Inspection on 15/06/07 for Elkington House

This inspection was carried out on 15th June 2007.

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

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

Other inspections for this house

Elkington House 25/07/06

Elkington House 09/02/06

Elkington House 19/07/05

Elkington House 24/02/05

Elkington House 21/09/04

Similar services:

Claremont House

Coopers Mill Ltd

Pocklington House

Newton Court (1-2)

Firstlings

Fen Road

Newton Court (3-4)

Dial House Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Elkington House 9 Imperial Avenue Westcliff On Sea Essex SS0 8NE Lead Inspector Pauline Dean Unannounced Inspection 15th June 2007 09:35 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 Elkington House DS0000015433.V343832.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. Elkington House DS0000015433.V343832.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elkington House Address 9 Imperial Avenue Westcliff On Sea Essex SS0 8NE 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) 01702 348200 01702 348200 Southend Blind Welfare Organisation Ms Sarah Jayne Richardson Care Home 25 Category(ies) of Dementia - over 65 years of age (25), Sensory registration, with number Impairment over 65 years of age (25) of places Elkington House DS0000015433.V343832.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th July 2006 Brief Description of the Service: Elkington House provides accommodation for twenty-five older people who have a sensory impairment with/without dementia. The home is situated within easy reach of the seafront and a local shop area at Westcliff on sea. The town centre and shopping centre of Southend on sea is a bus or train ride away. The home is close to rail and bus links. There is parking to the front of the property. The accommodation is on two floors and there are 2 passenger lifts to enable access to both floors. There are single and shared bedrooms, some of which have en suite facilities. There are lounges and a dining area and a large rear garden with a patio area with garden seating and ramp and step access to the garden. The current scale of charges as at June 2007 ranges from £445 for a double room to £467 per week for a single room. Hairdressing, chiropody, dentist, optician, personal toiletries, newspapers and magazines, clothing are charged at cost. Elkington House DS0000015433.V343832.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit of Elkington House took place on 15th June 2007 over a 9-hour period. The inspection involved checking information received by Commission for Social Care Inspection (CSCI) since the last inspection in July 2006, looking at records and documents at Elkington House and talking to Ms Sarah Richardson, the registered manager, care staff and catering staff. A tour of the premises was also completed. Questionnaires were left with the manager for distribution to all of the people living at Elkington House, but unfortunately none had been returned at the time of writing this report. In addition questionnaires were left for distribution to family and friends and healthcare professionals, but similarly none of these have been returned to the Commission. During the site visit four people who live at Elkington House were spoken with. All were pleased with the service and happy about way they are supported and assisted by the staff. They considered staff to be kind and courteous. Three visitors to the home were also spoken with and they too were positive with regard to their impressions of the home’s accommodation, the welcome they receive from care staff when they visit and the management of the home. Twenty-four National Minimum Standards were inspected. This included all key standards. Five requirements and four recommendations were made as a result of this inspection, with all outcomes either good or adequate. What the service does well: The home continues to have an established staff team with clear management structures. Both visitors and people who live at the care home praised the staff and management and felt that they were able to raise concerns should they need to. One person said that the “manager was approachable” and a visitor said that staff were “very welcoming.” Overall the home offers a warm welcome to both visitors and residents. Care practice observed on the day of the site visit was both sensitive and caring and this was particularly noticeable at lunchtime when staff were feeding residents and when medication was being dispensed. Elkington House DS0000015433.V343832.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. Elkington House DS0000015433.V343832.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 Elkington House DS0000015433.V343832.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 and 6. 