Inspection on 21/02/08 for Elim Lodge Limited

This inspection was carried out on 21st February 2008.

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

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 15/06/06

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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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 Key Unannounced Inspection 21st February 2008 11:30 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.V359890.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.V359890.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 Elimlodge@talktalk.net Elim Lodge Ltd 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.V359890.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 15th June 2006 Brief Description of the Service: Elim Lodge is a care home that is registered to provide care and accommodation to 21 older people, including those with dementia. The home is situated in the centre of Hornsea, which is a seaside town in the East Riding of Yorkshire, and there are local facilities such as cafes, pubs, hairdressers and shops within walking distance. 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. Private accommodation comprises of 15 single rooms and 3 shared rooms and communal accommodation consists of a dining room, a large lounge and a conservatory. The current fee paid by service users ranges from £334.80 to £385.00, with an additional charge being made for hairdressing, chiropody, daily newspapers and toiletries. Elim Lodge Limited DS0000019667.V359890.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This inspection report is based on information received by the Commission for Social Care Inspection (CSCI) since the last Key Inspection of the home on the 15th June 2006, including information gathered during a site visit to the home. The unannounced site visit was undertaken by one inspector over one day. It began at 11.30 am and ended at 4.40 pm. On the day of the site visit the inspector spoke on a one to one basis with four residents and the registered manager, as well as chatting to other residents, staff and the registered provider. Inspection of the premises and close examination of a range of documentation, including three care plans, were also undertaken. The registered provider and manager submitted information about the service in advance of the site visit by completing and returning the Annual Quality Assurance Assessment (AQAA) form. Survey forms were sent out prior to the inspection; four were returned by residents, one was returned by a relative, four were returned by staff and one was returned by a health care professional. Responses received in surveys were mainly positive; a health care professional recorded, ‘Caring, compassionate, good standard of care’. Other anonymised comments are included throughout the report. What the service does well: Care plans are well maintained and are a good record of how the health care needs of residents are met. Residents are encouraged and supported to live their chosen lifestyle and to take part in appropriate activities. The home is well maintained, clean and hygienic; health and safety practices are good. Residents are protected from harm by staff training on safeguarding adults. Staff take part in training programmes that equip them to meet the needs of residents accommodated at the home. The quality assurance system gives residents and others the opportunity to affect the way that the home is operated. Elim Lodge Limited DS0000019667.V359890.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. The summary of this inspection report can be made available in other formats on request. Elim Lodge Limited DS0000019667.V359890.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.V359890.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 was not assessed, as there is no intermediate care provision at the home. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are assessed prior to their admission to the home and only admitted if it is considered that their assessed needs can be met. EVIDENCE: We examined the care records for a newly admitted resident. These included an initial enquiry form and an admission form. The registered manager confirmed that this person was visited in hospital prior to their admission to the home, and that it was at this stage that the initial assessment commenced. Assessment information was thorough and included risk assessments for the risk of falls and for pressure care. This information had been used to develop an individual plan of care for the resident. We saw that information had been collated in preparation for the forthcoming initial review of care. Elim Lodge Limited DS0000019667.V359890.R01.S.doc Version 5.2 Page 9 The registered manager told us in the AQAA form that they aim to obtain a professionally published brochure about the home, and that they would like to set up a web site so that people who are interested in residential care can access information about Elim Lodge easily. Two members of staff also suggested this in the survey they returned to us. Elim Lodge Limited DS0000019667.V359890.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care planning documentation evidences that health care needs are met in a way that respects a person’s privacy and dignity. EVIDENCE: We examined two care plans in addition to the care plan for a newly admitted resident. These contained an individual care plan that was based on the needs assessment undertaken by the home as well as information gathered from care management and family members. There is a care plan agreement in place that has been signed by the resident or their representative - this records, ‘The people who support you recognise that you are a unique individual with your own needs and wishes’. Care plans include risk assessments for the risk of falls and pressure care, as well as those for more specific risks to the individual resident, such as smoking and the risk involved in leaving the building unaccompanied. We saw records on the day of the site visit that evidence that care plans and risk assessments Elim Lodge Limited DS0000019667.V359890.R01.S.doc Version 5.2 Page 11 are reviewed and updated on a regular basis. The registered manager informed us that annual reviews are organised by the local authority for the people that they fund and that the home organise an annual review of care plans for residents who are self funding. When asked what the service does well, a member of staff recorded in a survey, ‘To