Inspection on 25/09/08 for Elders (The)

This inspection was carried out on 25th September 2008.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Elders (The) 26/07/07

Elders (The) 21/11/06

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 13/03/2009.

CARE HOMES FOR OLDER PEOPLE Elders (The) The Elders Epsom Road Ewell Surrey KT17 1JT Lead Inspector Sally Hall Unannounced Inspection 09:30 25 September 2008 th 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.V367424.R02.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.V367424.R02.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) re.taylor@ntlworld.com 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.V367424.R02.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 26th July 2007 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. 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 passenger lift and a stair lifts for use by the residents. The fees at this service range from £450.00 to £500.00 Elders (The) DS0000013633.V367424.R02.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 one star . This means the people who use this service experience adequate, quality outcomes. The Inspector agreed and explained the inspection process with the Registered Manager at the start of the inspection. The focus of the inspection was to assess The Elders in accordance with the Care Home Regulations 2001 and the National Minimum Standards for Older People. In some instances the judgement of compliance was based solely on verbal responses given by those spoken with. The Inspector used a varied method of gathering evidence to complete this inspection, pre-inspection information such as the previous report and discussion and correspondence with the registered provider was used in the planning process to support the inspector to explore any issues of concern and verify practice and service provision. The home had completed an AQAA an annual quality assurance assessment questionnaire, which was received prior the site visit to the home. This provided the Inspector with information relating to what the home considers it does well, What we could do better, What has improved within the last 12 months and plans for improvement. Survey questionnaires were sent to the home prior to the inspection. Documentation and records were read. Time was spent reading of written policies and procedures, reviewing care plans and records kept within the home. Other area’s viewed included risk assessments, pre-admission assessments, staff files, training records and complaint records. A tour of the premises was undertaken with the registered manager. The Inspector identified four people who use the service for case tracking, speaking with two of them whilst assessing the available information held in the home pertaining to the care provision for them. In addition the Inspector met with the other People who use the service, which gave her a good opportunity to observe the quality of care being provided by the home and understand the impact the care provision has on their quality of life. The judgements have been made using the Key Lines of Regulatory Assessment (KLORA), which are guidelines that enable the CSCI to be able to make an informed decision about outcome areas. Further information can be found on the CSCI website with regards to information on KLORA’s and AQAA’s. Elders (The) DS0000013633.V367424.R02.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: 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.V367424.R02.S.doc Version 5.2 Page 7 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.V367424.R02.S.doc Version 5.2 Page 8 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 People who use the service experience good outcomes This judgement has been made using available evidence including a visit to this service. Service users can be confident that if they are offered a place at the home then there assessed needs can be met. EVIDENCE: Four service users files were sampled and included two of the most recent service users to be admitted to the home. The registered manager confirmed assessments as far as possible take place in the service users own home or in hospital if that’s were they are at the time of referral. The registered manager has also made arrangements more recently to invite would be service users to the home for the day or overnight for assessment if they are not local to the area in order to undertake the assessment. The assessment it self is completed fully in detail, it gives staff a good indication of the needs the service users may have once admitted to the home Elders (The) DS0000013633.V367424.R02.S.doc Version 5.2 Page 9 on a trail basis. It covers all aspects of the person’s physical, physiological and social needs. This home does not offer intermediate care service. Elders (The) DS0000013633.V367424.R02.S.doc Version 5.2 Page 10 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, 10. People who use the service experience adequate outcomes This judgement has been made using available evidence including a visit to this service. Service users benefit from detailed care plans and are supported by staff that treat them dignity and respect. Service users benefit from their health care needs being monitored, however their protection would be enhanced if comprehensive risk assessments were used. The home administers medication ensuring service user’s receive their prescribed medication, however procedures need to be reviewed to ensure that the administration of such medication meets with current guidance. EVIDENCE: Four service users files were sampled, the care plans were well written and crossed referenced well with the assessments seen. No evidence was seen that these had been discussed with the service users and or representative although the registered manager was sure that they were at this initial stage Elders (The) DS0000013633.V367424.R02.S.doc Version 5.2 Page 11 and at the six monthly reviews. Service users spoken to could not remember or were not sure. Evidence was seen of a monthly review for all service users, which looks at the events during the preceding months and makes provision for any changes in the individual’s condition and needs whether temporary or permanent. The six monthly reviews are also documented in detail and the registered manager said that the families and care managers are also