Inspection on 08/01/08 for Eldermere

This inspection was carried out on 8th January 2008.

CSCI found this care home to be providing an Adequate 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Eldermere 23/01/07

Eldermere 01/03/06

Eldermere 19/07/05

Eldermere 31/01/05

Eldermere 17/06/04

Eldermere 24/02/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Eldermere Knowle Lane Shepton Mallet Somerset BA4 4PF Lead Inspector Marion J Hurley Unannounced Inspection 8th January 2008 09:30 Eldermere DS0000029566.V357150.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 Eldermere DS0000029566.V357150.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. Eldermere DS0000029566.V357150.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Eldermere Address Knowle Lane Shepton Mallet Somerset BA4 4PF 01749 344642 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) Somerset County Council (LD Services) vacant Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Eldermere DS0000029566.V357150.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users may be admitted who have concurrent sensory impairment Date of last inspection Brief Description of the Service: Eldermere is a home providing care and support for six adults who have severe learning difficulties, multi-sensory and physical impairments. In addition, a high level of support is required in communication needs. Eldermere is a large detached property, with secure gardens at the rear and is located approximately two miles from Shepton Mallet. The accommodation is arranged on two floors. On the ground floor there is a lounge, dining room, laundry facility, kitchen and one bedroom with en-suite facilities. Five further bedrooms are located on the first floor. Service users have access to the homes shared transport. A team of staff throughout a twenty-four hour period supports the people who live at Eldemere. The home is owned by Somerset County Council Social Services. Eldermere DS0000029566.V357150.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 1 star. This means the people who use the service experience adequate outcomes. This inspection was undertaken as part of the statutory inspection process in accordance with the Care Standards Act, 2000. All key standards were assessed according to the Care Home for Adults (18-65) National Minimum Standards. Key inspections are aimed at making sure that the individual services are meeting the standards and that outcomes are promoting the best interests of the people living in the home. Pre inspection information was obtained from a variety of sources including an annual self-assessment. This assessment is aimed at looking at how services are performing and achieving outcomes for people. It is now a legal requirement for services to complete and return the Annual Quality Assurance Assessment (AQAA). The manager had comprehensively completed the AQAA identifying positive aspects of the service and areas for development. The site visit to the home was carried out over two days. The main focus of the visit was to review improvements made since the last inspection completed in January 2007 and the well being of the residents. Time was spent touring the building, talking to the staff and observing the people who live at the home and reviewing a selection of assessment, care plans, medication records, staff files and all documentation relating to health and safety matters. The manager and staff were very helpful and demonstrated a pro-active approach to ensuring that the people living at Eldermere were being supported to the best of their abilities and resources and the inspector would like to thank all those involved in the inspection for their support and assistance. Comment cards were circulated prior to the inspection and those returned from relatives were mainly positive including: “Eldermere provides a refuge for vulnerable people”. “They always try to make the lives of the client’s interesting”. “My daughter is well cared for”. What the service does well: The residents were comfortable and relaxed in their home and staff clearly were well aware of their individual needs. Despite the poor quality of the décor staff strove to make the environment homely and comfortable and the residents bedrooms were all different and reflected their individuality. Eldermere DS0000029566.V357150.R01.S.doc Version 5.2 Page 6 There is a core group of staff that have worked at the home for several years and know the residents well, this means residents are able to receive care and support from people they are familiar with. The management and administration of resident’s medication was good. What has improved since the last inspection? What they could do better: The manager hopes to move the service forward in a number of ways and has identified several areas for improvement many of which link specifically with the requirements and recommendations made following this inspection. A Statement of Purpose and Service User Guide need to be produced which should be available to prospective residents and their representatives. People living in the home should have a contract, which is relevant to them and provides clear information about the fees and extra charges and should be reviewed to reflect any changes. Although care plans were in place for each resident there was no consistent review of the plans. The plans should be person centred and reflect the individual’s abilities and needs and clearly identify their preferred lifestyle. The plans should illustrate how staff have involved each person in developing their own plan and how the individual has been supported and encouraged to identify to make choices. The care plans should include a practical risk assessment linked specifically to the person’s individual abilities and needs and assessments should give clear guidelines as to why some boundaries are imposed. The social, leisure and recreational opportunities need to be developed to ensure they reflect the individual abilities and interests of