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. A comprehensive admissions process ensures that people who come to live at Elkington House are assured that their needs are met. Intermediate care is not offered at Elkington House. EVIDENCE: On the day of the site visit there were twenty-three people living at Elkington House. Ms Richardson said that the primary care needs of these residents related to their old age with some people having visual impairment and dementia. All of the residents were permanent, many having lived in the area Elkington House DS0000015433.V343832.R01.S.doc Version 5.2 Page 9 for many years and some were able to continue to have contact with family and friends in the locality. The admission process was discussed and considered with Ms Richardson and paperwork was seen to support a comprehensive assessment and admission process. An initial assessment was conducted before admission to the home and then a detailed assessment was completed over a four-week period. During the site visit, we were able to speak with two people who live at Elkington House and both spoke of moving into Elkington House as “a big step” and a “very difficult decision”, but they both spoke of being given sufficient information to make the decision and both staff and management were said to be “supportive and approachable”. Ms Richardson said that the home was looking to update the Statement of Purpose and the Service Users’ Guide in a pictorial form with photographs and pictures. She said that they were also considering producing the Service Users’ guide in a tape form. No intermediate care is offered at Elkington House. Elkington House DS0000015433.V343832.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 adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Overall, care planning documents were comprehensive detailing health, personal and social care needs. Regular monthly reviews however need to be re-introduced to ensure that the people who use the service receive the care they wish and require. Overall, management of medication was well managed with the exception of the monitoring of medication stored in a fridge and record keeping relating to Controlled Drugs. People who live at the home were treated with sensitivity and respect. EVIDENCE: Elkington House DS0000015433.V343832.R01.S.doc Version 5.2 Page 11 The care plans of two people living at the home were sampled and inspected and they were used to case track care in the home. An assessment of needs identified health, personal and social cares needs. Detailed daily record keeping was seen to be in place, with additional records as needed. Within the sampled care plans, there was evidence of monthly reviews having been conducted in the past, but these had ceased early 2007 or had failed to detail whether there were any changes needed to the care plan. Care planning files had evidence of risk assessments with regard to moving and handling, behaviour assessment, pressure sore assessment, nutrition screening and falls risk assessment. Healthcare professional visits and appointments were recorded and noted in care planning files. Following interventions by healthcare professionals action had been taken and new equipment and treatment implemented. This was noted on one of the care plan files sampled. Ms Richardson said that the home uses a total of ten doctor surgeries and where possible the people who live at Elkington House continue with their current GP on admission to the care home. Records also evidenced other healthcare professionals involved in the care home such as the district nursing service, chiropodist, dentist and hairdressers. Medication administration and dispensing medicines at lunchtime was observed during the site visit. An assistant manager was responsible for this task and it was seen to be managed in a sensitive manner. Medication was stored in a medication trolley held securely in the lounge/dining room or in a medication storage cupboard found off the dining room. On the day of the site visit, the inspector was informed that none of the current residents were self-medicating. Lockable storage was seen in each bedroom. The Boots the Chemist’s monitored dosage system (MDS) was used for dispensing medication. An audit of medication entering the home was seen in place and records were made as to any changes during the 28-day dispensing period. Eye drops requiring storage were kept in a fridge. Previously records had been kept of the temperature of the fridge, but this had ceased. A record book for these entries was seen. Elkington House DS0000015433.V343832.R01.S.doc Version 5.2 Page 12 Controlled drugs were held for two people living at Elkington House. Secure CD storage was used, but the record keeping for the dispensing of two controlled drugs was confusing, for the home had adopted the practice of entering both medications in running order on one page rather than the practice as detailed in the Royal Pharmaceutical Society of Great Britain. During the site visit, staff were seen to treat all of the people living at Elkington House with respect and dignity. Within care planning notes there were the details of the preferred names, which some people wished to be called. It was also evident that the people living at Elkington House were also able to express their individuality in their accommodation, for there was evidence of personal possessions and photographs in their rooms. The management and storage of continence pads has been reviewed and the practice of publishing care plan needs on wardrobe doors had ceased. Elkington House DS0000015433.V343832.