invited to these meetings. The risk assessments however were not detailed and there was no in depth moving and handling assessment available for each service user, the registered manager had recently completed moving and handling training and was aware of the information now required for the moving and handling assessment and said he intends to review the form currently used to ensure all information is recorded. Although other risks had been recognised there was no comprehensive risk assessment/management form available to document and review these risks. The daily notes are kept, recording information of events and some of the care provision pertaining to individual service users mainly in the mornings. The information recording health issues and follow up measures taken and the outcomes are good. However the record says little about any care given during the rest of the day. The manager explained that it was the homes policy to only record specific incidents at night only. Currently no record is kept when care is being provided or events happen. Staff recording the time when things happen, along with a brief description of the care provided would give a fuller picture of the service users day. Daily records were not wholly contemporaneous with gaps seen between entries on a day-to-day basis and night staff recording events pertaining to service users in a book. It is strongly recommended that the home follow the Nursing and Midwifery Council guidance “guidelines for records and record keeping”. The home uses a monitored dosage system supplied by the local pharmacy. A medication audit was undertaken, checking the stock against the Mar (Medication Administration Record) sheet. This audited items of medication at random on five different Mar sheets and concluded that medication is being given out and recorded correctly. This is a great improvement on the findings of the previous inspection where staff were found to be double dispensing. However evidence was found that was of concern that some staff may be continuing this practice, the manager agreed to investigate and also look into how medication is conveyed around the building, as the current system for doing this is not suitable. The medication storage arrangements are adequate and there is correct storage for controlled medication, however one medication, which should be stored as such, was not nor was it being recorded correctly, the manager took steps to correct this oversight. There was a medication fridge available and the temperature is checked on a daily basis. Elders (The) DS0000013633.V367424.R02.S.doc Version 5.2 Page 12 Procedures with in the home need to follow The Royal Pharmaceutical Guide lines for Care homes, Good practice can also be found in the Commission for Social Care Inspection publication The administration of medicines in care homes. It is evident through observing members of staff at The Elders that the emotional health of the resident’s is of a high priority and that staff are proactive in maintaining and supporting service users with their emotional needs in order to maintain their quality of life. During the inspection the inspector noted that some service users were seen making choices about their lives and were seen to be part of the decision process. A relaxed atmosphere was noted with the resident’s interacting with staff. Elders (The) DS0000013633.V367424.R02.S.doc Version 5.2 Page 13 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): 12,13,14,15, People who use the service experience good outcomes This judgement has been made using available evidence including a visit to this service. Current service users an enjoy an overall good lifestyle, which meets with their expectations. Relatives are actively encouraged to maintain contact with their relatives. Activities are available however the range and amount could be extended. The service users benefit on the whole from appetising meals and balanced diet offered at the home. However opportunities to improve choice and menu planning are possible. EVIDENCE: The majority of the service users spoken with confirmed they were happy with the lifestyle at The Elders, however they felt that the activities could be increased, several said that there were some days of the week and in the morning particularly when there was little going on. There is an activity person who comes in to the home three days per week in the afternoon; records are kept of what the activity takes place. On the afternoon of the inspection a balloon was being used to encourage service users to move their upper body. Elders (The) DS0000013633.V367424.R02.S.doc Version 5.2 Page 14 Several service users indicated that this was an activity they did very often one felt that it was not something they wanted to do at there age. Service users confirm that Christmas parties take place and other celebrations are also organised. The manager and staff talked about the visitors form the local community that come into the home, and this included the opportunity for service users to take communion if they wished on a regular basis. However community involvement and outings are not being offered on a regular basis by the home. Family and friends feel welcome and know they can visit the home at any time. Visitors spoken with said they are made to feel welcome. The design of the lounge provides seating areas within it where service users can entertain their visitors, in addition to the privacy of their own room. Service users confirmed they are given choices, activities and the pattern of daily life. Evidence was seen that residents can bring in personal items for their rooms and the manager confirmed this was encouraged. The general feeling amongst residents was that the food was good, however two service users indicated that “if you said that you liked something you get it all the time”, this was referring to sandwiches at tea time. This indicated along with the fact several service users did not know the full range of food available at breakfast time that choices are not being actively offered on a daily basis. Breakfast is taken to service users rooms and served before service users assisted with any personal care. The menus were seen for a four-week period, it indicated a balance diet however it did not show a choice of meal at lunchtime. The manager said that this was decided daily and indicated on the