provide a level of care for each individuals needs and to promote independence in each individual service user’. Care plans include a person’s medical history and details of the medication that they are currently prescribed by their GP. There is a record of a person’s nutritional requirements, including any allergies and their likes and dislikes; people are also weighed on a regular basis as part of nutritional screening. There is a record of any visits from or contacts with health care professionals, including the reason for the visit. Care plans include information about any special mobility or personal care items needed by a person, such as bed rails, continence equipment and pressure care equipment. The only people that currently use a bed rail have been provided with hospital beds that have a fixed bed rail. The registered manager was advised that there should be a regular check on the safety of bed rails, and that these checks should be recorded. On the day of this site visit we observed the administration of medication by a senior carer; this was carried out in a satisfactory manner, although it was noted that staff sometimes sign medication administration records when medication is taken from the medication cabinet; staff were reminded that medication administration records should only be signed when the person has taken their medication. There is evidence that staff that administer medication have undertaken accredited training. There are sample signatures held with medication records to enable signatures on medication administration records to be checked for authenticity. Medication administration records are very clear; for example, bedtime medication has been highlighted in red to help staff identify medication that needs to be given out at this time. There is a divider in front of the records for each resident, and the divider has a photograph of that resident on it; this helps new staff to identify residents correctly and offers an additional safety measure. None of the current residents are prescribed controlled drugs. We checked storage and recording facilities and these are all in place should they be needed. Medication is stored in the senior care worker’s office; the medication trolley is fixed to the wall and the controlled drugs cabinet is fastened to the wall. Elim Lodge Limited DS0000019667.V359890.R01.S.doc Version 5.2 Page 12 The AQAA submitted by the registered persons records, ‘All staff are aware of a service user’s right to dignity and respect’. We observed on the day of the site visit that residents are spoken to sensitively with regard to personal care, and that staff respect a person’s privacy by knocking on bedroom doors and by closing doors when people were using the toilet and bathroom. Elim Lodge Limited DS0000019667.V359890.R01.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 and 15. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are encouraged and supported to maintain their chosen lifestyle and to continue with their hobbies and interests. Visitors to the home are always made welcome. Residents express some dissatisfaction with meals provided by the home. EVIDENCE: Care plans include information about a person’s life history and previous lifestyle, including details of family and friends, hobbies and interests. Care plans include information about a person’s preferred time to get up and go to bed, and this is supported by a ‘plan for the day’ for each resident that records this information as well as where they like to take their meals and where they like to spend the day. Residents confirmed that they can get up and go to bed as a time chosen by them, and that this can vary from day to day, depending on their preference. There is no activity coordinator employed at the home, but care plans evidence that care staff facilitate activities such as chair exercise, manicures, music sessions and playing board games. A relative visits the home once a fortnight Elim Lodge Limited DS0000019667.V359890.R01.S.doc Version 5.2 Page 14 to play the organ for the residents and there is evidence that key workers spend time with residents on a regular basis. Some people told the inspector that they prefer to spend their day reading, watching the TV, playing cards or going out for a walk. One person has had Sky TV installed in their bedroom. The AQAA records that a computer is to be provided for residents to use; on the day of the site visit we saw that this is now in place. The registered manager said that they are now just waiting for the Internet to be installed. Care plans now include information about activities undertaken by each resident, including any visitors seen, visits from the hairdresser and time spent with their key worker. This helps to provide a picture of how people spend their day. People told us that their visitors are always made welcome, and this was observed on the day of the site visit. Some residents have had a telephone installed in their own room; this assists them to remain in contact with family and friends. The registered manager told us that they have a policy on Advocacy and that residents are reminded that they can access this facility should they choose to do so. We advised the registered manager to obtain information from relevant advocacy services to display in the home; this enables people to access these services without having to ask someone for the information and promotes privacy and independence. Care plans record a person’s likes and dislikes regarding food. When asked in the survey, ‘Do you like the meals provided by the home’, three residents said ‘sometimes’ and one said ‘usually’. One commented, ‘Not always warm. Not as good as they were – not always to my liking’. On the day of the site visit to the home, people told us that the meals were ‘OK’ but some commented that they were not as good as they used to be. We told the registered manager about the comments made in the survey by residents and she agreed to pursue this. Residents did confirm that there is always a choice of meal available. Some residents take their meals in the dining room, and others have their meals in one of the lounges; small tables are provided to facilitate this. We observed that people are not rushed and staff offer appropriate assistance where needed. The menu is displayed in the hall and the choice of meals on offer on the day of the site visit was Cornish pasty or mince. The teatime menu was also on display; again, this offered various options. Soft diets are provided for residents who need them. We noted that a cooked breakfast is offered on a Sunday only – perhaps residents could be consulted about their wish to have a limited cooked breakfast menu every morning. Elim Lodge Limited DS0000019667.V359890.R01.