each person. Staff training is available however regular updates in mandatory training were not being completed and further opportunities in specialist training would benefit staff in their daily work with people who have complex needs and multiple disabilities. The Home does not have a system in place to show how they monitor the quality of service provided and this information needs to shape the practices within the home and show how the home is run in the resident’s best interests. Eldermere DS0000029566.V357150.R01.S.doc Version 5.2 Page 7 There were insufficient staff records to decide whether staff had been safely recruited or not to the Home. The manager was clear about good recruitment practices however was unable to support this knowledge as the records lacked essential information. The home has been without a registered manager for some time, a permanent manger is now in post and it is understood has made an application to be registered with the CSCI. 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. Eldermere DS0000029566.V357150.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 Eldermere DS0000029566.V357150.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 & 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home does not have a current Statement of Purpose or Service User Guide, therefore any prospective residents or their carers would only receive verbal information on which to base their decision about the homes capacity to meet their needs. Staff stated that residents would have their needs assessed prior to admission to the home. The current contracts do not fully protect peoples’ individual rights and make sure that are being provided with the service that the fees are being allocated for. EVIDENCE: The staff confirmed that the home has not admitted anyone since 1996, but described the principles and procedures for someone moving to the home. The support workers confirmed that people offered a place at the home would be supported throughout the admission process and care taken to make sure they settled into their new environment. Records showed that each person living at Eldermere had been issued with a general contract which include a weekly transport charge of £19.50 however not all the residents access the home’s available transport and at the current Eldermere DS0000029566.V357150.R01.S.doc Version 5.2 Page 10 time only two staff are willing to drive the vehicle. The home must ensure that all arrangements or financial commitments are fully agreed to and that residents have the support of an advocate or relative to make the decision. The contracts contain basic information but will need to work in conjunction with the Statement of Purpose and Service User Guide and be individualised as to the amount of support that is provided with regards to the fees that are being paid for. The home must produce a Statement of Purpose and Service User Guide and ensure the information is available in appropriate formats thereby promoting the rights and best interests of residents. The inspector acknowledges that the concept of a contract or Service user Guide is not one that could be comprehended by the people living at Eldermere however, these documents must still be available and in a format that is suitable to their abilities and needs. Eldermere DS0000029566.V357150.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All the residents have written documentation in the form of care plans and risk assessments however none had been adequately reviewed. All the care plans need to be updated to reflect changes in the residents needs and further work needs to be undertaken to ensure residents are involved in decisions about their lives as far as practicable. The care plans need to be comprehensive, and identify personal needs and goals and are specific to the individual. EVIDENCE: Discussion with staff demonstrated their knowledge and understanding of the people who live at the home however this knowledge was not reflected in the care plans and the home need to ensure that the detail of how to support people on a day to day basis with definite guidelines which are clear and direct. People living at Eldermere have complex needs and can present behaviours that may be a risk to themselves or others, and whilst there has been some Eldermere DS0000029566.V357150.R01.S.doc Version 5.2 Page 12 contact with specialist services the information and advice needs to be incorporated into the person’s plan. The concept of making decisions and choices for some people living at Eldermere is difficult and therefore it is recommended that the home obtain the support from independent advocacy services to ensure decisions are made and implemented in the “best interests” of the individual person. Support staff stated that people are offered choices in their daily lives but the care plans did not illustrate how people are encouraged to take some control over their own lives. Plans must contain sufficient information to guide staff practices when supporting people who may show aggressive tendencies or be vulnerable to self-harm. Risk assessments must be comprehensive and tailored to individual needs and aimed at supporting and promoting independence and should cover both environmental; and individual risks that are linked with the care plans. Where changes are identified these need to be incorporated into the care plans and regularly reviewed and monitored. Despite documentation not being up to date it is important to recognize that staff spoken to were knowledgeable about the needs of each resident and had a good understanding of their specific abilities and needs and the care given on a daily basis. Eldermere DS0000029566.V357150.