Inspection on 21/11/06 for Elders (The)

This inspection was carried out on 21st November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Elders (The) 25/09/08

Elders (The) 26/07/07

Elders (The) 20/07/06

Elders (The) 15/12/05

Elders (The) 18/08/05

Elders (The) 31/08/04

Elders (The) 29/04/04

Similar services:

Springfield House

The Shelley

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Elders (The) The Elders Epsom Road Ewell Surrey KT17 1JT Lead Inspector Sandra Holland Unannounced Inspection 21st November 2006 10:00 X10015.doc Version 1.40 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 Elders (The) DS0000013633.V316630.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 Older People. 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. Elders (The) DS0000013633.V316630.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elders (The) Address The Elders Epsom Road Ewell Surrey KT17 1JT 020 8393 9757 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) Golden Hours Fellowship Limited Mr R Taylor Care Home 21 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (21) of places Elders (The) DS0000013633.V316630.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Of the 21 residents accommodated up to 3 service users may be within the category DE(E), Older People with Dementia The age/age range of the persons to be accommodated will be: OVER 65 YEARS OF AGE 20th July 2006 Date of last inspection Brief Description of the Service: The Elders is a care home providing personal care and accommodation for up to 21 older people, of whom a maximum of 3 may suffer from dementia. The home is a large detached and extended property, close to the village of Ewell and Epsom town centre. Good transport links are nearby. The home is operated by a charity, the Golden Hours Fellowship. The registered manager has worked at the home for many years and lives very close by. He is actively involved in the day-to-day running of the home and is supported in this by a management committee. There has been considerable improvement to the premises in recent years, in order to comply with the National Minimum Standards for Older People. Bedroom accommodation is currently provided at ground and first floor level, with some rooms having en suite facilities. All rooms are single. The home has a lift and a stair lift for use by service users. The fees at this service range from£400.00 to £500.00 Elders (The) DS0000013633.V316630.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection was the second to be carried out in Commission for Social Care Inspection (CSCI) year, April 2006 to June 2007 and was carried out under the CSCI “Inspecting for Better Lives” programme. Mrs Sandra Holland, Lead Inspector carried out the inspection over nine hours. Mr Ronald Taylor, Registered Manager and Mrs Bridget Cumlin, Deputy Manager were present representing the service. Areas of the home were seen and a number of records and documents were sampled, including residents’ individual plans, residents’ financial records, staff records and medication administration record (MAR) charts. Eight residents and six staff were spoken with during the course of the inspection. A pre-inspection questionnaire was supplied to the home and this was completed and returned within the requested timescale. Information supplied in the questionnaire may be referred to in this report. A number of CSCI feedback cards were supplied to the home for distribution to residents, relatives and visitors and healthcare professionals. One card was completed and returned by a resident’s relative and this was complimentary and expressed satisfaction about the care provided. The people living at the home prefer to be known as residents and that is the term that will be used throughout this report. The inspector would like to thank the residents, staff and management for their hospitality and assistance. What the service does well: The home is well-maintained, is clean and freshly-aired and a new conservatory has been added this summer. Improvements have also been carried out to increase the bathroom and shower facilities. Appetising and well-balanced meals are served and enjoyed by the residents, either in the attractive dining room, or in their own rooms if preferred. The home has a very stable staff team, most of whom have worked at the home for many years. Staff are sensitive, observant and provide prompt assistance to residents. Elders (The) DS0000013633.V316630.R01.S.doc Version 5.2 Page 6 The preferences and choices of residents are catered and provided for. What has improved since the last inspection? What they could do better: It is recommended that all pre-admission assessments of residents’ needs are signed and dated by the person carrying out the assessment. Care plans must be drawn up for each resident and assessments of any risks must be updated if there are any changes to the risks. The receipt of all medication must be recorded and the amount of medication held in the home must accurately match the record held. Staff must receive updated training in the safeguarding of vulnerable adults. A full staff rota must be maintained and must record whether the rota was actually worked. Staff must not be employed to work at the home unless all the required records and information have been obtained. Criminal Record Bureau (CRB) disclosures must be obtained for any person having unsupervised access to residents. It is of concern that two immediate requirements made at the last inspection have not been met. Elders (The) DS0000013633.V316630.R01.S.doc Version 5.2 Page 7 The amount of a resident’s money held for safekeeping must accurately match the record held. It is good practice for both parties involved in any transactions of residents’ monies, to sign the record which is maintained, for the protection of residents and staff. 