out for dinner. There is a strong community spirit and lots of parties and celebrations to attend or host. Residents are supported to maintain and develop relationships with family and friends. The manager demonstrates an understanding of the need for people to have relationships and is careful to ensure that people get the right sort of information and support when considering closer relationships. L’Arche Lambeth has been operating for more than 30 years and has developed good relationships with local individuals and organisations. All residents are offered a minimum three weeks of holiday away from the home in each year, either alone (with staff support) or as part of a group with shared interest. Most go way more often. Records of the meals eaten show that a variety of meals are prepared. Food stocks are stored appropriately and contain plenty of fresh fruit and vegetables. Each resident chooses and prepares one evening meal each week to the best of their ability (with staff support as necessary) and as part of their skills development or assists in other aspects of mealtime chores, such as clearing up afterwards. There is good information about special diets (for example, gluten free recipes and food produce). Elmstone, The DS0000022763.V370841.R01.S.doc Version 5.2 Page 16 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 & 20. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents receive appropriate support to maintain their personal care. Physical and emotional needs are met and staff have improved records of medication given. Residents are supported to be self-medicating where possible and there is better information about each medication and any possible side effects. This makes it safer for residents. EVIDENCE: Times for getting up and going to bed are flexible and reflect planned activities. Residents are able to undertake their personal care with minimal support from staff and they choose their own clothes and hairstyles. Staff have assisted one resident to better plan her daily outfits by labelling cupboards and keeping colours in order. The resident was observed to be well dressed and obviously cared about things matching together well. One resident, who is visually impaired, has a bathing plan that allows independence. This plan has been replicated from her previous home, including the fitting of an adapted bath. Elmstone, The DS0000022763.V370841.R01.S.doc Version 5.2 Page 17 Staff support residents to make and attend healthcare appointments. Each persons care file has a detailed health information form to be given to medical staff in the event that a resident has to be taken to hospital in an emergency. This is good practice. The health care of two of the residents was looked at. Records of the outcome of any healthcare are well kept, and there is evidence that residents receive appropriate assistance to monitor and maintain their physical health. Staff seek medical advice if they think someone is unwell. Weight records have not been recorded often. This is a useful indicator of health. (See requirement 3) The Lambeth specialist team for adults with a learning disability provides input on referral from the home when necessary. Input includes psychology and speech and language therapy, occupational therapy and physiotherapy. Staff have reduced risk of injury for one resident who experiences seizures at night on occasion by obtaining a lower level ‘futon style’ bed, a soft textured bedside rug and adding padding to the headboard area. The local pharmacy provides staff with training and supplies prescribed medication in pre-filled measured dose packs. Homely remedies are used if necessary. There is stock record book of what is being kept, and authorisation from each resident’s GP about what ‘over the counter’ remedies they can safely use. Two of the residents are able to take a degree of responsibility for taking their own medication. Staff support them to do this in different ways and risks relating to self-medication are assessed and there are clear risk management plans in place. This makes it safer for residents. Medication is stored securely and staff administer medication to two of the residents. During the last inspection it was noted that there were gaps in recording and it was unclear whether medications had been administered on some days. Medication Administration Records examined during this inspection show no gaps in recording and t the requirement is therefore met. As required in the previous inspection report, medication records now include a photograph of the resident, details of what each medication is for and any potential side effects. Receipts and returns of medication are recorded in a separate log. Staff undergo a two-day training course by a pharmacist. There is an authorised signature list of staff that are trained to administer medication. Elmstone, The DS0000022763.V370841.R01.S.doc Version 5.2 Page 18 This list includes the names of staff from other L’Arche homes that occasionally work at the home. Elmstone, The DS0000022763.V370841.