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 and 18. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents and others know how to use the complaints procedure and residents said that staff listen to them. Staff training protects residents from the potential to be abused. EVIDENCE: There are appropriate complaints policies and procedures in place, and the complaints procedure is displayed in the reception area of the home. The registered manager recorded in the AQAA that a copy of the complaint’s procedures is given to residents and relatives at the time of their admission. All four residents that completed a survey said that they knew how to make complaint and all staff said that they knew what to do if a resident or relative had any concerns. Residents told us on the day of the site visit that they would speak to the manager or to their key worker if they had any complaints or concerns, and that they were confident that they would be listened to. There have been no complaints made to the CSCI since the last key inspection. The home has received some complaints from residents and these were recorded in the Quality Assurance document. There is also a ‘grumbles’ book in use. We saw evidence on the day of the site visit that concerns and complaints had been dealt with in a satisfactory manner. There are appropriate policies and procedures in place regarding the protection of residents from all forms of abuse. The registered manager and the deputy Elim Lodge Limited DS0000019667.V359890.R01.S.doc Version 5.2 Page 16 manager have attended a training ‘update’ on safeguarding adults that is designed specifically for managers, and we saw evidence that care staff have attended in-house training on this topic (using training materials supplied by the Adult Protection Committee). Staff also undertake training on this topic as part of National Vocational Qualification (NVQ) training. There have been no recorded allegations or incidents of abuse at the home since the last key inspection. Elim Lodge Limited DS0000019667.V359890.R01.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 and 26 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is clean, well maintained, well furnished and decorated and provides comfortable surroundings for residents. EVIDENCE: The AQAA records that new carpets have been fitted in corridor areas, a new fence has been erected in the rear garden and an electric locking system has been fitted to the front door; this was confirmed on the day of the site visit. The AQAA also records improvements to the environment that are planned for the next twelve months, such as a new carpet for the lounge and dining room, new curtains for the conservatory and the replacement of old bed tables. There is a maintenance and repairs book in use; this records day to day repairs undertaken by the handyman. We observed on the day of the site visit that the home is well maintained. Elim Lodge Limited DS0000019667.V359890.R01.S.doc Version 5.2 Page 18 There is a conservatory at the rear of the property, and some bedrooms have large windows; this allows residents ample access to sunlight. There is a small patio area and a rear garden, with access to the adjoining park and a view of the sea. We noted that residents are able to bring personal belongings into the home; some bedrooms are neat and tidy with few personal belongings on display and others are full of personal belongings, reflecting the personality of the individual occupant of the room. The home was clean and hygienic on the day of the site visit. Laundry facilities at the home are satisfactory and we observed good hygiene practices being used by staff on the day of the site visit. We saw evidence that most staff have undertaken training on infection control; this helps to protect residents and others from the risk of cross infection. Domestic and catering staff are employed; this enables care staff to concentrate on care duties and reduces the risk of cross infection. We noted that domestic staff undertake training such as infection control, food hygiene and COSHH (Control of Substances Hazardous to Health); this enhances infection control and food safety, and promotes health and safety within the home. Elim Lodge Limited DS0000019667.V359890.R01.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 and 30. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Recruitment practices must be more robust to ensure that only staff that are safe to work with vulnerable people are employed. Staff are well trained but induction training should be more robust to ensure that staff have the knowledge and skills to care for the people living in the home. EVIDENCE: We saw the staff rota and noted that the staff rota for the day of the site visit was a true reflection of the actual staff on duty. The rota records all staff on duty and this includes the role for which they are employed. Most care staff have completed NVQ Level 2 in Care and we saw evidence that the remaining staff are undertaking this training programme. This means that the requirement for 50 of care staff to have achieved this award has been met. Some staff that have achieved NVQ Level 2 in Care are now continuing with NVQ Level 3 in Care training. We examined the recruitment records for a new member of staff. These evidenced that an application form is completed and that safety checks are undertaken to ensure that staff are suitable to work with vulnerable people. However, in this instance, the member of staff commenced work before a Protection of Vulnerable Adults (POVA) first check had been received. The Elim Lodge Limited DS0000019667.V359890.R01.S.doc Version 5.2 Page 20 registered manager told us that this person did not assist with personal care tasks prior to their POVA first check being received; they worked from 3.00 – 6.00 pm preparing teas. We told the registered manager that all staff must have a CRB check (or POVA first check in exceptional circumstances) in place prior to commencing work at the home, and they agreed to ensure that this was the case for all future appointments. Two written references had been obtained for this staff member, but one of them was not dated so it was not possible to determine if both had been received prior to the person commencing work at the home. The registered persons were reminded that two