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Inspection on 27/01/06 for Elliot Lodge

Also see our care home review for Elliot Lodge for more information

This inspection was carried out on 27th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 43 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The inspection team observed staff interactions with service users to be entirely positive. Staff chatted with service users, and had a laugh and joke. Staff helped people with their personal care in a sensitive way. The exbyex said, "The staff were friendly and seemed to treat the residents with respect." Everyone who loves at Elliot Lodge has been on holiday, or got one planned. This is a really good thing. Staff have supported people to develop their bedroom in the way they like, with things in it which are important to them.

What has improved since the last inspection?

Twelve of the requirements made at the last inspection have been met. The home has improved medication management, assessment of manual handling needs, referred people to the Speech and Language therapist, provided hand towels, and tested the fire alarm weekly to achieve this.

What the care home could do better:

This is a home that the CSCI is concerned about, and which needs to get better in nearly all of the areas assessed to ensure that the needs of the people living at Elliot Lodge are well met. The service users care documents need to improve to show how all of the care needs are to be met. These documents need to be person centred. The plans need to be changed and developed as peoples care needs change.The files containing these records are large, and not in an easy to access order. They need to be more user friendly. The opportunities for people to go out of the home, or to undertake interesting activities within the home need to improve. At present people are not getting out of the home regularly, and on most days the main activity is watching TV or listening to music. The food has improved since the last inspection. The range of food and frequency with which it is served needs to carry on getting better. The Exbyex said, "One meal on the menu is not offering choice." The healthcare needs of people must be better planned. Staff must be provided with clear guidance on how to keep people safe, and support them when they are unwell. The qualified nurses need to check the medication to ensure it has all been given as prescribed. The policies around complaint and adult protection need to be updated. Staff need to be trained in adult protection. The environment needs a lot of work to ensure it is well furnished and decorated, to ensure it is clean, and to make sure things are stored appropriately. The people living at Elliot Lodge need to be provided with comfy chairs in addition to their wheelchairs. The exbyex said, "As I walked into the home the smell was horrible... There was hardly any furniture in the lounge; I refused to sit down, as the furniture was so bad. It was dirty and smelly it was also ripped. The carpets were in a dreadful state, they needed replacing." The manager must ensure that all the right checks are undertaken on nurses to ensure they are still qualified to practice. The frequency of supervisions must increase. Evidence that staff have received training and induction must be provided. The management of the home must get better to ensure that the needs of the people living here are well met, and that the home is organised and well run. Some health and safety checks need to be undertaken to ensure the home is a safe place in which to live and work. Some risks associated with the building, staff food and fire need to be assessed, and any action identified put in place to ensure residents and staff are kept safe.

CARE HOME ADULTS 18-65 Elliot Lodge 4 Newholmes Monyhull Hall Road Kings Norton Birmingham B30 3QB Lead Inspector Alison Ridge Unannounced Inspection 27th January 2006 09:30 Elliot Lodge DS0000062618.V279348.R01.S.doc Version 5.1 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 Elliot Lodge DS0000062618.V279348.R01.S.doc Version 5.1 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 Adults 18-65. 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. Elliot Lodge DS0000062618.V279348.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Elliot Lodge Address 4 Newholmes Monyhull Hall Road Kings Norton Birmingham B30 3QB 0121 444 0187 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) South Birmingham Primary Care Trust Family Housing Association Limited Janet Milutinovic Care Home 6 Category(ies) of Learning disability (6), Physical disability (6), registration, with number Sensory impairment (6) of places Elliot Lodge DS0000062618.V279348.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. A qualified nurse must be working in the home at all times and must not have responsibility for any of the other Newholmes bungalows. Six people with a learning disability under 65 years in receipt of nursing care. The seven requirements made in relation to the maintenance and decoration of the home at the unannounced inspection in December 2004 are met by 30 June 2005. 