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The views of residents are acted upon and listened to and residents re protected from abuse, neglect and self- harm. Record keeping must be improved in some areas relating to safeguarding. EVIDENCE: There is a complaints policy with a text version and a more accessible version for residents who may not be able to understand a text only document Regular house meetings provide residents with an opportunity to raise concerns. The record of complaints shows that there have been no complaints made since the last inspection. The home manager related that action taken to address concerns raised at house meetings. Steps taken ensure that residents get on better together. Abuse awareness training is part of the L’Arche induction and formation training undertaken by all new staff. The ‘response to abuse’ guidelines have been reviewed to ensure that they meet with protocols defined by the local authority safeguarding adults procedures. L’Arche has also developed better policy about relationships and sexuality. This is important, as residents may need education and support to make decisions in their best interest to protect them from abuse. Elmstone, The DS0000022763.V370841.R01.S.doc Version 5.2 Page 20 All residents require assistance with financial issues. Receipts are retained for all transactions and stored with the individual accounts that are in good order. There is no inventory of resident’s furniture and possessions. (See requirement 4) A record of visitors could not be located. (See requirement 5) Elmstone, The DS0000022763.V370841.R01.S.doc Version 5.2 Page 21 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, 26, 27, 28 & 30. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable and homely environment and each has their own bedroom. Environmental health have advised that a wash hand basin is required in the kitchen so that people can wash their hands before handling food. EVIDENCE: The premises are safe, comfortable, bright, airy, clean and free from offensive odours with sufficient lighting and heating. The home is in keeping with other homes in the area and is indistinguishable as a care home. The home offers good access to local amenities, transport routes and relevant support services. Furnishings and fittings are of good quality and there is a homely atmosphere with many photographs of residents and their friends displayed on the walls. Elmstone, The DS0000022763.V370841.R01.S.doc Version 5.2 Page 22 All bedrooms are single occupancy. The home has a men’s bathroom and a woman’s bathroom situated close to the bedrooms. Both rooms have a WC and a shower facility in the bath. A radiator cover had been fitted to the radiator on the mens side of the house as one of the residents has occasional seizures. Bathroom door locks are of a type that can be opened from the outside in an emergency. A separate toilet is available on the ground floor close to the dining area. There is a ground floor laundry room. A procedure is in place to ensure that soiled laundry is not carried through the kitchen during food preparation to prevent the spread of infection. The home has a communal lounge adjoining the kitchen. There is a separate dining room and large rear courtyard area with a fountain and seating areas. Smoking is permitted in the rear courtyard. Staff who sleep-in at the home have an adequate bedroom and places to keep personal belongings. The bathroom used by the two females now living at the Elmstone, has been fitted and decorated to enable a resident with visual impairment to maintain as much independence as possible during personal care. Environmental health have required that a hand washbasin be fitted in the kitchen area, to ensure good hygiene. This has not been done. There is a redecoration programme in place and communal areas of the home have been redecorated since the last inspection. The staff office has been relocated downstairs. Elmstone, The DS0000022763.V370841.R01.S.doc Version 5.2 Page 23 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 adequate This judgement has been made using available evidence including a visit to this service. There are good training opportunities but high staff turnover means that few staff stay long enough to become qualified. Residents are protected by recruitment procedures. EVIDENCE: House assistants within the L’Arche community are provided with board and lodgings. Each has a clear job description and contract of employment. Staff do not live on premises but take turns to sleep at the home to provide night cover in case of an emergency. L’Arche is a Christian community that requires staff to be part of all aspects of care and support and a committed community lifestyle. The community welcomes staff and residents from all faiths. Records are kept of all staff duty rosters. Between one and two members of staff are on duty in the home depending on the activities and needs of the residents. Elmstone, The DS0000022763.V370841.R01.S.doc Version 5.2 Page 24 A framework of policies and procedures provides staff with guidance. There is also ongoing staff support from the homes co-ordinator and other longstanding community staff. As assistants usually only stay for between one and three years they do not normally have an NVQ (National Vocational Qualification). One option being looked at to address this is the recruitment of more local people. This will help with staff retention and may also help the team to retain qualified staff and have fewer accommodation problems. There