Inspection on 03/09/08 for Elliott Residential Care Home

This inspection was carried out on 3rd September 2008.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Elliott Residential Care Home 02/02/09

Elliott Residential Care Home 01/11/07

Elliott Residential Care Home 22/06/06

Elliott Residential Care Home 22/11/05

Elliott Residential Care Home 23/05/05

Elliott Residential Care Home 24/01/05

Elliott Residential Care Home 02/08/04

Similar services:

Hillside

Applegarth

Trevayler Residential Care Home

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2009.

CARE HOME ADULTS 18-65 Elliott Residential Care Home 46-48 Highfield Street Leicester LE2 1AD Lead Inspector Helen Abel Unannounced Inspection 3rd September 2008 09:30 Elliott Residential Care Home DS0000006423.V371397.R02.S.doc Version 5.2 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 Elliott Residential Care Home DS0000006423.V371397.R02.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 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. Elliott Residential Care Home DS0000006423.V371397.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elliott Residential Care Home Address 46-48 Highfield Street Leicester LE2 1AD 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) 0116 254 4458 0116 254 4458 elliott4648@aol.com Mr M Elliott Mrs Elliott Mrs Shirley-Ann Kendall Care Home 17 Category(ies) of Learning disability (17), Mental disorder, registration, with number excluding learning disability or dementia (17) of places Elliott Residential Care Home DS0000006423.V371397.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No person to be admitted to Elliott Residential Care Home in categories LD or MD when 17 persons in total of these categories/combined categories are already accommodated in this home. To be able to admit the named person of category DE(E) named in variation application No. V35239 dated 2 August 2006. 1st November 2007 Date of last inspection Brief Description of the Service: The home is situated on 46-48 Highfield Street just off London Road, and a short distance from Leicester city centre. The home has 17 places for people with learning disabilities and/or mental health needs. It is close to bus routes, a mainline train station, shops, and a variety of places to eat and drink. There is a quiet lounge, a smoking lounge, and a dining room. To the rear of the home is a secluded paved garden with plants and a fountain. The weekly fees range from £298 to £396 per week - this information was provided on the inspection day. There are additional costs for expenditure such as hairdressing, private chiropody, toiletries, newspapers, A copy of the latest Commission for Social Care Inspection, inspection report is available from the home. Elliott Residential Care Home DS0000006423.V371397.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a ‘Key Inspection’ that focused on the key standards under the National Minimum Standards and the Care Standards Act 2000 for homes providing care for younger adults. The Inspector spent time planning the areas to focus on based upon information gained from reviewing the homes service history, the last inspection report, and the Annual Quality Assurance Assessment (AQAA). An Expert by Experience accompanied the Inspector for the whole day’s visit and produced a separate report. Extracts from that report have been incorporated into the body of this inspection report. The people living at Elliot House prefer to be called residents. The primary method of inspection used was ‘case tracking’ that involved selecting three residents and reviewing the care that they received through inspection of the written information available on their care, such as the care and support plans. Discussions took place with residents and staff. The registered manager was not present on the day of our visit. The visit was unannounced and started at 9.30 am on a Wednesday morning and took place over a period of approximately five hours. In addition policies and procedures and records in relation to residents, staff recruitment, complaints, and upkeep of the home were viewed. Upon our arrival one resident was observed peeling potatoes in preparation for lunch and another resident told the Inspector he was off to his job in town with a packed lunch. Due to the resident’s personal capacities, we will not be providing the inspection report summary in an easy read format. The quality rating for this service is 0 star. This means the residents who use this service experience poor quality outcomes. What the service does well: Trial periods are offered to see if residents are appropriate for the surroundings and see if they would fit comfortably into the home. Staff will Elliott Residential Care Home DS0000006423.V371397.R02.S.doc Version 5.2 Page 6 ensure the resident’s relatives can visit whenever they like and are made welcome. The service aims to give each resident freedom of choice in most things they do. The service encourages residents to do jobs around the home. This helps them with time keeping, and motivates them into working, for which they receive a reasonable wage. Residents are also supported to go into the laundry room and assisted to do their own laundry. There is a set menu for meals but within this there is plenty of choice. Resident’s individual cultural needs are recognised and are adequately dealt with. Residents are offered a healthy varied diet. Residents told us, “I am confident that staff are approachable and happy with their responses to date.” “Very happy with the staff from whom I have never had so much kindness.” These sentiments were to be echoed throughout the day by other residents. Residents told us that other residents were “happy” and “good company” and the management were “top rate. ” One resident said, “ I have not a bad word to say about staff and management. They are better than they used to be.” Staff confirm they have positive feedback from social workers that visit, and service users relatives say they are very happy with the service and the way in which the care home is run. The Inspector observed members of the staff work with a very challenging situation in a professional, caring and considerate manner during our visit. The outcome ensured the safety welfare of residents living at the home was met. The staff are to be commended. What has improved since the last inspection? Elliott Residential Care Home DS0000006423.V371397.R02.S.doc Version 5.2 Page 7 All staff have received Adult Protection training and will be receiving further learning through working towards National Vocational Qualifications (NVQ’s). Two resident’s bedrooms door locks have been changed to enable staff entry in an emergency. The registered manager makes regular checks of the medication systems to ensure all records are accurate and signed off appropriately. 