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 & 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff ensure the residents dignity and privacy is respected. Some activities are provided however; work is needed to ensure more opportunities are available to the people living at Eldermere. People living at Eldermere are supported and enabled to keep in contact with their family. Residents receive a healthy and varied diet. EVIDENCE: The people living at Eldermere have significant care needs and all require a high level of support from the staff team. Staff said the routines of the home are planned around the resident’s needs and wishes for example, the morning routine is very relaxed and within reason people can get up when they choose. Eldermere DS0000029566.V357150.R01.S.doc Version 5.2 Page 14 People predominantly are reliant on staff and family members recognising and identifying their likes and dislikes. Staff gave examples of individual likes/dislikes though there was no written evidence to support their knowledge and understanding of peoples’ wishes. The home operates a monitoring chart known as “My day plan”, which requires staff to log the amount of time spent on different activities the person experiences throughout the 24-hour period for example daily task time (care & support), option time (activities chosen or identified by staff as of interest to the individual) and self directed time. (watching TV) People no longer attend day care services and there are no formal activity programmes though the manager described some of the different places and activities residents participate in. Two people go swimming at a local leisure centre but this is dependent on the staff rota having drivers available. Frome Resource Centre (social service day centre) runs adult learning and leisure classes and two people have joined a drama class and another is enjoying animal husbandry. The manager has also arranged for in house music therapy sessions and several people enjoy going to a weekly disco / karaoke evening. Staff have not received any training in organising and arranging activity programmes for people with complex needs and consideration needs to be given to providing training in this area. The manager was aware of the need to improve this area of practice. Despite the manager identifying key worker days on the rota staff said it was not always possible for the resident to benefit from this as some people require two staff to support them when out in the community but the rota regularly only allowed for one to one support. Staff felt one member of staff would not be adequate cover to ensure the safety of the remainder of people in the home. The manager is currently in discussion with staff as to the best way to resolve the issue. People are supported to maintain family links and staff encourage individuals to send cards at significant occasions for example birthdays. Staff said most residents had contact with their families and were able to see visitors in the lounge or in their bedrooms. The manager and staff promote a healthy eating menu. Lunch is the main meal of the day and is generally a cooked meal and this presents staff with difficulties, as there is not a dedicated cook the staff in addition to looking after six highly dependent people have to prepare and cook the meal. Staff do not eat with the residents though were present in the dinning room to assist those residents who needed help with eating. Residents able to manage their own meals were provided with adapted cutlery. Meals appeared to be enjoyed by the residents. It is recommended that staff sit with the residents at meal times and try and make the occasion more leisurely and social. Eldermere DS0000029566.V357150.R01.S.doc Version 5.2 Page 15 Some residents were eating on a small dining table in the kitchen and others in the adjacent dinning room. A serving hatch links the two rooms. Due to the pressure on staff the member of staff supporting the people eating their meal in the kitchen also starts to tidy up the kitchen and wash up whilst the people are still eating their meal. The kitchen does not have a dishwasher one might eradicate this problem. And allow staff time to sit down with the residents. Eldermere DS0000029566.V357150.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 adequate. This judgement has been made using available evidence including a visit to this service. The personal and health care needs of people are met, promoting and protecting their dignity. Individual care plans need to be regularly reviewed to reflect any changes in their health and personal needs. There are policies and procedure in place for the safe storage, administration and recording of medication. EVIDENCE: All the residents are registered with a GP and records showed that people have access to chiropodist, dentist and optician services. Storage of all medication was found to be satisfactory. A sample of medication records were checked and found to be accurately maintained with no omissions or errors noted. The manager explained that most people living at Eldermere have some continence difficulties and referrals to the Continence service have recently been submitted. The manager hopes with professional support to reduce people’s reliance on continence aids (pads). Since coming to Eldermere the manager has removed all plastic sheeting previously found on the beds and appropriate bedding has been supplied. Eldermere DS0000029566.V357150.R01.S.doc Version 5.2 Page 17 Eldermere DS0000029566.V357150.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A satisfactory complaints procedure is in place although the people living at Eldermere would not understand the concept of how to make a complaint. The people living at Eldermere are safeguarded by adult protection policies and procedures and by staff that are trained to protect them. EVIDENCE: There is a complaints procedure in place and staff stated they were aware of the procedures to follow. Staff have undertaken adult protection training and showed an awareness of the recognition of abuse. Policies and procedures are available to all staff. All people living at Eldermere have a named key worker and this role needs to be developed to ensure the key worker has time to work alongside the individual to encourage them to express any opinions and to identify any concerns the person may be feeling. Staff said that all residents are assisted with their personal allowances. Individuals have their own allowances and staff confirmed that the Court of Protection safeguards in theory all resident’s finances and the manager is appointee for all residents. Since the last inspection no complaints or adult protection issues have been raised. Eldermere DS0000029566.V357150.