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. Elders (The) DS0000013633.V316630.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Elders (The) DS0000013633.V316630.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service The needs of prospective residents have been assessed before they moved into the home. EVIDENCE: The files of a number of recently admitted residents were seen and it was clear that their needs had been assessed before they moved in. The needs of two residents had been assessed by the deputy manager and those of another resident by an experienced member of the senior care staff. It was noted that one of the pre-admission assessments had not been signed and another had not been dated and it is recommended that this is carried out for future assessments. The deputy manager advised that some residents at the home are supported financially by local authorities. Where this is the case, an assessment is also carried out under the care management process. It was pleasing to see that Elders (The) DS0000013633.V316630.R01.S.doc Version 5.2 Page 10 the care manager’s assessment had been obtained and retained for a recently admitted resident. The manager stated that intermediate care is not provided at the home. A recommendation has been made regarding Standard 3. Elders (The) DS0000013633.V316630.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ individual plans need to be drawn up and assessments of any known or identified risks must be reviewed if changes occur. The system of medication administration must be reviewed as the receipt of medication had not been recorded, the amount of medication held did not accurately match the record held and it was not possible to follow an audit trail. EVIDENCE: The files of a number of recently admitted residents were seen and it was noted that for two residents, no individual plan of care had been drawn up. The manager stated however that the details of support and care needs which had been gathered on the pre-admission assessment, were being used to guide staff. This information is not as comprehensive as seen in fully completed individual plans and as it was gathered before the resident was admitted, the needs that are referred to may have changed. Elders (The) DS0000013633.V316630.R01.S.doc Version 5.2 Page 12 It was noted that assessments of risks to residents have been drawn up, but one of these had not been amended to reflect a known change. The risk assessment for one resident regarding going out alone, stated that this was “seldom” likely to occur and “no level of risk” had been recorded. The assessment had not been changed, even after the resident left the building without telling anyone and was later returned by her son. From the records seen and speaking to residents, it is clear that residents’ healthcare needs are well met. A new patient assessment form is completed when a resident moves into the home, if they are not retaining their existing general practitioner (GP). This is supplied to the GP to provide a background history and basic information regarding the resident. Any referrals that need to be made to specialists such as a dietician, are made through the GP, the deputy manager advised. A chiropodist and a domiciliary optician service visit the home on a regular basis or on request. The deputy manager advised that the home had started using a new medication recording system the day before the inspection. It had been anticipated that medications would be supplied in a monitored dosage system, using individual “blister” packs, but medication was supplied as previously, in multiple filled “nomad” trays, which are dispensed by the pharmacist. It was noted that the medication administration record (MAR) sheets supplied by the pharmacist only recorded the medication contained in the nomad trays, but other medications or prescribed creams or ointments were not recorded. Staff at the home had established a secondary medication record sheet for these medications. It was also observed that for other medications which were managed as controlled medications, which two staff administer and sign for, a separate book was being used to record doses given, but these were not being recorded on the MAR sheet. As a running balance of the remaining medication was not maintained, it was not possible to calculate how much medication should be present. At the last inspection carried out on 20th July 2006, an immediate requirement was made that the receipt of all medication into the home must be recorded. It is of serious concern that this requirement has not been met. Medication had been received on behalf of a resident, but the date and quantity received had not been recorded, so it was not possible to know how much medication should be present or to follow an audit trail. Staff were observed to interact with residents in an informal, but appropriate way, which respected their dignity. Support with personal care was provided discreetly and promoted the privacy of residents. Staff were very observant and responded promptly to any resident requiring assistance. The resident group is of mixed gender, although the staff group is predominantly female, Elders (The) DS0000013633.V316630.R01.S.doc Version 5.2 Page 13 with the manager and chef as the only male staff. There is some cultural and racial diversity amongst the staff group, but the staff are predominantly British which reflects the resident group. Two requirements have been made regarding Standard 7 and an immediate requirement was made regarding Standard 9. Elders (The) DS0000013633.V316630.