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. Elliott Residential Care Home DS0000006423.V371397.R02.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Elliott Residential Care Home DS0000006423.V371397.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s needs and aspirations are not adequately met through the needs assessment procedures. EVIDENCE: A Service User Guide and Statement of Purpose are given to new residents. These documents contain key information about the service to make an informed choice about where to live. Staff will talk through these documents so as a prospective resident has a clear understanding. Trial periods are offered to see if residents are appropriate for the surroundings and see if they would fit comfortably into the home. Staff will ensure the resident’s relatives can visit whenever they like and are made welcome. A new resident had some prior knowledge of the home and specifically asked to come to Elliot House. Some information around assessment of need for this new resident was examined, but a support plan had not been developed. Needs assessment procedures are important and ensure individuals aspirations and needs are properly assessed and must be undertaken. Elliott Residential Care Home DS0000006423.V371397.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents support plans do not accurately reflect their needs, and individuals are not well supported to take reasonable risks. EVIDENCE: A support plan for a new resident user was not in place. Other support plans examined were varied in content and lacked detail. Support plans were not signed in agreement by residents. However annual reviews were taking place involving the resident, staff at the home and a local authority representative. Daily records around resident’s life in the home were not well recorded. Suggestions were given to staff on how the format could be improved. Risk assessments were not evident for aspects of support for one resident with complex needs, and a new resident. This had the potential to put both residents, and others at risk of harm. With good risk management strategies in Elliott Residential Care Home DS0000006423.V371397.R02.S.doc Version 5.2 Page 11 place residents can be supported to take risks as part of an independent lifestyle. The need for improvements around risk assessments was made a requirement upon our last visit to the home. The Inspector asked for all the support plans to be reviewed and ensure they contain all the information as required under Regulation 17. Schedule 3. The service aims to give each resident freedom of choice in most things they do. For example residents will bathe themselves whenever they wish. Staff told us if it gets to a point were they feel individuals need to bathe, then staff will gently coax them. There are plans to invite two residents to future staff meetings to take part in our decision-making in the home. Elliott Residential Care Home DS0000006423.V371397.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have opportunities for vocational, leisure and community activities and enjoy a varied diet. EVIDENCE: The service encourages residents to do jobs around the home. This helps them with time keeping, and motivates them into working, for which they receive a reasonable wage. Over the past twelve months the service gives as many residents small jobs as possible in order for them to earn money to provide them with items that they wouldnt otherwise be able to afford. One resident was observed peeling potatoes in preparation for lunch and another resident told the Inspector he was off to his job in town with a packed lunch. One resident confirmed he helped the registered provider with jobs around the home, and another resident had a seasonal outdoor maintenance job. Elliott Residential Care Home DS0000006423.V371397.R02.S.doc Version 5.2 Page 13 A resident told us “It is very frustrating that so many people in care are being denied access to computers.” The resident was encouraged to speak with staff about his IT aspirations. Two service users told us that occasionally, different personalities in the home cause unrest, but also readily accepted that the close environment can sometimes be difficult. A resident told us about his life at the home- he is active and goes out most days and simply exercises his right to independence as opposed to the trips that are arranged by the home. He knows that his money is safe in the care of staff and his privacy is observed whilst absent because he has his own key to his room. He is, with the encouragement of staff, in touch with relatives who occasionally visit. He enjoys the choice of food and is obviously very comfortable with staff and fellow residents and was quick to reassure us that he had no complaints. The registered manager helps all residents with their benefits/finances, and with any other financial difficulties. Some residents take part in day centers, but if chose not to attend have the right not to, and alternative activities are arranged within the home. Residents are actively supported to maintain contact with family and friends, and visitors and people were seen coming to the door to talk to residents. Meals are served in the dining room. There is access to a large fridge for service users and kettle and facilities in the dining room. There is s set menu for meals but within this there is plenty of choice. Resident’s individual cultural needs are recognised and are adequately dealt with. A detailed list displayed in the kitchen outlines resident’s individual dietary requirements, which staff follow. Residents are offered a healthy varied diet. The Expert by Experience was invited to take lunch with residents. All attending residents were served with freshly cooked, nourishing meals of their choice and returned their dirty crockery to the servery for washing up. Elliott Residential Care Home DS0000006423.V371397.