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The residents live in a home where decoration and furnishings are not of a good quality. All the communal areas are in need of decoration and refurbishment to ensure people live in a comfortable, homely and safe environment that suits their lifestyles. There were no unpleasant odours in the home at the time of the visit. EVIDENCE: The home is situated in a quiet lane just outside the centre of Shepton Mallet. There is no public transport available and for most residents the walk to the nearest shops would be too far though some people enjoy short walks along the lane. The property is surrounded by large gardens and has ample private car parking. The rear garden is secure. Some areas of the home are looking in a poor state and it is not a particularly comfortable or homely environment for people to live in. The manager confirmed that money has been identified to decorate the communal areas. The carpets are steamed cleaned once a month and whilst Eldermere DS0000029566.V357150.R01.S.doc Version 5.2 Page 20 this minimises any odours it does require all the residents to leave their home for this period of time. All the bedrooms, except one, are kept locked due to one person who is prone to enter other people’s bedrooms and disrespect the possessions. The manager and staff need to think of alternative methods of protecting the resident’s possessions whilst not restricting anyone from accessing their own bedroom throughout the day. All the bedrooms are personalised and reflect the different personalities and interests of the residents. The kitchen has previously been kept locked however the manager does not wish to restrict residents’ access though staff stated that this was sometimes difficult to manage as several of the people present a risk to themselves and others if they are in the kitchen without sufficient supervision. The kitchen would benefit from being refurbished with new appliances, which could include a dishwasher. The passageway to the office appears damp and this needs to be resolved. The home has a good size laundry with two washing machines (only one working at the time of this visit) and a tumble dryer. Cleaning materials and other hazardous products are kept securely in locked cupboard. The home was clean and tidy and benefits from a part time employee specially recruited to maintain these standards. Eldermere DS0000029566.V357150.R01.S.doc Version 5.2 Page 21 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. Residents are supported by staff that know and understand their needs and preferences. Staffing levels do not always allow residents to be supported in routinely taking part in their calendar of activities. EVIDENCE: Staff spoken to and observations made demonstrated that they were focussed on the needs of the people living in the home and that they tried to work closely with the individuals. The home has been through a period of change in the last year with some staff seconded from other homes to support the day-to-day running of the home. This has affected the stability and leadership of the home for residents and staff. Inspection of the duty rota and discussions with the manger and other staff indicated that staffing levels are generally satisfactory. Though some staff felt there were not sufficient numbers on duty to ensure residents social and emotional needs to be comprehensively met. Eldermere DS0000029566.V357150.R01.S.doc Version 5.2 Page 22 Despite the home having its own transport, currently a bus, several staff are unwilling to drive it and this impacts on the choice of activities available to the people living at Eldermere. The manager hopes to replace this vehicle with at least one smaller people carrier. It was difficult to establish how much training staff had received because individual training records were not in place. Annual appraisals and supervision were also not up to date. All mandatory training must be completed and staff must be regularly nominated for refresher training. This is needed to ensure the health and safety of both residents and staff. The manager was aware of the need to address these matters and had produced a rolling programme of mandatory training and to introduce more specialised subjects. The manager has to do further work to complete a formal training plan and was aware of what aspects of the programme needed to be developed and reviewed urgently. The home has a recruitment and selection policy and procedure that the manager understood and uses when appointing new members of staff however it was not possible to decide if staff were recruited safely to the home, as some staff records were incomplete and did not contain the required information. In general staff supervision and mandatory training is not being regularly completed and needs to be established. It is important systems are in place to show proper managerial oversight of the home and to ensure the manager receives the support and direction she needs to implement good practice. The manager intends to give all staff individual portfolios, which will include training records, annual appraisals and supervision records. Eldermere DS0000029566.V357150.R01.S.doc Version 5.2 Page 23 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 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home now has a permanent manager, which will provide more consistency and stability for those living and working at Eldermere. It is understood the manager has applied to register with the CSCI, which will enable them to be effective in their