information board in the lounge, service users spoken to did not seem aware of this, and on the day of inspection the meal offered was roast lamb or roast chicken these are not significantly different alternatives. The meal at lunchtime was sampled, it was well cooked, tasty and well presented. Elders (The) DS0000013633.V367424.R02.S.doc Version 5.2 Page 15 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, 18 People who use the service experience good outcomes This judgement has been made using available evidence including a visit to this service. Service users are aware of their rights with regard to making a complaint and to whom to complain. Service users are also protected from the risk of abuse by the home’s Adult Protection policy and procedures. EVIDENCE: The home has a complaints procedure which details the times scales for action. There was a complaints and compliments folder, no complaints were seen recorded here. A small number of minor complaints were seen recorded in a book; this contravenes the Data Protection Act 1998, as issues relating to different service users were entered on the same page page. Complaints are responded to and the manager said that they take all complaints seriously. However the recording of complaints needs to be reviewed. The CSCI has not received any complaints since the previous site visit. The home had a policy on protection of vulnerable adults and a copy of the local authority (Surrey County Council) procedures on safeguarding adults. Further evidence confirmed that the home had a whistle blowing policy. Evidence was seen that most staff have attended adult protection training Elders (The) DS0000013633.V367424.R02.S.doc Version 5.2 Page 16 within the last three years, the manager confirmed that further training has been arranged. Elders (The) DS0000013633.V367424.R02.S.doc Version 5.2 Page 17 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): 19,26 People who use the service experience adequate outcomes This judgement has been made using available evidence including a visit to this service. The people who use the service can feel confident that the home will be clean and free from odour, however the there are large areas within the home that need redecoration and new furniture. EVIDENCE: The service provides a homely environment, set in well maintained grounds. It does not however provide a rolling programme to improve the decoration, fixtures and fittings, and this was very evident during the tour of the building. Although staff work hard to keep the home clean, the poor state of the décor throughout the home makes it look un cared for. The paint work is badly chipped, wall paper is coming away from the walls in places, the ceilings and paintwork no longer look white. Elders (The) DS0000013633.V367424.R02.S.doc Version 5.2 Page 18 In the hall way and in a number of service users bedrooms furniture was seen in need of repair. Other service users bedrooms seen had a mismatch of furniture, which was old and not well cared for. The manager indicated that much of the furniture belonged to the service users, being brought in with them. However this was found not necessarily to be the case. The manager stated that he would investigate the ownership of furniture and look to replace items as soon as possible. All the rooms in the home are single and many of these have en-suite facilities. Service users are encouraged to personalise their rooms and choose where they sit in the communal areas. Service users spoken to they are comfortable, the home is clean and warm. The toilets and bathrooms are situated near to service users rooms and the communal areas. The dinning room is a beautiful room in need of redecoration which because of it shape and the position does not have a great deal of natural light, however this could be improved if a bay tree out side one of the two windows was cut back or removed. The natural light throughout the rest of the home is good and electric lighting is of a domestic nature. The home has three laundries around the home to reduce the need for transporting dirty laundry around the home. Currently the home does not have a washing machine with a sluice facility specifically for foul linen, however at this time the quantity of this type of laundry is very small. The down stairs laundry does have a washing machine that can reach the high temperatures necessary to disinfect. Radiators in the home are covered and the manager confirmed that all sources of hot water used by service users have thermostatic valves to protect the service uses from scalding. The homes staff also check the water temperatures around the home on a regular basis. Elders (The) DS0000013633.V367424.R02.S.doc Version 5.2 Page 19 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, 30 People who use the service experience good outcomes This judgement has been made using available evidence including a visit to this service. Service users care, social and emotional needs are promoted by on the whole well trained care staff in sufficient numbers to meet their needs and are protected by the recruitment procedures within the home. EVIDENCE: The ratios of care staff to service users is determined according to the assessed needs of service users. Following discussions with the manager, reviewing the rota and observations sufficient staff were on duty. The home does not employ ancillary staff to work as cleaners; this role is part of the care staff duties and why there appears to be more care staff than for another home of this size. The home does employ 2 cooks, gardener/ maintenance staff. Thus allowing care staff the time to meet the needs of resident’s. From documentary evidence seen the standard of staff training was adequate overall with the majority of staff completing basic courses. However shortfalls were noted with regard to 50 achieving a NVQ (National Vocational Qualification) Level 2 or above care qualification. The manager confirmed that he would ensure that all staff have completed both adult protection and refresher moving and handling training. Dementia training was identified as a Elders (The) DS0000013633.V367424.R02.S.doc Version 5.2 Page 20 need within the home to enable staff to support resident’s further as their needs change, a number of care staff have undertaken this training. The manager confirmed staff receive induction training to specification