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents receive appropriate personal support and health care. However for individuals self medicating, are not protected by the homes policies and procedures for dealing with medicines. EVIDENCE: Residents personal support needs are not clearly documented and are difficult to follow through. These should be reorganised so as information is easily assessable to help guide staff on the support residents require. Arrangements are in place for accessing additional support from physiotherapist and other professionals to meet additional physical health needs that some residents have. Psychiatrists in the community monitor some residents. Medication and general reviews are held following the Care Programme Approach. One resident following on a review showed the Inspector his new glasses and confirmed this has helped him, and staff agreed this had reduced the frequency of falls he had been experiencing. Elliott Residential Care Home DS0000006423.V371397.R02.S.doc Version 5.2 Page 15 A mix of ages of younger adults lives at Elliot House. Residents have their own distinct clothes sense, hairstyle, and their appearance reflects their personality. A key worker” system does not operate in the home, instead residents choose whom they wish to talk to and when, and time is always made available. Systems for storing medication are generally adequate. Advice was given around checking with the pharmacist on the storage of controlled drugs. The Registered Manager who was absent on the day of inspection makes a regular audit of medication. Staff confirmed a good relationship with the pharmacist and have all had medication training. A resident had not undertaken a risk assessment to check they are safe when taking charge of their own medication. During the day the individual became very unwell. A safe keeping area is available in bedrooms to store medication, but there was difficulty accessing this area to check. Staff were unclear if the identified resident had taken their medication. Records of this person’s current medication were not available. The Inspector asked for improved procedures around individuals self-medicating to ensure residents are protected. Elliott Residential Care Home DS0000006423.V371397.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents concerns are listened to and acted upon. EVIDENCE: Residents told us, “I am confident that staff are approachable and happy with their responses to date.” “Very happy with the staff from whom I have never had so much kindness.” These sentiments were to be echoed throughout the day by other residents. The complaints procedure is displayed within the kitchen/dinning area. At all residents meetings staff fully explain the contents of the complaints procedure. The Expert by Experience and Inspector suggested the procedure is reviewed to ensure procedures are clearer and easy to follow; with contact information around advocacy services, and confirmation that the procedure can be made available in alternative formats. All staff to have undertaken protection of vulnerable adults (POVA) training and are under supervision until they have had such training to keep residents safe. All staff are due to start further adult protection training through learning with National Vocational Qualifications (NVQ’s). Elliott Residential Care Home DS0000006423.V371397.R02.S.doc Version 5.2 Page 17 For good practice the Inspector suggested the managers considers attending Alerter training via the local adult protection team. This is for senior staff to keep them fully aware of vulnerable adult issues and their responsibilities for the safety and protection of residents at Elliot House. Elliott Residential Care Home DS0000006423.V371397.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a homely and comfortable environment. EVIDENCE: The Expert by Experience was then taken on a tour of the rooms by a willing resident:- all bathrooms, showers and toilet’s seen were of a good standard, whilst some of the rooms and hallways would benefit from fresh air the overall comfort levels are good. The interior décor is looking a little tired and soiled bed linen in one room but whilst being shown the laundry room I witnessed a resident with his washing who assured me it was a “wash day”. A fact later confirmed by staff. Parts of the home needs refreshing and an ongoing plan of decoration are recommended. Elliott Residential Care Home DS0000006423.V371397.R02.S.doc Version 5.2 Page 19 Staff told us they constantly encourage all residents to maintain a safe and hygienic environment, for example participate in the cleaning of their own rooms, if they wish. Residents are also supported to go into the laundry room and assisted to do their own laundry. A cleaner is employed and was observed cleaning parts of the home. The inside of the resident’s fridge in the dining room was found to be worn and rusty and needs repair or replacement. Staff confirmed the registered provider would replace this. The registered provider confirmed two bedrooms locks have been repaired and residents can use them, and staff can get in, in case of an emergency. Elliott Residential Care Home DS0000006423.V371397.R02.