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A range of recreational activities are available and a varied, well balanced menu is offered. Residents are encouraged and supported to make their own choices and to maintain contact with their families and friends. EVIDENCE: Staff advised that they are allocated to carry out recreational activities on a daily basis and the activity carried out is recorded, to include the names of residents who took part. The record showed that indoor bowls, dancing and manicures had been carried out recently and that a number of residents had been involved. On three days each week, an activities organiser visits the home for a short and varied activity session, the deputy manager stated. The public library regularly visits the home and leaves a supply of books and a holy communion service is held each month and this was carried out on the day of inspection. Some residents said that they prefer to spend their time in their rooms, and their choice is accommodated. A number of residents were spoken with in their rooms, and meals were seen being delivered to them. It was pleasing Elders (The) DS0000013633.V316630.R01.S.doc Version 5.2 Page 15 that residents had brought items from their previous home, to personalise their rooms, including smaller items of furniture, pictures, photos and ornaments. Residents stated that their visitors were made welcome in the home and were offered refreshments. Staff advised that visitors were able to visit at any time, but that many came to the home at weekends. Details of a local advocacy service were made available in the entrance hall, to support residents who may need it. A two week menu was supplied with the pre-inspection questionnaire and this was seen to include well-balanced and wholesome meals. Staff advised that the main meal of the day is served at lunchtime, with a lighter high tea served in the early evening. Residents spoken to said they enjoyed their meals and the lunch being served was attractively presented and looked appetising. The dining room is a large, spacious room, with a number of tables accommodating different numbers of residents. The tables were well laid with table cloths, placemats and silk flowers. Elders (The) DS0000013633.V316630.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A complaints procedure is available and has been made available to all who may wish to use it. Staff are aware of their responsibilities in the protection of residents. EVIDENCE: A requirement was made at the last inspection that the complaints record must be made available to all who may wish to use it and this has been met. A compliments, comments and complaints record is now openly available on the entrance hall table. Residents stated that although they were not aware of the home’s complaint procedure, they would inform the manager or deputy manager if they were unhappy in any way. From the records seen, the majority of the staff and the manager have received training in the Protection of Vulnerable Adults (now known as Safeguarding Adults) in the past, but it was noted that the most recent of these training courses, was attended in 2004. A requirement was made at the last inspection that this training must be updated, with a timescale of 20th October 2006, but this has not been met. The home has obtained an updated copy of the Surrey Multi-Agency Procedure for the protection of vulnerable adults as recommended at the last inspection. Elders (The) DS0000013633.V316630.R01.S.doc Version 5.2 Page 17 The deputy manager advised that this was to be discussed with staff at the next staff meeting. Staff spoken to stated that they would inform the manager or person in charge, if they had any concerns about the abuse or possible abuse of residents. A “Whistle-Blowing” leaflet is provided on the staff notice board and staff were aware that they could contact CSCI, in the event of concerns that they felt were not being addressed. The deputy manager advised that monies are held for safekeeping for a small number of residents. It is of concern that the amount held for one resident did not accurately match the record held. Please see Standard 35 for full details. Elders (The) DS0000013633.V316630.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home presents as a comfortable place in which to live and was clean, tidy and fresh. EVIDENCE: A tour of the premises was carried out and it was seen to be clean, spacious, airy and well maintained. A new conservatory that links with the lounge, has recently been completed, which enables residents to spend time away from each other and has created an additional sitting room overlooking the garden. The deputy manager stated that a new shower has been fitted in an existing bathroom to increase the choices for residents and to ensure that they do not have to go far from their bedrooms for bath and shower facilities. Elders (The) DS0000013633.V316630.R01.S.doc Version 5.2 Page 19 Residents were spoken with in their bedrooms and stated how happy they were with the care and facilities provided. Two residents told