CARE HOME ADULTS 18-65
Ellesmere 43 High Street Wolstanton Newcastle under Lyme Staffordshire ST5 1EN Lead Inspector
Irene Wilkes Announced 09 June 2005 09:30 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 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Ellesmere CS0000004937.V194266.R01.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Ellesmere Address 43 High Street Wolstanton Newcastle under Lyme Staffordshire ST5 0ET 01782 620155 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Choices Housing Association Mrs Jill Millar Care Home 5 5 Category(ies) of LD registration, with number of places Ellesmere CS0000004937.V194266.R01.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: 1) 1 Maybe LD(E) Date of last inspection 20 January 2005 Brief Description of the Service: Ellesmere is a residential care home that is registered to provide five places for adults with a learning disability. The home is operated by Choices organisation, a local provider with a number of small homes across North Staffordshire.The home is a mature semi detached house located on the busy High Street of Wolstanton, near to Newcastle-under-Lyme, and within easy access of all local amenities and public transport. The property is well maintained and presents a warm and welcoming atmosphere. The design and layout of the premises promotes normal daily living. The home is tastefully furnished and communal space consists of a pleasant lounge and a large kitchen/ diner that has recently been refurbished. There is one en-suite bedroom situated on the ground floor. The other 4 bedrooms are on the first floor. These are not en-suite, but each has a wash-hand basin. The bedrooms are decorated to reflect each service user’s interests and personality. The bathroom and toilets are in close proximity to the bedrooms and communal areas. Laundry facilities are available within the home, and service users are supported to undertake their own laundry tasks. There is a patio style garden at the rear of the property with a rockery garden which the service users maintain. The home does not have space to provide car parking for visitors or staff. Cars have to be parked in the surrounding side streets. Ellesmere CS0000004937.V194266.R01.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This announced inspection took place over 5 hours by 1 inspector. Making it an announced inspection afforded the guarantee of the manager being on duty, as the previous inspection, when the home was new to the inspector was unannounced and the manager was not available. 5 gentlemen currently live at the home, whose ages range from 30 to 69 years old. There have been no new admissions since the last visit. A tour of the home and grounds was undertaken. 1 service user chatted to the inspector for some time in the lounge and throughout the day, another service user had chatted previously in the week when the inspector had unexpectedly met up with him, and the other 3 service users were happy to have a limited chat at various intervals throughout the day. The manager and 2 staff were on duty at the visit. Full discussion was held with the manager and the other 2 staff were spoken to in varying degrees. There were no visitors to the home at this particular visit. The care plans of 3 gentlemen were examined in detail. The information contained in them was cross referenced with the service users to further confirm this evidence, and further clarification was sought from the manager and a staff member about their role in supporting the service users. In this way a full picture of the service users’ needs and aspirations and if these were being met was built up. Staff practice was observed throughout the inspection. Staff records regarding training were seen, as were records relating to medication, food, residents meetings, staff meetings, staff rotas, complaints and maintenance. What the service does well:
All of the service users said that they were happy at the home. ‘I like all of the staff. I do my own thing’ was a comment made that well reflected the relaxed atmosphere in the home where the gentlemen are independent in personal care and also enjoy making their own decisions in a supportive environment. It was clear from observation of the staff speaking with each service user that they had an excellent rapport with each of them. All of the gentleman laughed and joked with the staff on duty and they were clearly relaxed. Every effort is made by the home to ensure that the wishes of the service users are met. There are up to date person centred plans that are developed with the full involvement of the service users and are reviewed regularly to check on the progress being made. The 2 service users spoken with more fully each confirmed that they lead an independent lifestyle but are well supported by the staff who assist them to make wise choices and provide advice as needed. The manager and a member of staff were also asked about the needs and interests of each person and they had an excellent understanding of each individual. The service users at Ellesmere range in ages, interests and abilities,
Ellesmere CS0000004937.V194266.R01.doc Version 1.30 Page 6 and their individual plans and lifestyle reflected this. Some are able to participate in paid work via employment with the Choices Handycare Scheme, when minor works are undertaken at each of Choices homes by an employee who also acts as supervisor to the service users employed to work in the scheme. This gives a feeling of self worth and also provides another source of income. The service users said that they enjoy their food. Individual choices are made at breakfast and lunchtime, with service users coming and going dependent on their activities on that day. They all choose the menus for the main meal on a weekly basis, but confirmed that they could change their mind and have something else if they wished. Each service user has a Health Action Plan that addresses both physical and mental health needs, and any professional appointments needed are followed up and acted upon. The plans held in the office hold all of the basic information staff need to be aware of to properly support the residents, whilst the residents themselves keep more detailed information in a file in their bedrooms. Records were seen for all health appointments and the follow up action needed. There is an experienced manager at Ellesmere who is a qualified nurse, as is her deputy. She leads a well trained staff team who all work hard together to provide the support required by the service users. There was obvious trust and an excellent rapport between service users and staff. What has improved since the last inspection? What they could do better:
Ellesmere has a history of providing a good service and this visit saw no departure from this high standard. The manager has excellent leadership skills whilst promoting an open and inclusive atmosphere.