30th August 2005 Date of last inspection Brief Description of the Service: Elliot Lodge is a purpose built care home, on the site of the former Monyhull Hospital. The home is owned by Family Care Housing, and the care and staffing is provided and managed by South Birmingham PCT (NHS) Trust. The accomodation comprises of a communal lounge, dining room, kitchen, shower room, assisted bathroom, wc, laundry, and six single bedrooms. A qualified nurse is on duty across the twenty four hour period. They are supported by a minimum of three care staff during the day, and one care staff at night. The home is conveniently located for Kings Heath and Kings Norton. There are good public transport links. The home has a people carrier towards which the service users contribute financially. Elliot Lodge DS0000062618.V279348.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken by one inspector, and an Expert By Experience (Exbyex) Stephen Ellis. The inspection was undertaken across one day. During the visit the inspection team were pleased to meet with all the people that live in the home, the staff on duty and two night staff. The inspection team looked around the premises, read records about care, staffing and health and safety and looked at medication. It is suggested that this report be read along side the previous report, written in August 2005. The inspection team extend their thanks to everyone who assisted with the inspection. What the service does well: What has improved since the last inspection? What they could do better: This is a home that the CSCI is concerned about, and which needs to get better in nearly all of the areas assessed to ensure that the needs of the people living at Elliot Lodge are well met. The service users care documents need to improve to show how all of the care needs are to be met. These documents need to be person centred. The plans need to be changed and developed as peoples care needs change. Elliot Lodge DS0000062618.V279348.R01.S.doc Version 5.1 Page 6 The files containing these records are large, and not in an easy to access order. They need to be more user friendly. The opportunities for people to go out of the home, or to undertake interesting activities within the home need to improve. At present people are not getting out of the home regularly, and on most days the main activity is watching TV or listening to music. The food has improved since the last inspection. The range of food and frequency with which it is served needs to carry on getting better. The Exbyex said, “One meal on the menu is not offering choice.” The healthcare needs of people must be better planned. Staff must be provided with clear guidance on how to keep people safe, and support them when they are unwell. The qualified nurses need to check the medication to ensure it has all been given as prescribed. The policies around complaint and adult protection need to be updated. Staff need to be trained in adult protection. The environment needs a lot of work to ensure it is well furnished and decorated, to ensure it is clean, and to make sure things are stored appropriately. The people living at Elliot Lodge need to be provided with comfy chairs in addition to their wheelchairs. The exbyex said, “As I walked into the home the smell was horrible… There was hardly any furniture in the lounge; I refused to sit down, as the furniture was so bad. It was dirty and smelly it was also ripped. The carpets were in a dreadful state, they needed replacing.” The manager must ensure that all the right checks are undertaken on nurses to ensure they are still qualified to practice. The frequency of supervisions must increase. Evidence that staff have received training and induction must be provided. The management of the home must get better to ensure that the needs of the people living here are well met, and that the home is organised and well run. Some health and safety checks need to be undertaken to ensure the home is a safe place in which to live and work. Some risks associated with the building, staff food and fire need to be assessed, and any action identified put in place to ensure residents and staff are kept safe. 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. Elliot Lodge DS0000062618.V279348.R01.S.doc Version 5.1 Page 7 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 Outcomes Statutory Requirements Identified During the Inspection Elliot Lodge DS0000062618.V279348.R01.S.doc Version 5.1 Page 8 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 the following standard(s): Not assessed at this inspection. EVIDENCE: This home has a stable service user group, and no residential vacancies. These standards were not assessed at this inspection. Elliot Lodge DS0000062618.V279348.R01.S.doc Version 5.1 Page 9 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 the following standard(s): 6, 7, 9, 10 Service users needs and choices are not well planned or met. There is not evidence that service users or their representatives are involved in planning or reviewing care. Risks service users take, present and are exposed to are not well assessed or managed. Information is stored and transmitted securely. EVIDENCE: The plans of two people who live at Elliot Lodge were assessed. The plans did not contain evidence that the service users needs or goals had been well assessed and planned. It is an outstanding requirement that ways of making the plans more person centred be explored. Five of the service users accommodated would not be able to contribute easily to the development or review of their plan of care. The manager reported that family members had been involved in recent review meetings, (IPP’S) the minutes of these meetings did not evidence this. Plans had not been written in