within 6 weeks of appointment to their posts, and foundation training within 6 months which meets the Skill’s council’s workforce training targets. The home showed that it undertakes a recruitment practice including submission of an application form detailing all previous work history and copies of qualification certificates, seeks two written references, and confirms work status. The staff also have a CRB (Criminal Record Bureau) check, however proof of the staff member identity is not being retained on file. The home’s recruitment files were reviewed for the most recently employed staff. It was noted that the application form did not request references for past employers and this was brought to the attention of the manager as it asked for personal references. Fortunately the last employers had been given as referees however it was noted that one request was not sent to the place of employment rather a persons home. It is good practice that all reference requests be sent to the company address and marked for the attention of the manager, with the company stamp being asked for. Elders (The) DS0000013633.V367424.R02.S.doc Version 5.2 Page 21 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, 32, 33, 38 People who use the service experience adequate outcomes This judgement has been made using available evidence including a visit to this service. Service users benefit from an overall well run home with an experienced manager in post who recognises their views and opinions are important. However shortfalls were noted with regard the Reg 26 visits and the general upkeep of the environment. EVIDENCE: Te registered manager has a great deal of experience managing this home over many years and confirmed that he has attained the RMA (Registered Managers Award). Throughout the inspection the manager was open and assisted in the inspection. The manager is aware of the issues raised and showed a commitment to work diligently to address them. However he will Elders (The) DS0000013633.V367424.R02.S.doc Version 5.2 Page 22 need the support of the committee, which on behalf of the charity Golden Hours Fellowship, are responsible for funding. The Trustee’s of the charity that is the registered provider of the home are required to regularly visit the home and complete a report known as a Regulation 26 visit. This requires the provider to assess the quality of care within the home and ensure that it is meeting with the required National Minimum Standards. These unannounced visits would normally be arranged on a monthly basis, with the provider visiting the home talking to service users and staff, look at complaints, to ensure the quality of care being provided. They would also tour the building and talk to the manager about issues raised and improvements that are needed to improve the quality life for the service users living there for example. From observations of the staff and manager’s interactions with the service users, it was clear that there was an atmosphere of openness and respect, although some service users do need to be enabled and encourage to make more choices. It is the responsibility of the manager of the home is to ensure that general maintenance and redecoration is planned in a timely way to ensure the fabric of the building remains at a high standard. Whilst it has been recognised that extensive works have been undertaken to bring the fire precautions up to date this year that weren’t budgeted for, the environment seems to have been neglected for sometime. The manager must identify and complete an action plan that includes realistic timescales and a budget for improving the environment, ongoing replacement of furniture and maintenance of the building. Following the previous inspection carpets have been replaced in the corridors etc there by eliminating the risk of trips and falls on frayed carpets. The last inspection highlighted the need secure storage of chemicals around the home, this has been facilitated and the COSHH file was seen easily available should an accident with chemicals occur. The home as an accident book and staff record incidents appropriately. The training records show that most staff have undertaken the health and safety associated courses, further courses have and will be arranged to rectify the shortfalls, the manager confirmed. The AQAA, (Annual Quality Assurance Assessment ) completed and sent by the manager confirmed that the maintenance certificates pertaining to servicing and the standard of services and appliances are in date. Elders (The) DS0000013633.V367424.R02.S.doc Version 5.2 Page 23 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 2 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 2 x x x x 3 Elders (The) DS0000013633.V367424.R02.S.doc Version 5.2 Page 24 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 OP8 Regulation 17(1)(2)( 3) schedule 3 13(4)(b),( c) Requirement The registered person ensures that the daily record for individual service users includes care provision and events throughout the 24 hour period. The registered person identifies any risks pertaining to service users, records the action to minimise the risk and reviews this on a regular basis. The registered manager to ensure that a record is kept of the food provided for service users The registered manager is required to supply an action plan in respect of the timescale for redecoration and refurbishment by Timescale for action 30/10/08 2. OP7 30/11/08 3. OP8 Schedule 4,13 23 (2)(b)(d), 30/10/08 4. OP19 30/11/08 5. OP33 26 As part of effective quality 30/10/08 assurance and quality monitoring systems, the organisation is required to carry out regulation 26 visits on an ongoing regular monthly basis. Elders (The) DS0000013633.V367424.R02.S.doc Version 5.2 Page 25 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. 1 Refer to Standard OP7 OP7 Good Practice Recommendations Make sure that gaps are not left between daily notes made Evidence made available showing that service users plans of care are drawn up with each service user, which provides the basis for the care to be delivered. Elders (The) DS0000013633.V367424.R02.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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.V367424.R02.S.doc Version 5.2 Page 27 - 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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