Ellesmere CS0000004937.V194266.R01.doc Version 1.30 Page 7 The involvement of the service users in checking the quality of the service and seeking advice on any areas that need further development is undertaken. The Commission was reliably informed some time ago that Choices organisation is undertaking a review of its policies and procedures, with the involvement of a group of service users on the review panel. It is understood that this review has not yet been completed. A briefing as to the progress made, and what input the service users have had in the process would be helpful, and is recommended in the report. The findings would then possibly illustrate any further improvements that could be made to the service at this excellent home. 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. Ellesmere CS0000004937.V194266.R01.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Ellesmere CS0000004937.V194266.R01.doc Version 1.30 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 and 2 Service users have their needs assessed prior to admission, and there is full information about the home available via the Statement of Purpose and Service User Guide. This full attention to detail gives prospective service users and their families full information about the home, and also the reassurance for them and the staff that their needs can be met at Ellesmere. EVIDENCE: There are 5 gentlemen living at Ellesmere and each has lived there for a few years now. Each of their personal files have been seen previously during different inspection visits when each showed that a full assessment had been made of their needs prior to admission. 3 service user files were seen at this visit and each held the original assessment undertaken before each service user moved into the home. Full information is available about the home via a comprehensive Statement of Purpose. Each service user has their own Service User Guide, known as the ‘handbook’ and also a licence agreement linked to their tenancy. Staff confirmed that the contents of the handbook and the licence agreement were discussed with the service users, and 1 of the gentleman spoken with had an understanding of what was being talked about when the content of the documents were discussed.
Ellesmere CS0000004937.V194266.R01.doc Version 1.30 Page 10 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 and 9 The manager and staff work well with each service user to find out what they want from life, and these goals are recorded in their individual plans. The risks that arise from the independent lifestyle that results are thoughtfully considered with each person, and an agreement made with them about the most appropriate way to manage these risks. In this way the service users lead the life that they choose but know that they are well supported by the staff team. EVIDENCE: All 5 of the service users were at home at some part of the visit, either getting ready to go out to their individual activities or leisurely getting up, bathing and having their breakfast. 1 service user was happy to chat at length, another service user had been seen 2 days before when he was working at another home that was having an inspection and he had spared the time to chat, and the other 3 service users each preferred a briefer conversation. The personal files of 3 of the men were looked at and their content was cross-referenced to the outcome of the discussions. The manager and staff also discussed the individual needs of each of the gentlemen and their written plans. Ellesmere CS0000004937.V194266.R01.doc Version 1.30 Page 11 The files showed that each person had a 6 monthly review of their person centred plan (PCP) and that progress towards what had been decided at that planning meeting was evaluated monthly. Each file contained comprehensive details about the goals that each person was working towards in terms of greater community presence, meaningful activities to secure a valued lifestyle etc. The service users spoken with had a full understanding about their written plans, and their involvement in their development and review, and 2 spoke about their lifestyles and how they made decision for themselves. For example, 1 service user who has a bus pass talked about going into Newcastle for a walk around and going to the local pub to meet his friends. He used to go most days to a local market to help out but following a disagreement there he had discussed with staff and decided not to go anymore. Another service user chooses to drink, also has a girlfriend who lives some distance away in the Potteries, and he discussed how he makes his own decisions about some of the problems that this presents, with staff being there for him to mull things over with and advise him. The files each contained relevant risk assessment related to the service users chosen lifestyles and the ultimate risks that present. For example, the 2 service users referred to above had risk assessments in place relating to accessing the community alone, accessing public transport, going to the pub, violence and aggression, alcohol consumption to name a few. Each of these risk assessments showed the hazards for the individuals associated with these activities, but the steps that were put in place to minimise each hazard as they were part of the lifestyle that the men had chosen for themselves. The plans, risk assessments etc were also discussed with the manager and staff who confirmed how they supported the gentlemen to live independent lives, but also described the support systems in place to offer advice, minimise risk etc. Ellesmere CS0000004937.V194266.R01.doc Version 1.30 Page 12 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15, and 17 Service users enjoy a varied lifestyle and take part in activities linked to their interests and abilities. They enjoy good relationships both within and outside the home. This lifestyle enables them to become full members of the local community. Meals are nutritious and enjoyed in a relaxed environment that means that service users good health is supported by the diet provided. EVIDENCE: 2 of the service users chatted about their lifestyles and what they said was also confirmed in their individual plans. The oldest gentleman living at the home is nevertheless extremely active and he was pleased to talk about how he spends his time. He is employed by Choices organisation for 1 day a week on their ‘handycare scheme.’ The organisation has its own internal small repairs service, and a number of men living at various Choices houses work with a supervisor undertaking small works. He is very pleased about this as it means he has extra spending money for his cigarettes, holidays etc. He enjoys going into town on the bus, wandering around the shops, going to car boot sales, and visiting the local pub for a drink. Another younger man also works for the ‘handycare scheme’ goes out socialising, has a girlfriend who visits him,
Ellesmere CS0000004937.V194266.R01.doc Version 1.30 Page 13 and he visits her, and he generally leads his life the same as any young man of similar age. The way that the service users filled their day at this particular inspection visit supported all of the above. They were seen getting ready to go out, telling staff that they were off out and the comings and goings were the same as in any household. In discussion with the service users it also became evident that they maintain contact with their families. 1 man visits his family every week, another man has family who live abroad but he maintains phone contact, and the other service users also maintain contact with their families. Each also has friends living in the community who either visit the home or they visit them. Note of such family and friends contact was recorded in each individual plan, and the manager also talked about the particular relationships enjoyed by the gentlemen, and the advice and support provided by the home to enable such contacts to be maintained. Service users said that they enjoyed their lives. ‘I like the staff. I do my own thing’ was a typical comment made. Meal times were discussed with 2 gentlemen and they were quite happy with the food provided. There were nutritional screening forms in place for individual service users. It was explained that the men sit down on a Sunday evening and decide between them what they want for their main meals for the following week. Staff give advise on nutrition etc. Alternative choices are provided later in the week if someone decides they want something else. The menu plan for the week is written up on a board in the dining room, and this particular weeks menu showed a good variety, from cottage pie and vegetables to chicken salad. Other meals are selected on an individual basis, or may be eaten out. Menu plans are also recorded in a permanent record book. Meals are enjoyed at the large dining table in the spacious dining room. Ellesmere CS0000004937.V194266.R01.doc Version 1.30 Page 14 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 and 20 Service users are independent in personal care, although staff are on hand for support should this be required. All aspects of their physical and mental health are assessed and appropriate actions taken to follow up any issues. Medication procedures are sound. This all results in the gentlemen remaining generally fit and well, but safe in the knowledge that should any health issues arise they are reacted to promptly. EVIDENCE: The individual plans examined and discussion with staff and service users showed that each person is independent in personal care and only prompting is required on occasions. Each person had a 24 hour plan of care in place with appropriate plans in place for areas of health need such as nutrition screening, epilepsy, diabetes management. Each also had a Health Action Plan with basic information that staff needed to know kept in their main file, and a fuller plan kept by the service users in their bedrooms. The Heath Action Plan had a full list of physical and mental well being areas for action throughout the year, with dates in place for appointments, follow-up action etc. The manager was very knowledgeable about the health needs of the service users. Those service users asked said that all of their health needs were addressed. 1 service user is subject to a Guardianship Order and therefore is entitled to the Care Programme Approach involving other professionals in reviews and
Ellesmere CS0000004937.V194266.R01.doc Version 1.30 Page 15 action plans for his mental well being. Psychiatric services maintain a close involvement and the manager advised that the home puts into place the support recommended by these health professionals. The service user came in and out during the visit and said that he was feeling much better than when the inspector last saw him. He seemed very relaxed in the home. None of the service users at the home self medicate, each feeling that they would prefer the staff to keep and provide them with their medication. Procedures for the storage and recording of all medication given were looked at by sampling and were satisfactory in each case seen. The manager of the home and her deputy are qualified nurses and there was good information available for staff about all of the medication taken by service users in the home. There were PRN (as and when) and homely remedy policies in place and medication for either of these being taken was separately recorded. In the absence of a qualified member of staff being on duty and such medication being required there is a sound procedure in place where the home must contact a qualified member of staff at another home for advice, or the qualified member of staff on call. These procedures and records were seen as well as being discussed with the manager. Ellesmere CS0000004937.V194266.R01.doc Version 1.30 Page 16 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 The home has an appropriate complaints procedure in place and staff talk to service users about their rights to be heard and to be treated with respect. Staff have a good understanding and are aware of their responsibilities in protecting service users from any form of abuse. This attention to advising both service users of their rights, and training staff in their responsibilities ensures the protection of the service users. EVIDENCE: The home has an appropriate complaints procedure and each service user has a copy in the handbook (service user guide). 