of bringing their own furniture and belongings into the home to personalise their rooms. A maintenance book is used by staff to advise the maintenance person of the tasks requiring attention, the deputy manager advised. The maintenance person visits the home on a weekly basis to attend to day to day jobs, and for longer periods if larger projects such as decorating are being carried out. A split in the dining room carpet has been sealed with tape to prevent it creating a tripping hazard, but this is unsightly. The removal of the carpet in this small area which is used to position food trolleys, was discussed with the inspector. The suggestion to replace the carpet in this area with non-slip flooring was agreed as a more practical option, until the whole carpet is due to be replaced. All areas of the home were freshly aired and odour control in the home was good, except in one bedroom. The manager advised that the carpet in this bedroom is regularly cleaned. It would be good practice to record this in the maintenance programme to ensure that it is carried out to the required frequency. Staff were seen to use gloves and aprons appropriately to prevent the spread of infection and a number have undertaken training in the control of infection. Hand-washing facilities were provided in all appropriate places and in most bathrooms and toilets, paper towels and fabric towels were available. Liquid, anti-bacterial soap has now been supplied to prevent the spread of infection. The deputy manager stated that the home now has a contract for the collection of clinical waste, and a weekly collection is carried out. Elders (The) DS0000013633.V316630.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are supported and their needs are met, by a stable team of staff. The recruitment practices still need to be more robust to fully protect residents. EVIDENCE: From the information provided in the pre-inspection questionnaire and from speaking to staff, it was clear that a stable and long-standing team of staff are employed to meet the needs of the residents. Many of the staff have been employed at the home for at least two years and some for much longer. It was noted that a formal rota of the staff working hours is not held or maintained, although a daily work allocation sheet is used to record which staff are on duty and which areas of the home they will be working in. The deputy manager stated that these are not retained after the week to which they apply. It is a requirement of The Care Homes Regulations, that a copy of the duty roster of persons working at the care home, and a record of whether the roster was actually worked, is maintained. These should be retained in the home with other records for the required periods (three years for most records except medication records, which must be retained for eight years). Elders (The) DS0000013633.V316630.R01.S.doc Version 5.2 Page 21 Staff advised that the team is made up of care staff in the main and they carry out housekeeping and laundry tasks as well as providing personal care. A cook is employed to provide meals on five days each week and another member of staff who is employed as a weekend cook also works as a carer on other days. The management team carry out administrative tasks. A number of staff have achieved or are currently undertaking National Vocational Qualifications (NVQ’s) at Level 2 or 3 in Care and the home has achieved the recommended target of having fifty per cent trained staff. Staff files were seen and it was clear that the standard of recruitment practices in the home still needs to be more robust to fully safeguard residents. An immediate requirement was made at the last inspection that no person must be employed to work at the care home unless the person was fit to work there and the information and documents specified in Schedule 2 of The Care Homes Regulations had been obtained in respect of that person. It is of concern that the immediate timescale for this requirement has not been met. The file of a recently recruited member of staff was seen and it was noted that the application form and references were all dated after the date given in the pre-inspection questionnaire as the start of employment. Although the deputy manager stated that the start date was incorrect, the new date given was still before the references had been received. The deputy manager stated that a Criminal Record Bureau (CRB) disclosure has not been obtained in respect of the maintenance person(s). As these people may have access to vulnerable residents, it is required that disclosures are obtained for all staff who may have unsupervised contact with residents. The home does not currently require prospective staff to complete a health questionnaire, so it has no way of assessing whether applicants are physically or mentally fit to work in the home. The home’s application form does ask if applicants are in good health and provides for a yes or no answer, but no specific details regarding health conditions are obtained. A training record is maintained and indicates that staff have undertaken training required by law, such as fire safety, first aid and food hygiene and other training to develop their knowledge and skills, such as dementia care. It was noted (and referred to at Standard 18), that although staff have undertaken training in the past for safeguarding adults (formerly the protection of vulnerable adults), this needs to be updated. An immediate requirement has been made regarding Standard 29 and requirements have been made regarding Standards 27 and 30. Elders (The) DS0000013633.V316630.