are currently five care assistants, one has an NVQ and the manager is currently undertaking the award. (See requirement 5) Recruitment records do not currently contain copies of individual training records although a range of training is available. There must be a training plan that ensures that all staff are adequately trained to work with residents of the Elmstone. For example, NVQ, refresher courses in mandatory training, epilepsy, sensory impairment, autism and communication). (See requirement 6) Recruitment records are held at the L’Arche head office. They were made available during the inspection. Two sets were examined and there is evidence that adequate checks are made prior to recruitment. L’Arche provides all new assistants with induction training in the first six weeks. ‘Foundation training’ is undertaken in the first year, this is a combination of ‘in-house training’ and training provided by the local specialist learning disability team. Mandatory training includes first aid, health and safety (including epilepsy), food hygiene, manual handling, Sign-along, medication administration, challenging behaviour as communication, Gentle Teaching and training around taking risks and making choices. Elmstone, The DS0000022763.V370841.R01.S.doc Version 5.2 Page 25 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, 41, 42 & 43. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The manager is experienced but has yet to register with the Commission. The views of the residents underpin the running of the home. Areas of record keeping must be improved to ensure vulnerable residents are adequately protected. Steps are taken to ensure that the home environment is safe, but more could be done to plan for emergency evacuations. The registered provider is not monitoring the quality of the service being provided often enough. EVIDENCE: The previous manager left before registering with the \commission and a new manager is in post. The new manager was previously registered as manager for another home in the L’Arche community and knows the residents well. Elmstone, The DS0000022763.V370841.R01.S.doc Version 5.2 Page 26 The new manager is currently undertaking an NVQ at level 4 and the Registered Mangers Award. The manager facilitated the inspection well and was able to relate key areas of planned service development. The L’Arche community has an annual development plan for quality assurance in place. Regular house and community meetings are held to ensure that the views of the residents impact on the running of the community and planning home life. The registered provider has not carried out monthly-unannounced inspection visits with the required frequency. These visits are essential to monitor the safe running of the service and to provide the manager with feedback. (See requirement 7) Fire evacuation drill frequency has been increased, as required in the previous inspection report and the results are recorded. Records show that evacuations are often slow. (See recommendation 1) Accidents and incidents are recorded and reported appropriately. A maintenance manager assists staff to monitor and improve environmental safety. Fire and environmental risk assessments are in place and are reviewed annually. Elmstone, The DS0000022763.V370841.R01.S.doc Version 5.2 Page 27 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 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X 2 2 2 Elmstone, The DS0000022763.V370841.R01.S.doc Version 5.2 Page 28 Yes 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 YA6 Regulation 15 Requirement The registered persons must ensure that the cultural needs of each resident are clearly identified in written plans for their care. The previous timescale of 30/11/07 for action to be taken to meet this requirement is not met. Risk assessments must be reviewed regularly. The weight of each resident must be recorded on a regular basis. There must be a record of furniture and possessions owned by each resident. The registered person must ensure that plans are in place to ensure that care staff hold a care NVQ 2 or 3, or are working to obtain one by an agreed date; or can demonstrate that through past work experience and training staff meet that standard. The registered person must ensure that there is a training DS0000022763.V370841.R01.S.doc Timescale for action 31/12/08 2. 3 4. 5. YA9 YA19 YA23 YA32 12 13 12 17 18(1)(a) 07/11/08 07/11/08 31/12/08 30/08/09 6 YA35 18 31/12/08 Elmstone, The Version 5.2 Page 29 7. YA43 YA39 26 needs analysis that results in a training and development plan for staff working at the Elmstone. The registered provider must 07/11/08 ensure the service is visited in accordance with Regulation 26 to conduct quality-monitoring inspections and supply the home and the Commission with the outcomes of these visits. 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 YA42 Good Practice Recommendations Advise should be sought on how fire safety can be improved, as some residents are not responding well to the fire evacuation drill alarm. Elmstone, The DS0000022763.V370841.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Elmstone, The DS0000022763.V370841.R01.S.doc Version 5.2 Page 31 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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