1 service user was asked what he would do if he wished to make a complaint and he was clear about his rights to complain and who to complain to. The pre-inspection questionnaire showed that 6 complaints had been made, with 1 substantiated. A Complaints Book is kept by the home and this was examined. The complaints were about day to day living issues and also external complaints, one from a relative. Examination of the approach to dealing with the complaints was appropriate in each case. 1 staff member was spoken to about her understanding of signs of abusive practice. She was a new staff member and confirmed that she had received training about abuse during induction and that she had a good understanding of her responsibilities. Training records showed that all staff had had training in this area. Service users were asked about how staff treated them and in every case they confirmed that they had a good relationship with all of the staff. The service user handbook contains details in pictorial format about what service users should do if they are not happy at any time with the way that they are being treated. A house meeting also takes place every 3 months, and the records of
Ellesmere CS0000004937.V194266.R01.doc Version 1.30 Page 17 the last one undertaken at the beginning of May showed this was discussed with service users. The majority had signed their agreement. Discreet observation of staff and service users interaction throughout the day gave an impression of mutual respect between them and that service users were relaxed in the home. Appropriate risk assessments are in place for areas where service users may be vulnerable to self harm, e.g. alcohol consumption. Ellesmere CS0000004937.V194266.R01.doc Version 1.30 Page 18 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 and 30 Ellesmere provides a spacious, safe and comfortable home for the service users where each person is encouraged to take responsibility for maintaining a high standard of cleanliness in the home. Bedrooms are personalised to reflect individual tastes and interests. This all results in a very pleasant environment in which to live. EVIDENCE: A tour of the accommodation was made. At the last inspection the patio flags were uneven and were considered a safety hazard, and following some problems from damp, one of the service user’s bedrooms required redecoration. It was pleasing to see that these areas had been addressed. The rest of the home continues to maintain a high standard of decoration and fitments. There is an attractive and relaxation promoting lounge, a large and well fitted dining room, a downstairs toilet, 2 bathrooms and single bedrooms for each of the gentlemen that are pleasant and well personalised. One bedroom is downstairs and has an en-suite bathroom with shower. This is the bedroom of the oldest gentleman. There is a small but sufficient laundry, and the office is on the third floor. Ellesmere CS0000004937.V194266.R01.doc Version 1.30 Page 19 Outside the home has a small garden to the front with the rear garden being laid with slabs. There is external seating for the service users to enjoy. Ellesmere provides a spacious and comfortable home for the service users. All of the gentlemen have agreed to do jobs around the home, such as hovering, as well as maintaining their own bedrooms and assisting with their laundry. The home is very clean and hygienic, including liquid soap and paper towel dispensers being provided to all sinks. Ellesmere CS0000004937.V194266.R01.doc Version 1.30 Page 20 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 Staff receive all of the mandatory and specialist training required to ensure that the individual and joint needs of the service users are appropriately met. EVIDENCE: Choices organisation pays considerable attention to the training needs of staff and there was no exception to this in this home. The pre-inspection questionnaire provided by the manager showed that all mandatory training was up to date and that the manager and her deputy had also taken additional relevant training. 2 staff training files were seen that showed a record of the individual training completed, with dates when mandatory training needed to be renewed. All mandatory training was up to date. One of the files seen related to a relatively new member of staff who was also on duty that day. The file showed that she had received induction training of 1 weeks duration, and had also received medication training, food hygiene, moving and handling, first aid and fire training. Her record of training was discussed with this new member of staff. She was still in the process of completing her full induction record of practical tasks completed, such as service user finances, dealing with aggressive outbursts. Following involvement in a range of practice areas her method of dealing with the task or issue is discussed with a more senior member of staff, and then signed off when it is considered by both parties that she is competent in that area.