such a way as to demonstrate that the service users known likes and preferences had been included. Elliot Lodge DS0000062618.V279348.R01.S.doc Version 5.1 Page 10 These minutes did not clearly state the outcomes from the meeting, or make clear who would be responsible for addressing them or within what time scale. Risk assessments were generally scored to be a high, medium or low risk. No indication of what this means, or if the risk is an acceptable risk to take was available. Clinical risk assessments were assessed. Some of these were overdue for review. Others did not clearly underpin the risk being assessed. All information was stored secured, and no breaches of confidential information were noted. Elliot Lodge DS0000062618.V279348.R01.S.doc Version 5.1 Page 11 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 the following standard(s): 11, 12, 13, 14, 15, 17 Service users are not offered opportunity to undertake a range of varied or interesting activities consistent with their peers. Service users family are made welcome at the home, and come to visit. The food offered is of good quality, but further work to ensure it is varied and nutritious is required. EVIDENCE: The social and leisure opportunities for two service users were assessed. For one of the service users the opportunities recorded as being offered to him, and observed being offered to him during the inspection were unacceptably low. The inspector tracked back for one month, and the service user had not been out of the home during that period. Some structured in house activities (six) had been recorded, on all other days the entries were “listened to music”, “watched TV”, “personal care” and “bed rest”. Elliot Lodge DS0000062618.V279348.R01.S.doc Version 5.1 Page 12 The second service user tracked had been out of the home on four occasions. While this was positive the remainder of days showed that they had mainly been spent on “bed rest” and “watching TV”. This service accommodates people with a high level of dependence for whom self-engagement or stimulation is very difficult. The plans of care and record of activities offered and undertaken did not evidence that this area of need was being well met. The exbyex reported, “Everyone was grouped together in the lounge with nothing to do. One resident had a tambourine on his lap, and half the residents were asleep, so if had started to use it, it would have woken the rest up. No one else had any sensory objects to hold or touch.” During the inspection staff interaction with service users was positive. For the majority of the visit the service users were positioned around the television. A short activity with musical instruments was undertaken, and one service user went for a local walk. The records of daily events did show that family contact is maintained. The manager reported that family and significant people are consulted regarding the service users plan of care. The facilities for visitors at the home are very poor. There is no space (except for service users bedrooms) in which people can meet in private, as the small lounge is taken up with storage. The lounge contained no comfortable clean chairs on which visitors could sit. The exbyex declined to sit down during the visit as the furniture was so heavily soiled. The menu of food eaten has been revised, and the planned menu was seen to be varied and nutritious. The record of food eaten varied significantly from the planned menu, and the same level of variety, snacks and fresh fruit and vegetables were not recorded. This was an area brought to the attention of the manager at the time of inspection. The menu did not offer a choice of meals. Elliot Lodge DS0000062618.V279348.R01.S.doc Version 5.1 Page 13 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 the following standard(s): 18, 19, 20 Service users had been supported to undertake personal care to a good standard. Service users healthcare needs had not all been planned for and met. Medication was generally well managed. EVIDENCE: The six service users all appeared to be well presented, and support was offered with personal care throughout the time of inspection. Staff had been developing new plans of care regarding personal support, and the plans already in place were very individual and detailed. At the start of inspection the assisted bathroom was not in operation, as it was being used for storage of excess stock. The inspector raised this as a serious immediate concern and the responsible individual arranged prompt removal of the items. It was unacceptable that the manager had not already raised this and found more suitable storage prior to this. The healthcare needs of two service users were assessed. It was positive to see that appointments with the GP, chiropodist, dentist and optician had been arranged. Elliot Lodge DS0000062618.V279348.R01.S.doc Version 5.1 Page 14 It was disappointing to see that glasses provided were not being worn by the service user, despite this being brought to the staffs attention during the visit. The records regarding this were generally muddled, often with duplicate but slightly contradictory information being provided in each file. Some care plans were in a state of development. It was of concern that the goals of the plan were not clearly stated e.g the weight plan, which had no target weight. Not all care plans had been signed or dated. The plan of care for epilepsy could potentially put service users at