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. The daily routine and activites in the home were flexible and optional, with people who live at Elkington House being encouraged to make choices with regard to their social, cultural, religious and leisure activities. Family contact and visiting arrangements were open and relaxed, with family links encouraged and promoted. Links with the local community are encouraged and promoted as wished by the individuals living at Elkington House. Elkington House provides a varied and nutritious menu for individuals to select from. EVIDENCE: Elkington House DS0000015433.V343832.R01.S.doc Version 5.2 Page 14 Throughout the day of the site visit, the people who live at Elkington House were seen to come and go as they pleased. Some people choose to sit in the main lounge/dining room, whilst others sat in their rooms listening to the radio or talking books. One or two of the residents assisted with laying the table and sorting and folding napkins during the morning. During the afternoon some people choose to watch television in the front lounge or they choose to have a rest on their beds. After lunch, residents were heard to ask or were asked what they wished to do and they were assisted as needed to the lounge or their bedroom. A carer has responsibility for arranging social activities in the home. She was on holiday on the day of the site visit. Three times a week, quizzes, reminiscences, light exercises and games of dominos are instigated. Some entertainment is booked for the home, with festival and birthday celebrations arranged. Records kept on these activities evidenced activities on offered and those attending. Ms Richardson said that visitors are welcomed, with no restrictions placed on visiting times. During the site visit, two visitors confirmed that they are made very welcome when the visit their relative and they could meet with them either in a communal area or in their room. They said that they regularly visit their relative and on each occasion are made welcome with staff being “very pleasant.” A third visitor also confirmed that the found the staff and home “very welcoming,” and they were very approachable should they need to speak with them. Ms Richardson said that people who live at Elkington House are encouraged to manager their own financial affairs with the assistance of their family, friends and advocates. Small pieces of furniture and personal items were evident in residents’ bedrooms. She said that these are agreed to on admission to the home or as the individual settles into the home. Evidence was seen of beds. Chairs, bedding, pictures and photographs in resident’s bedrooms. A four-week rotation menu is used to plan meals at Elkington House. At least two choices were offered for both the main meal of the day – lunch and also at teatime. At the site visit, lunch was observed. The majority of people living at Elkington House were seen to enjoy their lunch in the dining room. Tables of four setting were seen, with flowers and condiments on each table. One person had their usual alcoholic drink with their meal, whilst others were served either orange squash or blackcurrant juice with their lunch. Those people who require assistance were seen to be assisted either at the table or at their Elkington House DS0000015433.V343832.R01.S.doc Version 5.2 Page 15 individual table in the lounge/dining room. One carer was seen to quietly and sensitively feed a resident with their meal. Whilst the main course was served up in the kitchen, desserts were brought into the dining room and were served from there. Special diets were said to be catered for and on the day of the site visit, the diet of a diabetic was being considered. A separate dessert was created for this person. Record keeping evidenced foods eaten. The only exception being breakfast, when no records were present to evidence the food offered or the food eaten. Elkington House DS0000015433.V343832.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. 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. People who live at Elkington House were well treated and listened to, with complaints and adult protection procedures in place. EVIDENCE: Two different complaint procedure formats were found in the home on the day of the site visit. It was agreed with the registered manager that these need to be reviewed for some references were made to the previous Commission of the National Care Standards Commission (NCSC). Advice was given that the complaint would need to pursue complaints with the Commission for Social Care Inspection (CSCI). Ms Richardson acknowledged that these documents need to be reviewed and revised to ensure that they do not mislead a complainant into the understanding that the Commission will investigate complaints and the details are current and correct. Ms Richardson said that adult protection policies and procedures were being reviewed and revised and were currently with the trustees for review. The Elkington House DS0000015433.V343832.R01.S.doc Version 5.2 Page 17 need to add Social Services details and local authority guidance and information was acknowledged. Definitions of the different types of abuse and the signs and symptoms were detailed in a document produced by a consultancy – Mulberry House and these gave guidance as to how staff needed to refer concerns. During the site visit, two staff members spoken to were clear as to the need to make management aware of any concerns. They confirmed that they had attended Safeguarding Adults training in the past. Ms Richardson said that they had recently attended a manager’s course on the Protection of Vulnerable Adults and the need to review staff training and awareness was acknowledged. Elkington House DS0000015433.V343832.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. 