written references must be in place prior to staff commencing work at the home. Induction training does take place but the registered persons are reminded that this should commence as soon as staff start to work at the home, and that basic training such as fire safety and moving and handling should take place immediately; induction training should be completed within twelve weeks from the date a person starts to work at the home. There is a record of the individual training needs and achievements for each member of staff. These evidence that staff undertake core training such as moving and handling, first aid, fire safety, adult protection and infection control. Some staff undertake more specialised training, such as palliative care and nutrition. There is no communal training and development plan in place to record training information for all staff; this is needed to provide an overall picture of the needs and achievements of staff, and to alert the registered manager to the need for refresher training. Records seen on the day of the site visit evidence that some training is due to be updated; some staff had not done moving and handling training since 2005. This was acknowledged by the registered manager. Elim Lodge Limited DS0000019667.V359890.R01.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, 33, 35 and 38. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is well managed and the health, welfare and safety of residents and others are protected by the systems in place at the home. EVIDENCE: The registered manager has achieved NVQ Level 4 in Care and the Registered Manager’s award. There is evidence that she keeps her practice up to date by undertaking refresher training and in-house training with staff, and by obtaining up to date information via the Internet. We observed on the day of the site visit that there were good interactions between the manager and staff, and between staff and residents. When asked in surveys what the home does well, one member of staff recorded, ‘Meets all the needs of the residents and support and help the staff’. Elim Lodge Limited DS0000019667.V359890.R01.S.doc Version 5.2 Page 22 The home has achieved the Investors in People award and the Quality Development Scheme (QDS) Parts 1 and 2, the quality scheme operated by the local authority. The quality assurance systems in place at the home enable residents and others to affect the way in which the home is operated. Surveys were distributed to residents and visitors a year ago, and a document was produced that recorded the outcome of these surveys and any action taken by the registered persons; a copy of this document was sent to the CSCI. Surveys are now due to be undertaken again so that progress can be monitored and new targets can be set. There is an annual business plan in place. Regular resident and staff meetings take place, and the registered manager undertakes an audit of various topics on an annual basis, such as health and safety, medication, accidents and recruitment and selection. Complaints and grumbles are analysed as part of the quality assurance process. We examined the records for monies held on behalf of residents and crosschecked these with actual monies held - both were found to be accurate. Receipts are obtained for monies received from relatives and for any purchases made on behalf of residents. We examined health and safety documentation held at the home. Monthly health and safety checks are undertaken by the registered manager, and environmental risk assessments have been undertaken that record details of any areas of risk and how the risk is controlled. Weekly fire tests take place as well as regular fire drills; records include a list of the names of staff that have taken part in fire drills. All other health and safety documentation was seen to be in order, such as a gas safety certificate and maintenance certificates for mobility hoists, bath hoists and the passenger lift. Records held at the home evidence that staff undertake training on health and safety topics, although some staff are now due to have refresher training. The AQAA recorded that the water supply in the home has been tested for the presence of Legionella and that this test was negative. On the day of the site visit we saw evidence that water temperatures at outlets accessible to residents are tested on a regular basis to reduce the risk of scalding; a different sample area is tested on a monthly basis and there is an annual check of all outlets. Temperatures were seen to be consistently between 41 – 43°C, which are the recommended temperatures to ensure safety for residents. Accidents are recorded appropriately and the CSCI are informed of any accidents to residents that require medical intervention. Elim Lodge Limited DS0000019667.V359890.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 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Elim Lodge Limited DS0000019667.V359890.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. 1. Standard OP29 Regulation 13 Timescale for action A CRB check (or POVA first check 21/02/08 in exceptional circumstances) must be in place prior to care staff and ancillary staff commencing work at the home. Requirement Elim Lodge Limited DS0000019667.V359890.R01.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. 2. Refer to Standard OP8 OP9 Good Practice Recommendations Bed rails should be checked for safety on a regular basis, and these checks should be recorded. Staff are reminded that medication administration records should only be signed when the person has taken their medication, not when it is removed from the medication cabinet. Information about Advocacy services should be displayed in the home so that is easily accessible. Further consultation should take place with residents to improve their satisfaction with meals provided. All employment references received should be dated to evidence that they were in place prior to staff commencing work at the home. The inspector recommends that a training and development plan that records the training achievements and needs for all staff is developed. This would assist the manager to identify when ‘refresher’ training is required and would provide evidence of the skills and qualifications of the full staff group. 3. 4. 5. OP14 OP15 OP29 6. OP30 Elim Lodge Limited DS0000019667.V359890.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Elim Lodge Limited DS0000019667.V359890.R01.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. 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!