risk, as the plan gave no clear description of the seizure usually experienced, usual recovery period, and the action to take in the event of this not being the case. Plans did not cross reference well with each other. The plan made no mention of risks associated with community access, nor did it cross reference to a document found later in the file regards this. The document did not evidence that the action to be taken would protect the persons dignity or ensure they would receive prompt treatment. A requirement was made previously regarding one person difficult to manage behaviour. It was positive that referrals had been made to psychology. It was not evident that full records of the incidents were being completed, or that the incidents were being evaluated to inform or direct care practice. This remains outstanding. The plan of care for one service user whose needs had recently changed was assessed. The whole contents of the plan required review to reflect the new situation. Staff had undertaken consistent monitoring of healthcare, including seizures and bowel movements. Medication management was generally good. The record of medication administered and received was robust. Auditing of medicines identified one medication for which excess stock was available indicating the medication may not have been given as prescribed. The manager needs to commence audits of medication not blister packed. Elliot Lodge DS0000062618.V279348.R01.S.doc Version 5.1 Page 15 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 the following standard(s): 22, 23 The policy and procedure available for complaints and adult protection would not ensure the correct action is taken. Staff require training in adult protection. EVIDENCE: There have been no complaints raised about this home and there have been no reports of an adult protection nature. The policies and procedures to underpin these events were assessed. The complaints policy requires further development to include the role and contact details of the CSCI, and assurances that the complaint will be taken seriously, and the complainant will not be victimised for raising concerns. The Adult Protection policies available were dated 29/10/01 and 14/1/02. Neither document contained the correct procedure to be followed in the event of abuse being reported or suspected. It is required this be obtained. It was positive that a copy of the multi agency guidelines was available in the home. Adult protection training remains a requirement for approximately half the staff team. Elliot Lodge DS0000062618.V279348.R01.S.doc Version 5.1 Page 16 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 the following standard(s): 24, 25, 26, 27, 28, 29, 30 The communal lounge at Elliot Lodge is squalid and the entire home requires significant urgent attention to ensure the comfort and safety of service users, staff and visitors. EVIDENCE: Elliot Lodge was purpose built as a care home. At the time of inspection the environmental standards had fallen far below an acceptable standard. The décor, carpeting and some furnishings all required attention. The inspector is aware that work to address these shortfalls is imminent. It is of serious concern that the premises had got into such a bad state of repair throughout, and that conditions of registration regarding this matter were breached. It is of further concern that the West Midlands Fire service raised concern about communal lounge furniture in November 2005. This furniture remained in the home at the time of inspection and the manager had no date on which new furniture could be expected. Staff raised concerns that the communal lounge could be infested with fleas and showed the inspector raised red spots, which could have been bite marks. The inspection team declined to sit in the lounge furniture available due to this and its very dirty condition. Elliot Lodge DS0000062618.V279348.R01.S.doc Version 5.1 Page 17 At the time of the inspector’s arrival the assisted bathroom and “smoke room” were out of use due to an excess of stock. This was removed from the bathroom at the inspector’s request, but remained in the smoke room. These rooms comprise part of the homes registration and must be available at all times. All service users have a single bedroom. These were very personalised with things important to each individual. One service user reported favourably about the Sky TV he has provided in his bedroom. All rooms urgently required redecoration, and plasterwork making good where it had been chipped. In one bedroom a dirty incontinence pad had been left on the floor. This had a negative impact on both the service users dignity and infection control. The home has a sensory bathroom, which is a great resource. It was reported that service users enjoy this facility, although it wasn’t observed as an activity on the daily records sheets sampled. The shower room requires attention to ensure it provides a pleasant and practical place in which to undertake personal care. It was positive a new shower chair had been provided as required by an OT assessment. The initial assessment showed the provider has taken three years to produce this equipment. It is recommended that the hot water delivery temperatures be increased slightly, as these were below the required 43°c. Five of the service users do not have seating except for their wheelchair. It is required that they be assessed for this, and that this be provided. The inspector noted