role and to be able to support staff and residents. Residents’ health and welfare would be increased with improved care documentation, staff training, resident information and development of a structured quality assurance programme. EVIDENCE: All records relating to health and safety tests were checked and some regular testing of fire alarm equipment and emergency lighting had not been Eldermere DS0000029566.V357150.R01.S.doc Version 5.2 Page 24 completed. e.g. no water temperatures had been recorded since November 2007, emergency lighting October 2007, weekly fire alarms November 2007. The records indicate that all staff received fire safety training in July 2007 but no subsequent training. Fridge and freezer temperatures were recorded and annual small electrical appliance testing had been completed. The regulations governing the home require that regular visits take place by the registered person or their representative and should include reviewing health and safety around the home, the people in their own home and discussions with staff. There were no records of these visits having been conducted. (Regulation 26 reports) The manager since being appointed in June 2007 has identified a number of key areas for improvement including and it is important that the manager is supported to ensure the work come to fruition. The manager will be required to study for the Registered manager’s award/NVQ level 4. Eldermere DS0000029566.V357150.R01.S.doc Version 5.2 Page 25 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 1 2 2 3 x 4 x 5 2 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 2 25 x 26 x 27 x 28 x 29 X 30 3 STAFFING Standard No Score 31 x 32 2 33 x 34 2 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 x 2 x LIFESTYLES Standard No Score 11 x 12 2 13 2 14 x 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 x 2 x 2 x x 2 x Eldermere DS0000029566.V357150.R01.S.doc Version 5.2 Page 26 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 YA1 Regulation 4(1) 5(1) Requirement The registered person must produce an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions and produce a service users guide to the home. The registered manager must develop for each person a written and costed contract/statement of terms and conditions between the home and the service user, which is specific to the individual. The registered manager must ensure that the service user’s care and support plans are kept under review and ensure it reflects the current needs of the individual. This requirement has not been achieved and the inspector has agreed a new timescale for action. The Registered Manager must ensure that detailed risk assessments are completed to ensure service users are not put at unnecessary risk. DS0000029566.V357150.R01.S.doc Timescale for action 31/03/08 2. YA5 5(1)(b) (c) 31/03/08 3 YA6 15 (2) (b) (c) 31/03/08 4 YA9 13 4 (b) (c) 31/03/08 Eldermere Version 5.2 Page 27 5 YA13 16 (2) (m) This requirement has not been achieved and the inspector has agreed a new timescale for action. The Registered Manager must ensure that service users are provided with opportunities to participate in social and community activities, including evenings and weekends. This requirement has not been totally achieved but is work in progress. The inspector has agreed a new timescale for action. The registered person must operate a thorough recruitment procedure and ensure the required documentation and information is available. The registered person must that there is a staff training and development programme and all staff have an individual assessment and training profile. Please note the manager has commenced work to achieve this standard. The registered manager must ensure that an effective quality assurance and quality monitoring system is developed to measure success in achieving the aims, objectives and statement of purpose of the home. The registered manager must ensure safe working practices and ensure all staff receive regular training in safe working practices. 31/03/08 6 YA34 Sch.2 (5) 31/03/08 7. YA35 18(1) (c) 31/03/08 8. YA39 24(1) (2) 31/03/08 9. YA42 23(4) (a) (c) (d)(e) 31/03/08 Eldermere DS0000029566.V357150.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations The registered manager should consider ways in which service users can be supported to be involved in the development and review of their care and support plan. The registered manager should introduced documentation to record how and when service users are offered choices in day-to-day living when using photos/symbols. The registered manager should continue to encourage and seek varied opportunities for people using the service and ensure these are person centred. The registered manager should encourage staff to support service users to participate in the local community in accordance with assessed needs and the individual Plans. The registered manager should ensure people have access to their bedrooms and communal areas at all reasonable times. The Registered Manager should review the needs of the service users in relation to eating and drinking to ensure that staff support is provided where needed. Personal care and support should be provided according to the individual’s assessed needs and their preferences noted. The Registered Manager should consider re-locating the medicines cabinet into an area of the home that does not intrude so much on the service users living space. The registered manager should consider ways to ensure residents are supported to express their opinions. The registered manager needs to consider ways to make the environment feel more homely and comfortable. 2. YA7 3. 4. 5. 6. YA12 YA13 YA16 YA17 7. 8. 9. 10. YA18 YA20 YA22 YA24 Eldermere DS0000029566.V357150.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Taunton Local Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Eldermere DS0000029566.V357150.R01.S.doc Version 5.2 Page 30 - 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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