Inspection on 15/06/06 for Elim Lodge Limited

This inspection was carried out on 15th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Elim Lodge Limited 06/10/08

Elim Lodge Limited 21/02/08

Elim Lodge Limited 10/01/06

Elim Lodge Limited 15/09/04

Elim Lodge Limited 30/06/04

Elim Lodge Limited 15/01/04

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Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

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Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Elim Lodge Limited 54 Cliff Road Hornsea East Riding Of Yorks HU18 1LZ Lead Inspector Diane Wilkinson Unannounced Inspection 15th June 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 Elim Lodge Limited DS0000019667.V300008.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. Elim Lodge Limited DS0000019667.V300008.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elim Lodge Limited Address 54 Cliff Road Hornsea East Riding Of Yorks HU18 1LZ 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) 01964 535944 Elim Lodge Limited Elizabeth Mary Coates Care Home 21 Category(ies) of Dementia - over 65 years of age (21), Old age, registration, with number not falling within any other category (21) of places Elim Lodge Limited DS0000019667.V300008.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To admit one service user under pensionable age Date of last inspection 10th January 2006 Brief Description of the Service: Elim Lodge is registered as a care home that offers care and accommodation to 21 older people, including those with dementia. The home is owned by Elim Lodge Limited and was first registered on the 14th August 1995. Fees paid by service users range from £328.80 to £340.00 and an additional charge is made for hairdressing, chiropody, daily newspapers and toiletries. The home was fully occupied on the day of the inspection, with one of the 21 residents having respite care. An additional service user was at the home for day care. The home is situated in the centre of Hornsea, which is a seaside town on the East Riding of Yorkshire coast. All the local facilities are within walking distance. The home is an old building that has been converted to meet the needs of older people. Private accommodation comprises of 15 single rooms and 3 twin rooms and communal accommodation consists of a dining room, a large lounge and a conservatory. There is a lift to the first floor and service users have access to the grounds of the home and the adjacent park area. There is a small car park at the front of the property. Elim Lodge Limited DS0000019667.V300008.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection report is based on information obtained from the pre-inspection questionnaire, information received by the Commission for Social Care Inspection (CSCI) since the last inspection of the home and from the site visit on the 15th June 2006. This unannounced site visit was undertaken by one inspector over one day; the site visit commenced at 10.00 am and finished at 5.40 pm. The site visit consisted of a tour of the premises and examination of documentation, including four care plans. On the day of the inspection the inspector spoke on a one to one basis with five service users and three care staff, as well as the registered manager and the home’s administrator. Prior to the site visit surveys were sent to eight relatives, four health and social care professionals and three general practitioners. Four were returned by relatives and two were returned by health and social care professionals. Feedback from the surveys was shared with the registered provider (anonymously). The inspector would like to thank service users, staff, the home’s administrator and the registered manager for their assistance on the day of the inspection. What the service does well: Medication is managed in a safe way that protects service users. Service users are able to choose where and how to spend their day, and are encouraged to maintain their level of independence. The home employs sufficient staff to care for the numbers of service users accommodated. One service user said, ‘Staff always make time to speak to you, even when they are very busy’. Staff are skilled and well trained and are equipped to care for the service users accommodated at the home. One service user said, ‘I have never known such courtesy’ when speaking about the staff. The home is maintained in a clean and hygienic state and laundry facilities are suitable for the number of people resident at the home. Elim Lodge Limited DS0000019667.V300008.R01.S.doc Version 5.2 Page 6 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. Elim Lodge Limited DS0000019667.V300008.R01.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 Elim Lodge Limited DS0000019667.V300008.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 not applicable, as no intermediate care is offered by the home. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are provided with the information they need to make an informed choice about where to live, and are only offered accommodation at the home if their assessed needs can be met. EVIDENCE: The inspector examined the records for a newly admitted service user. These include an assessment of needs that was completed prior to the person being admitted to the home. The registered manager told the inspector that she had visited this person in hospital, and a relative had visited the home on behalf of the service user, who was not well enough to do so. Service users told the inspector that they had either looked around the home, or relatives had done so on their behalf, and that they had enough information prior to their admission to make a decision about where they would like to live. Elim Lodge Limited DS0000019667.V300008.R01.S.doc Version 5.2 Page 9 The registered person was reminded that, following initial assessment, service users should be informed that their current assessed care needs can be met by the home. The home offer one place per day for day care and the registered manager was advised to record this in the home’s statement of purpose. Elim Lodge Limited DS0000019667.V300008.R01.