that visitors to the home do not use the front door, but enter the home via a side door direct into the lounge. A fence obscures use of the front door. The effect on the temperature of the opening of the side door direct into the room was significant and it is required that proper access be provided to the front door, and that this entrance be utilised. It is recommended that the doorbell be replaced/repaired as this was not in full operation. The storage space in the home was inadequate to safely house the stock held in the home at the time of inspection. Upon review of the home it appeared that valuable space was being wasted by items that could be discarded, placed in the shed (if doors were fitted) archived or stored differently. It is required that a review of the home is undertaken and items be removed or additional storage be provided as is required. Elliot Lodge DS0000062618.V279348.R01.S.doc Version 5.1 Page 18 The old chairs and equipment stored at the rear of the home must be discarded. The cleanliness of the kitchen required improvement. Drawer and door fronts and cupboards all required wiping. It is recommended that hygienic hand wash and dry facilities be provided in all bedrooms to further promote good infection control practice. It is recommended that new crockery, mugs and glasses be obtained. Many items observed were chipped or miss matching. It is recommended that old and broken appliances such as food processors and blenders be discarded, at the time of inspection a large number of broken appliances were evident in the kitchen. The kitchen bin must be replaced. Elliot Lodge DS0000062618.V279348.R01.S.doc Version 5.1 Page 19 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34, 36 The number of staff provided during the day Monday to Friday appeared adequate to enable service users to be well supported. It was not evident good use was being made of the staff provided. Staff are checked prior to starting work in the home, the manager must ensure qualified staff are currently registered. Staff are supervised to a good standard. The frequency of supervision needs to increase. EVIDENCE: The inspector was pleased to meet staff on duty, and two of the night staff who visited the home. Staff interactions with service users were entirely positive and very supportive. The number of staff as identified on the rota appeared to be adequate if effectively used to meet the needs of the service users. It is required that the role of the nurse in community activities be risk assessed and reviewed. If this is required then adequate numbers of qualified staff must be provided. It is recommended that the day be reviewed to stager the rest times to enable staff to support service users with meaningful activities. The recruitment files of three staff were assessed. Elliot Lodge DS0000062618.V279348.R01.S.doc Version 5.1 Page 20 It was not evident in the files of qualified staff that current PIN numbers were available, and had been checked. Two files contained no record of any training or induction. It was of concern that one staff had commenced work in the home in the autumn of 2005. At that time a POVA check was obtained. No evidence of a CRB check being received or risk assessment regarding this status was available in the file. Supervisions undertaken were to a high standard. The frequency of these is required to increase. The Manager reported that manual handling training, fire safety training and Food Hygiene training had been delivered, staff were awaiting training in the area of Adult Protection. Elliot Lodge DS0000062618.V279348.R01.S.doc Version 5.1 Page 21 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 41, 42 The service users do not benefit from a well run home. Record keeping and health and safety must improve to ensure the service users staff and visitors are safe. EVIDENCE: The inspection raised serious concerns about the management of the home. Significant shortfalls were identified in all of the areas assessed, and it was not apparent that the manager had taken all possible action to see these situations improve or be resolved. There was a current certificate of insurance and registration on display in the home. The CSCI has received some copies of owner visits. It is not evident these are undertaken monthly as is required. The records within the home were not in good order, and it was evident many of them could be rationalised, archived or destroyed. Care records should be presented in a user-friendly format that encourages staff to use them. Elliot Lodge DS0000062618.V279348.R01.S.doc Version 5.1 Page 22 Evidence that all the required health and safety tests had been undertaken was not available. It is required that the electrical hard wiring, PAT tests and legionella screening be obtained. Records showed that fire safety, gas equipment and hoists and baths had been tested as required. Staff had undertaken the required tests of the fire alarm, emergency lighting and fridge/freezer. It is required that the recording of food core temperatures improves. The fire risk assessment was overdue for review. The manager is required to develop risk assessments for the premises, for staff, and to further develop the food risk assessment. Elliot Lodge DS0000062618.V279348.R01.S.doc Version 5.1 Page 23 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 Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 ENVIRONMENT Standard No Score 24 1 25 1 26 1 27 1 28 1 29 2 30 2 STAFFING Standard No Score 31 X 32 2 33 2 34 2 35 X 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 3 LIFESTYLES Standard No Score 11 1 12 1 13 1 14 1 15 1 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 1 X X X 1 1 X Elliot Lodge DS0000062618.V279348.R01.S.doc Version 5.1 Page 24 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 YA6 Regulation 12(2) Requirement Timescale for action 01/06/06 2 YA6 3 4 5 6 YA6 YA9 YA9 YA11YA12 7 YA13YA14 Unmet from the previous inspection. Service users must be offered opportunity to undertake person centered planning. 