Ellesmere CS0000004937.V194266.R01.doc Version 1.30 Page 21 A range of questions were posed and the member of staff proved knowledgeable about each area discussed. The pre-inspection questionnaire showed that there are 2 qualified nurses at the home and 6 care staff. 3 of the care staff are qualified to NVQ 2 or above. Further training courses are planned for one of the staff to undertake the NVQ Assessors course, for 2 further staff to complete NVQ 2, and training for all staff in computers, as a computer has recently been installed. Staff were discreetly observed throughout the visit talking to service users. There was also discussion with 1 of the staff about her role. Staff had a good understanding of each service users’ needs, and they showed the utmost respect to the service users both in their actions, i.e. knocking on doors, respecting their privacy and dignity, and in the various interactions with them. It was clear from observations that there was an excellent rapport between everyone. Ellesmere CS0000004937.V194266.R01.doc Version 1.30 Page 22 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 and 42 Ellesmere is a well run home. Service users views are sought about how the home operates. This ensures that the home functions in the way that the service users would wish, underpinned by their health, safety and welfare being at the heart of its management. EVIDENCE: The service users each have an individual review meeting twice a year when their individual needs are discussed with them. Regular house meetings are held on a quarterly basis when the approach of the staff and the way that the home is run is discussed with the service users. A record was seen of all of these meetings and the minutes of the last one that was held was studied in greater detail. This considered whether any improvements were required to areas such as food, holding discussions in private, participation in the cleaning rotas for the home. Choices organisation is currently undertaking a review of all of its policies and procedures. Representation of service users from a number of homes across
Ellesmere CS0000004937.V194266.R01.doc Version 1.30 Page 23 the organisation is included. The review is wide ranging and looking at alternative communication methods for the dissemination of the information in the policies and procedures as widely as possible to all of the users of Choices services. Progress on the review has not as yet been made available. It is recommended that the organisation provides a briefing as to the stage that the review is at, as report that it is underway has been made for some time now, and progress on the outcome would be helpful. A pre-inspection questionnaire had been completed by the manager prior to the visit that showed that maintenance and associated records were up to date for all applicable areas, such as fire, temperature checks, hoist and adaptations servicing and COSHH (Control of Substances Hazardous to Health). At the visit a sample check was made of fire records, COSHH storage, fridge and freezer temperatures and food probing checks and all of these had been maintained appropriately and showed no obvious problems. All mandatory training for staff was up to date. Risk assessments both for the environment and on an individual basis were in place. Ellesmere CS0000004937.V194266.R01.doc Version 1.30 Page 24 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x x x Standard No 22 23
ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 4 3 x 3 x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 3 x x x x x 4 Standard No 11 12 13 14 15 16 17 x 4 4 x 3 x 3 Standard No 31 32 33 34 35 36 Score x x x x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Ellesmere Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 3 x CS0000004937.V194266.R01.doc Version 1.30 Page 25 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Regulation Requirement No requirements 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. Refer to Standard 39 Good Practice Recommendations Provide the Commission with an update as to progress with the review of policies and procedures, and the input that has been afforded the representative service users. Ellesmere CS0000004937.V194266.R01.doc Version 1.30 Page 26 Commission for Social Care Inspection Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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. Extracts may not be used or reproduced without the express permission of CSCI Ellesmere CS0000004937.V194266.R01.doc Version 1.30 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!