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. Overall, Elkington House provides a safe environment that is accessible to the people who live at the home. It is homely and meets individuals needs. EVIDENCE: Elkington House is a detached property in the residential area of Westcliff on sea. Bedroom accommodation for the twenty-five residents is on the ground and first floor. A new passenger lift has been installed since the last inspection, offering residents access to each floor via two passenger lifts at each end of the building. Two double rooms have been altered into four single rooms with large en-suite facilities and the main lounge and dining room has Elkington House DS0000015433.V343832.R01.S.doc Version 5.2 Page 19 been enlarged and expanded. Access to the rear garden was through a sliding concertina door with no steps to the outside patio area. Overall the premises were light and bright and well decorated. New curtaining, blinds and furnishings were in evidence. The registered manager identified maintenance and decoration issues, which were planned and programmed for completion. A new parker bath had been fitted to a newly enlarged bathroom on the first floor. Ms Richardson said that this bath had proved popular and was appreciated by both residents and staff. At the front of the property more car parking spaces have been created, with ramp access to the home. Hanging baskets, pots and flowerbeds created a pleasant entrance to the home. At the rear of the property, Elkington House has a large garden. A new large patio area with ramp and stairs access to the garden has been created. Garden furniture was seen on the patio for residents use. Ms Richardson said that further landscaping of the gardens is planned with the widening of footpaths to take wheelchairs. Garden sheds were seen in the garden for garden equipment storage. In-house laundry facilities are to be found at the home. A laundry person is on duty six days a week. Two industrial washers with sluice programmes and two industrial dryers are located in the laundry with ironing equipment available. The laundry person on duty was able to demonstrate a good understanding of the routine practice and procedures operating in the laundry and clarified practices should clothing require labelling. Elkington House DS0000015433.V343832.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. 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. Staff were roistered in sufficient numbers to ensure the people who live at Elkington House are safe and their individual needs are addressed. Elkington House has a good staff team and the people who live at the home are protected by the home’s recruitment practices and training. EVIDENCE: Ms Richardson outlined care, management and auxiliary staffing levels in the home. Consideration has been given to the assessed dependency needs of people living at Ekington House and flexibility was seen in the staff rota. This was further evidenced in staff interviews, for two care workers spoke of additional staff support offered as and when required by the people living at the care home. In addition, we observed that staffing levels had been considered during the day and at lunchtime it was evident that staffing levels are calculated and Elkington House DS0000015433.V343832.R01.S.doc Version 5.2 Page 21 deployed to enable staff to assist and support residents who require assistance with feeding at this time. National Vocational training is ongoing. Four care staff have achieved a National Vocational Qualification (NVQ) level 2 in care, whilst four care staff have NVQ level 3 in care. One care worker is currently on a NVQ level 2 in care and two care workers are to sign up for this course. In total Elkington House has eight out of fifteen staff with this qualification and is therefore meeting this requirement. Staff recruitment practices and paperwork were sampled and inspected for three care staff. Overall the record keeping and practice was seen to be in good order. The majority of shortfalls highlighted were to be found in employment records dating back to 1996/1997 when two written references were not obtained as a normal working practice and the home’s application form was lacking in a request for detail. The most recent staff recruitment paperwork seen was in good order, with a detailed completed application form and two written references. All staff files sampled had evidence of the start of employment and statements of terms and conditions had been issued to all three staff members. Criminal Record Bureau Enhanced disclosures had been completed for all three sampled care workers. Discussion took place as to the management and storage of Criminal Record Bureau (CRB) disclosures and Ms Richardson was advised to view guidance held on the Criminal Record Bureau (CRB) website. Elkington House has a training and development plan in place, covering July 2007 onwards. Training courses are planned for the management of Challenging Behaviour, management of Death & Dying, Basic Food Hygiene, Fire Training, COSHH Training, Health & Safety Training, training on Visual Awareness, First Aid & CPR and Basic Awareness of Dementia. Ms Richardson said that the majority of training is offered in-house with all staff encouraged to take part. One care worker interviewed said that they had been employed at the home for over twenty years and in that time had been offered a variety of training courses. The most recent training had been training in safeguarding adults and they had found this very interesting and informative. Elkington House DS0000015433.V343832.