12(1)(a) Unmet from the previous 15 inspection. The service users plan must be kept up to date. 12(1)(a) Goals set must evidence how 12(3) they were decided upon, who how and when they will be met. 13(4)(a-c) Risk assessments must be kept under review, routinely and as needs change. 13(4)(a-c) Risk assessment outcomes/scores must be made clear. 16(2)(m,n) Unmet from the previous inspection. Service users must be offered opportunities to undertake personal development. 16(2)(m,n) Unmet from the previous inspection. Service users must be offered a range of interesting leisure opportunities in the community and at home. 01/04/06 01/04/06 01/04/06 01/04/06 01/05/06 01/05/06 Elliot Lodge DS0000062618.V279348.R01.S.doc Version 5.1 Page 25 8 YA17 16(2)(i) 9 10 YA19 YA19 12(1)(a) 12(1)(a) 11 YA19 12(1)(a,b) 12 13 YA20 YA22 13(2) 22 14 YA23 13(6) 15 YA24YA30 13(3) 16 YA24YA28 23(2)(d) 17 YA24YA28 23(2)(d) Unmet from the previous inspection. A varied and nutritious diet must be availbale and offered to service users. Service users must be supported to wear prescribed aids. Clear guidance on how to meet all health care needs must be provided in the service users plan. Unmet from the previous inspection. Behaviour records must be reviewed and used to inform and direct practice. Staff must undertake an audit of medicines to ensure they are being given as prescribed. The complaints procedure must be further developed as identified in the text at Standard 22. The Adult Protection policy must be further developed as identified in the text at standard 23. Advice regarding the possible infestation of fleas must be sought and the required action undertaken. Unmet from the previous inspection. Lounge furniture must be replaced. Unmet from the previous inspection. The carpets must be replaced in three service users bedrooms. The identified service users. bedrooms must be redecorated. The lounge must be redecorated The flooring in the dining room must be replaced. The carpet in the hallway must be replaced. DS0000062618.V279348.R01.S.doc 01/04/06 01/03/06 01/04/06 01/04/06 01/04/06 01/06/06 01/06/06 01/03/06 14/03/06 01/04/06 Elliot Lodge Version 5.1 Page 26 18 YA24YA28 23(2)(e) 19 20 22 YA24 YA24 YA29 23(2)(a) 16(2)(k) 23(2)(n) 23 YA30 13(3) 24 25 26 YA30 YA30 YA33 13(3) 13(3) 16(2)(j) 18(1)(a) 27 YA34 19 Sch2&4 28 29 YA34 YA23YA35 19 18(c,i) 30 YA36 18(2) 31 YA35 18(1)(a,c) All communal areas of the homes registration must be available for service users to use. Access must be made availbale to the front door of the home. Unwanted furniture must be discarded from the rear garden of the home. Unmet from the previous inspection. Aids and adaptations as required by service users must be provided. Unmet from the previous inspection. The sharps box must be discarded. A new kitchen bin must be provided. An acceptable standard of cleanliness must be maintained in the kitchen. The manager must review the allocation of staff to ensure the best outcomes for service users are achived. Unmet from the previous inspection. Recruitment records (As detailed in schedules 2 and 4) must be available in the home. The manager must ensure all qualified staff have current professional registration. Unmet from the previous inspection. Evidence that staff have received training in adult protection, must be available in the home. Unmet from the previous inspection. All staff must be supervised at least six times a year. (Pro rata for part time staff) Staff files must evidence all staff have received the required DS0000062618.V279348.R01.S.doc 01/04/06 01/04/06 01/03/06 01/05/06 01/03/06 01/03/06 01/03/06 01/04/06 01/04/06 01/04/06 01/05/06 01/06/06 01/06/06 Page 27 Elliot Lodge Version 5.1 32 YA37 9 33 YA41 17 34 YA42 13(3) 23(5) 35 YA42 13(4)(b-c) 23(5) 36 YA42 23(2)(c) 37 YA42 13(3) mandatory and service user specific training. The provider is required to review the effectiveness of the homes management and provide, support, training or take required action to ensure the home is well run. Records must be rationalised to ensure they are accessable, current and inform care practice. Unmet from the previous inspection. The fly screen must be utilised. The fly screen on the door must be repaired or replaced. Unmet from the previous inspection. Risk assessments for the premises and staff must be developed. The food risk assessment must be further developed. All health and safety tests to include PAT tests, electrical hard wiring and legionella screening must be undertaken. Staff must take and record the core temperature of food. 01/04/06 01/06/06 01/03/06 01/04/06 01/02/06 01/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Elliot Lodge DS0000062618.V279348.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Elliot Lodge DS0000062618.V279348.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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