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The health and personal care needs of service users are met in a way that respects the privacy and dignity of service users. EVIDENCE: Four care plans were examined by the inspector. These evidence that assessment information is used as the basis to develop an individual plan of care. Risk assessments are in place for moving and handling (including the risk of falls) and more specific risks such as smoking. Care plans are checked monthly and any changes to the care plan are dated. Daily records are maintained and key workers record time spent with service users. The inspector was informed that staff are working towards care plans being more consistent in the way that recording takes place. New service users are asked to sign to record that they are aware that there is a care plan in place and some service users told the inspector that they are aware of their individual care plan. Elim Lodge Limited DS0000019667.V300008.R01.S.doc Version 5.2 Page 11 One of the four relatives that returned the questionnaire stated that they are not kept informed of important matters affecting their relative, and that they are not consulted about their care. All said that they were satisfied with the overall care offered by the home. If it is felt that a person’s individual care needs cannot be met, appropriate input is sought from health and social care professionals so that a decision can be made about meeting future care needs. There is now evidence that nutritional screening takes place. All service users have a ‘waterlow’ risk assessment in place to record the risk of developing pressure sores, and service users are now weighed on a regular basis. There is a record in individual care plans of all contact with health professionals, including the reason for the visit/contact and the outcome. Chiropody is provided both privately and by the NHS. A dentist has been identified to provide domiciliary visits for service users. Medication is supplied in ‘blister’ packs by a local pharmacist. Medication records include a photograph of each service user to assist accuracy of administration for new staff. There is a list of signatures for staff that have responsibility for the administration of medication – this enables records to be checked to ensure only trained staff administer medications. Medication is stored safely; there was a lot of medication in stock on the day of the inspection and the registered manager explained that medication for the next month had just been delivered. Some medication was awaiting return to the Pharmacist and a returns book was in use. Care plans include a ‘Management of Medication’ record. Four service users have been prescribed controlled drugs; the inspector checked associated records and found them to be correct. Controlled drugs are also stored in a satisfactory manner. Service users told the inspector that they are treated with respect and that their right to privacy is upheld. Most service users have a single room and are therefore able to see visitors and health professionals in private. One relative commented that they are not able to see their relative in private as they are always sitting with other service users when they visit. The registered manager said that relatives are always asked if they would like to go to the service user’s bedroom or to a private area of the home, and that they will ensure that staff are vigilant about this. One service user said, ‘I have never known such courtesy’ when speaking about the staff. Two service users that share a room have their own smoking area and dining area. Elim Lodge Limited DS0000019667.V300008.R01.S.doc Version 5.2 Page 12 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 at least once during a 12 month period. 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 from evidence gathered both during and before the visit to this service. Service users are supported to take part in activities both inside and outside of the home, and visitors to the home are made welcome. Meal provision at the home is good considering that there is currently no cook employed. EVIDENCE: Care plans record the previous lifestyle and leisure interests that service users had prior to their admission to the home. There is an activity programme in place and this records a different activity each day – there is a wide range of activities provided in an attempt to meet the varying needs of service users. The ‘activities book’ records the activities that have taken place each day, and which service users have taken part. The inspector recommends that this information is transferred into individual care plans, so that there is a full picture of the care offered to each service user. On the day of the inspection a barbeque had been arranged and service users enjoyed ‘doing something different’. Some service users go out into the town to use local amenities. One service user said, ‘Staff always make time to speak to you, even when they are very busy’. Elim Lodge Limited DS0000019667.V300008.R01.S.doc Version 5.2 Page 13 Service users told the inspector that their visitors are always made welcome. Some service users went out on the day of the inspection and the inspector observed that a visitor was invited to stay at the home for a meal. There is evidence that service users are assisted to exercise choice and control over their lives. Some service users go out for a walk and all care plans record a service users preferred time to get up and go to bed. Staff told the inspector that they assist service users to choose what to wear, where to spend the day and what to have for meals. Staff said that they would record any major decision making in care plans, and that a note would have to be made if any routines changed. Staff say that they sit and listen to service users, and make suggestions to assist service users to make appropriate decisions. One member of staff told the inspector that staff ‘listen to residents and support their rights’. The cook left the home recently, so care staff are currently having to prepare meals. Some service users said that staff are coping very well with this, although one or two said that they have noticed that the meals are ‘not so good’. One service user said, ‘The food is brilliant – it is all home cooked food’. A menu is displayed. The inspector saw the menu on the day of the inspection and a choice of meal is recorded. Service users told the inspector that there is always a choice at mealtimes. Care plans