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34, 35 and 38. 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. Elkington House benefits from clear management structure. People who use this service do not benefit from a developed quality assurance and quality monitoring system. People who use this service benefit, from safeguarding cash held in safe custody. Safe working practices are promoted through ongoing training. Health and safety certification and insurances promotes a safe working environment. Elkington House DS0000015433.V343832.R01.S.doc Version 5.2 Page 23 EVIDENCE: Ms Richardson said that she has two units of her Registered Manager’s Award (RMA) to complete and she is hoping to finish this within the year. In line with National Minimum Standards, a qualification at a level 4 in care or equivalent is required and she was advised of the need to pursue this qualification. Ms Richardson said that she would look into this as she is completing her RMA. At the site visit management in the home was found to be open, and positive. Staff and people living at the home had a clear understanding of the management structure within the home and relatives spoken to were fully aware of who they should speak to should they need to. Ms Richardson said that questionnaires had recently been given out to the relatives of people newly resident at Elkington House. Discussion took place as to how these would be incorporated into a quality assurance system and how the information received could be made available to the people living at the home and their families. One to one discussions with residents and relatives are seen as a positive way of sharing information in the home. Ms Richardson said that insurance cover was in place to cover loss or damage to the assets of the business and cover is in place for business interruption costs. A certificate of Employers Liability was on display and was current. Monies and records of money held on behalf of the person living at the care home was sampled and checked. These were found to be accurate and in good order. At the site visit, Ms Richardson was unable to show the inspector records of staff supervisions, as they were not in the home. She said that records are kept of one to one supervision sessions and there was some evidence of contracts with staff around staff supervision. Two staff spoken to confirmed that staff supervision does take place although it was not possible to ascertain the detail and content of this supervision without seeing the records. As stated earlier in this report there was evidence of an ongoing programme of basic training courses to ensure that safe working practices are found within the home. Safety certifications were sampled and inspected at this inspection. These included certificates of inspection of Fire Extinguishers, Fire Alarm & Detectors & Emergency Lighting, the Emergency Lighting System Log and the Fire Alarm System weekly testing log. Elkington House DS0000015433.V343832.R01.S.doc Version 5.2 Page 24 Elkington House DS0000015433.V343832.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 2 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 2 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 3 3 2 X 3 Elkington House DS0000015433.V343832.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 (2)(b)(c) Schedule 3(1)(b) Requirement People who use the service must be assured that their care plans must be reviewed by care staff at least once a month, updated to reflect changing needs and current health and personal care needs. People who use the service must be assured that controlled drugs are recorded on receipt, administration and disposal through a Controlled Drug Register in the correct way. People who use the service must be assured that they are safeguarded by a clear, accurate complaints procedure. People who use the service must be assured that they are safeguarded by clear, accurate adult protection procedures. An effective quality assurance and quality monitoring system must be introduced to ensure a through review of the care and services offered in the care home. Timescale for action 27/08/07 2. OP9 13(2) 17(1)(a) Schedule 3(3)(i) 22(1)–(7) Schedule 4 (11) 12(1)(a), 13(6), 21 24(1)(a) (b), (2) (3) 27/08/07 3. OP16 27/08/07 4. OP18 27/08/07 5. OP33 27/08/07 Elkington House DS0000015433.V343832.R01.S.doc Version 5.2 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations People who use the service should be assured that medication which is required to be stored in a fridge is held at the correct temperature at all times. Temperature record keeping will evidence this. Daily nutritional records should be developed to fully detail all food offered and eaten. These records should include details of breakfast served and eaten. The manager achieves NVQ level 4 in management and care. This is a repeat recommendation from the last inspection. Care staff to receive formal supervision at least 6 times a year. Supervision records should be readily available in the home. This is a repeat recommendation from the last inspection. 2. 3. OP15 OP31 4. OP36 Elkington House DS0000015433.V343832.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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. 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