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Management of the home and of residents’ monies held for safekeeping, must be more robust. EVIDENCE: It was of concern, that two of the three immediate requirements made at the last inspection on 20th July 2006, have not been met. As indicated, immediate requirements must be met from the date on which they are made, as they may have a serious impact on the health, safety or welfare of residents. An additional immediate requirement was made at this inspection regarding resident’s monies held for safekeeping. Elders (The) DS0000013633.V316630.R01.S.doc Version 5.2 Page 23 The manager is supported by a deputy manager who has completed NVQ level 3 in care and is undertaking the Registered Manager’s Award, to develop her knowledge and skills. During the last inspection the support manager advised that a residents’ questionnaire was supplied to residents in April this year to ask their views on the quality of the service provided and a summary of the responses received was provided at that inspection. Respondents had said that the food was well cooked and was hot when served, that staff were polite and that the bathrooms were warm enough when having a bath. A more mixed response had been given to questions about the activities on offer, staff knocking on residents’ bedroom doors, privacy at bath-times and being involved in care planning. The deputy manager stated that no further surveys had been carried out since then. A CSCI feedback card was completed and returned by a resident’s relative which was very complimentary about the standard of care and attention provided. The deputy manager advised that monies are held for safekeeping for a small number of residents. It was noted that the records regarding residents monies held for safe keeping had been improved, but still do not fully protect residents. Transactions such as deposits were listed in individual record books, but two signatures, that of the person depositing or withdrawing money and the signature of the person handling the transaction, had not been recorded as previously recommended. It was also noted that for one resident, the amount of money present did not accurately match the record held. A receipt was present for an item which had been purchased, but the entry made in the record did not match the amount on the receipt. No hazards to the health or safety of residents were noted during the tour of the premises. From the information provided in the pre-inspection questionnaire, appropriate maintenance and checks have been carried out to the equipment and systems in the home, to the required frequencies. An immediate requirement has been made regarding Standard 35. Elders (The) DS0000013633.V316630.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 X X 3 Elders (The) DS0000013633.V316630.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 Requirement Timescale for action 22/12/06 2 OP7 14 (4) (c) 3 OP9 13 (2) A written care plan must be drawn up in consultation with the resident or their representative, to record how the resident’s needs in respect of their health and welfare are to be met. Unnecessary risks to the health 22/12/06 or safety of residents must be identified and so far as possible eliminated. Arrangements must be made for 21/11/06 the recording, handling, safekeeping, safe administration and disposal of medications received into the care home. A record must be maintained of all medication received into the home, to enable an audit trail to be followed. Immediate timescale of 20/07/06 not met. The registered person must 21/11/06 maintain in the care home the records specified in Schedule 4. Specifically, (a) A copy of the duty roster of persons working at the care home, and a record of whether the roster was actually DS0000013633.V316630.R01.S.doc Version 5.2 4 OP27 17 Elders (The) Page 26 5 OP29 19 & Sch. 2 6 OP18 OP30 18 (1)(c)(i) worked, and (b) an accurate record of all money or valuables deposited by a resident for safekeeping or received on behalf of a resident. Persons must not be employed to work at the care home unless the person is fit to work at the care home, and the information and documents specified in Schedule 2 have been obtained in respect of that person. Immediate timescale of 20/07/06 not met. Staff must receive training appropriate to the work they are to perform. Staff must receive updated training in the safeguarding of adults (formerly the protection of vulnerable adults). Timescale of 20/10/06 not met. 21/11/06 09/02/07 7 OP31 10 (1) The registered manager must 21/11/06 carry on the care home with sufficient care, competence and skill. Specifically, any immediate requirements that are made must be met from the date they are made. 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 2 Refer to Standard OP3 OP35 Good Practice Recommendations It is good practice to ensure that pre-admission assessments are signed and dated by the person carrying out the assessment. It is good practice and strongly recommended that records of transactions of residents’ monies should be signed and dated by both parties involved in the transaction. DS0000013633.V316630.R01.S.doc Version 5.2 Page 27 Elders (The) Elders (The) DS0000013633.V316630.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Elders (The) DS0000013633.V316630.R01.S.doc Version 5.2 Page 29 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!