record any specific dietary requirements and these are met by the home. Diabetic meals are catered for. Elim Lodge Limited DS0000019667.V300008.R01.S.doc Version 5.2 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Complaints are dealt with effectively and service users and relatives are confident that any complaints will be listened to and acted upon. Service users are protected from potential abuse by the training and skills of the staff group. EVIDENCE: There is a satisfactory complaints policy and procedure in place, and a complaints log that allows for the recording of the details of the complaint and any action taken. There is also a ‘grumbles’ book in place – the inspector observed that some minor complaints have been recorded and dealt with appropriately. The complaints procedure is displayed in the home next to the visitor’s book. The inspector noted that the address of the CSCI on the written procedure has now been recorded correctly. The complaints procedure invites service users and their representatives to make a complaint or a suggestion, and states that the complainant will be notified of the outcome within fourteen days. Service users told the inspector that they would talk to the manager if they had a complaint, although they had never had to make one. One of the four relatives that returned the questionnaire stated that they were not aware of the home’s complaints procedure, although the inspector noted that the policy is displayed in the entrance hall. Elim Lodge Limited DS0000019667.V300008.R01.S.doc Version 5.2 Page 15 There are appropriate policies and procedures in place that are designed to protect service users from all types of abuse. These include whistle blowing, dealing with aggression from service users and the protection of service user monies. All care staff have now undertaken training on the protection of vulnerable adults from abuse. Staff spoken with had a good understanding of the identification of various types of abuse and how to protect service users, and the use of the whistle blowing policy. Elim Lodge Limited DS0000019667.V300008.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 and 26 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users live in a safe, well-maintained and homely environment, although some carpets in corridor areas need to be replaced. The home was clean and hygienic on the day of the inspection. EVIDENCE: A maintenance person is employed by the home and there is a maintenance programme in place. The inspector noted that some of the items recorded such as ‘drive to be regravelled’ had being done. The vinyl in the corridor that leads to a toilet and the laundry room caused a trip hazard and has now been replaced. The domestic periodically cleans the carpets during the night, but carpets in some corridors are very stained and need to be replaced. This was discussed with the registered manager who agreed that the appearance of the home would be improved if the carpets were replaced. Elim Lodge Limited DS0000019667.V300008.R01.S.doc Version 5.2 Page 17 The water supply at the home has now been tested for the presence of Legionella and the result was negative. The home is centrally heated and heating can be controlled in individual bedrooms. Service users are able to use the conservatory so that they can have access to sunlight and fresh air, even if they do not wish to sit or walk outside. Domestic staff are employed every day. The home was clean and hygienic on the day of the inspection – there were some minor malodours but all were being controlled satisfactorily. Laundry facilities at the home meet required standards, and there is a separate sluicing room. There are appropriate systems in place to prevent the spread of infection. One service user said, ‘the home is beautiful and clean, including my bedroom’. Elim Lodge Limited DS0000019667.V300008.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. 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 from evidence gathered both during and before the visit to this service. There are sufficient staff on duty to ensure that service users’ needs can be met. Current recruitment practices do not fully protect the service users from the potential to be abused. Staff receive appropriate induction training and ongoing training to equip them to work with the service users accommodated at the home. EVIDENCE: The home was fully staffed on the day of the inspection. There was a satisfactory staff rota in place but the inspector recommends that the rota should record the role of each member of staff. In addition to care staff, there is a cook and one or two domestic staff on duty each day, and a handyman is employed for two days per week. All relatives that completed the questionnaire said that they thought there were always enough staff on duty. The three staff that the inspector had a discussion with stated that they have enough time to spend with residents. Two staff have achieved NVQ Level 2 in Care and three staff have achieved NVQ Level 3 in Care. A further five care workers have enrolled for NVQ Level 2 in Care training. The home is on target to meet the 50 qualification requirement. Appropriate induction training is undertaken by staff. Elim Lodge Limited DS0000019667.V300008.R01.S.doc Version 5.2 Page 19 No care staff have been employed since the last inspection of the home. The recruitment records for a new domestic worker were examined by the inspector. Two written references had been obtained prior to the person commencing work but the registered manager was under the impression that domestic staff did not require a CRB check, so a new CRB disclosure or POVA first check had not been requested. The person concerned did have a very recent CRB disclosure that had been completed at a local home where they were employed as a domestic. The inspector confirmed with the registered manager following the inspection that a standard CRB disclosure needs to be obtained for ancillary staff (unless they have regular one to one contact with service users, when an enhanced disclosure is required). The inspector noted that the application form used by the home does not ask applicants if they have a criminal record and the registered manager agreed to amend the form to include this information. The application form has already been amended and the inspector has seen a copy. Individual staff records record training undertaken by staff and the training needs of staff. There is a training and development plan in place and this records that twelve care staff have recently undertaken training on the protection of vulnerable adults from abuse and that moving and handling training has been booked for the 20th June 2006. It also records that food hygiene and first aid training will be organised for the year 2006/7. The training and development plan records the staff that have achieved NVQ qualifications and those staff that are ‘working towards’ the qualification. The inspector recommends that all training achievements and needs of staff are recorded in one place, as this gives a clear picture of the training that needs to be organised, and details of any training that is due for renewal. Elim Lodge Limited DS0000019667.V300008.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home is managed by a suitably qualified and skilled person, who ensures that the health and safety of staff and service users is protected and that service user monies are handled in a safe way. The quality monitoring system enables service users and others to affect the way in which the home is operated and would be further improved by the introduction of an annual development plan. EVIDENCE: The former deputy manager has now completed the registration process with the Commission for Social Care Inspection (CSCI) and has become the registered manager of Elim Lodge. The former registered manager is now employed as the home’s administrator. This new arrangement appears to be Elim Lodge Limited DS0000019667.V300008.R01.S.doc Version 5.2 Page 21 working well and the service users that the inspector spoke to were aware of these changes. The inspector noted that all staff had been sent a letter by the provider confirming these new arrangements – the letter congratulated the manager on her success in completing the registration process with the CSCI and asked staff to support the registered manager and the administrator in their new roles. The registered manager has completed NVQ Level 4 training in Care and in Management. The home has achieved the Investors in People award and there is now a quality monitoring system in place. This includes audits of the policies and procedures that are in place. Surveys are given to relatives/visitors, to service users, to staff and to health and social care professionals. The outcome of these surveys are collated and published via the homes notice board and staff and service users meetings. It was recommended that the outcome of surveys are used as the basis for an annual development plan regarding quality improvements at the home. The outcome of surveys have been made available to the CSCI. The inspector saw minutes of staff meetings and of service user meetings. Staff confirmed that they are able to ‘put their point of view across’ at staff meetings, and are able to ‘reach agreed decisions’. Financial systems for monies held on behalf of service users were examined by the inspector. Associated records and monies held were checked and were found to be accurate. These monies are held securely. A record is now made of any monies received from relatives or others (relatives sign the financial record) and when monies are spent or purchases made on behalf of service users. The registered provider acts as appointee for one service user and this arrangement is clearly recorded, as are associated monies. Some service users have been provided with lockable storage to enable them to safely hold money, valuables and medication. Care plans record whether or not service users have the capacity to handle their own financial affairs. All health and safety documentation is in place and up to date. In house fire checks take place every week and a fire drill is held every month. The fire alarm system and emergency lighting were checked by a contractor in May 2006 and the fire risk assessment is reviewed monthly. The nurse call system is checked on a regular basis. Water temperatures at outlets accessible to service users are checked and recorded on a regular basis and a test to detect the presence of Legionella in the water system was undertaken in May 2006 and was negative. There is a gas safety certificate in place and portable appliances were tested in October 2005. The passenger lift was serviced in October 2005 and bath/mobility hoists are serviced on a regular basis. There are environmental risk assessments in place for topics such as use of the kitchen, use of the laundry room, use of the staff room, smoking and the exterior of the building. Health and safety training takes place at the time of induction and on an on-going Elim Lodge Limited DS0000019667.V300008.R01.S.doc Version 5.2 Page 22 basis. Accident records were seen by the inspector and were found to be satisfactory. Elim Lodge Limited DS0000019667.V300008.R01.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 3 9 3 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 3 2 X X X X X 3 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Elim Lodge Limited DS0000019667.V300008.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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. 3. 4. 5. 6. Refer to Standard OP3 OP12 OP19 OP27 OP29 OP30 Good Practice Recommendations Following initial assessment, service users should be informed that their current care needs can be met by the home. Activities undertaken by service users should be recorded in their care plan so that there is a full picture of the care provided. Some carpets in corridor areas are stained and should be replaced. The role of each staff member should be recorded on the staff rota. A CRB check or POVA first check should be in place prior to ancillary staff commencing work at the home. The inspector recommends that a full record of the training achievements and needs for all staff is developed. This would assist the manager to identify when ‘refresher’ training is required. There should be an annual development plan in place that is based on the outcome of quality surveys. 6. OP33 Elim Lodge Limited DS0000019667.V300008.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 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. 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