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are not adequately supported and protected by trained staff and recruitment processes. EVIDENCE: Residents told us that other residents were “happy” and “good company” and the management were “top rate. ” One resident said, “ I have not a bad word to say about staff and management. They are better than they used to be.” The Expert by Experience observed the calm manner in which residents acquitted themselves allowing the staff and management to concentrate on a severely distressed resident. He also confirmed staff provided -good levels of care to residents who are clearly relaxed, comfortable and respected in their home. Residents at Elliot House are supported by a staff group of young women and men from different cultural backgrounds from the local community. Staff recruitment records were sampled and confirmed all the required checks had taken place but information was difficult to locate on the day of inspection. The Elliott Residential Care Home DS0000006423.V371397.R02.S.doc Version 5.2 Page 21 Inspector continued to follow this up with senior staff after our visit. It is recommended staff recruitment records are better organised. Maintaining thorough recruitment procedures will ensure residents are supported and protected by the homes recruitment policy and practices. Staff confirmed trial periods take place for new staff in consultation with residents before offering permanent employment contracts. The same aspect applied to staff training records, which were difficult to locate and track. Staff tell us, 80 of permanent staff are working towards National Vocational Qualification (NVQ’s). Training records should be kept in good order and up to date. Records should include any statutory training completed, and an identified training plan for individual staff, including domestic staff. Staff reported monthly and annual appraisals but there was little evidence to support these meetings take place. Staff confirmed over the next twelve months plans to upgrade staff training, and keep it ongoing. Good opportunities for staff training and development will ensure individuals and joint needs, are met by appropriately trained staff. Elliott Residential Care Home DS0000006423.V371397.R02.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 41, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems are in place to ensure resident’s views inform the way the service is delivered. Record keeping required by regulation to safeguard residents is not adequately maintained. EVIDENCE: The registered manager was absent on the day of inspection and outcomes around Day-to-Day Operations will be checked at our next visit. One of the outcomes of a resident survey was the request for a pool table. The registered provider purchased one and this is set up in the front lounge when residents want it. Staff confirmed they have one-to-one meetings with Elliott Residential Care Home DS0000006423.V371397.R02.S.doc Version 5.2 Page 23 residents to see if they feel all of their needs are being met. Resident’s views are listened to on how they would like the home to be run. Staff confirm they have positive feedback from social workers that visit, and service users relatives say they are very happy with the service and the way in which the care home is run. Many policies were updated in January 2008. Some had been passed to residents to read and sign, and signed copies were held in their support plans. However it appeared the consultation process had not been carried out effectively resulting in some residents being consulted and others not. For example the May 2007 Smoke Free policy was present in an individuals support plan but not signed off by the resident. It was unclear, if the resident had been made aware of this aspect. It was noted over our visit that a number of records required by regulation were not up to date or in good order. It is important residents records are kept up to date ensuring their rights and best interests are safeguarded by the homes record keeping policies and procedures. The Inspector observed members of the staff work with a very challenging situation in a professional, caring and considerate manner. The outcome ensured the safety and welfare of residents living at the home was met. They are to be commended. The Annual Quality Assurance Assessment (AQAA) confirmed the required health and safety checks have been carried out in the home to ensure the health and safety of residents are promoted and protected. Elliott Residential Care Home DS0000006423.V371397.R02.S.doc Version 5.2 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 Standard No Score 1 3 2 2 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 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 2 33 x 34 2 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 x 1 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 1 x x x 3 2 1 2 x Elliott Residential Care Home DS0000006423.V371397.R02.S.doc Version 5.2 Page 25 Yes 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 YA2 Regulation 14 Requirement Residents must have a full assessment undertaken prior to entering the home. This will ensure residents individual aspirations and needs are met. Each resident must have a written plan in place and be kept under review. This will ensure residents know their assessed and changing needs are reflected in their support plan. Risk assessments are required to be more detailed to enable staff to fully aware of what action to take to lessen risks for residents. This is to protect residents and staff in the home. Timescale for action 26/12/07 has expired. Residents who self medicate must have a risk assessment framework drawn up. This will ensure individuals health and welfare is not compromised. The registered provider must have a record of medicines currently prescribed for residents that self medicate. These should be included on the individuals Medication Administration Record DS0000006423.V371397.R02.S.doc Timescale for action 04/09/08 2. YA6 15 04/09/08 3. YA9 13 04/09/08 4. YA21 13 04/09/08 5. YA21 13 04/09/08 Elliott Residential Care Home Version 5.2 Page 26 6. YA22 22 7. YA24 23 8. YA36 18 9. YA41 17 (MAR) and will protect resident’s health and welfare. To ensure resident’s views are listened to, the complaints procedure should be reviewed. This will ensure procedures are clearer and easy to follow; with contact information for advocacy services; and confirmation that procedures can be made available in alternative formats. To ensure residents live in a comfortable environment a programme of decoration to be undertaken to the internal décor. This is to ensure a well-trained and effective staff team. All staff must have formal supervision and appraisals as part of the staff development in the home. Timescale for action 26/01/08 has expired. Resident’s rights and best interest must be safeguarded. 31/10/08 31/01/09 03/10/08 03/10/08 10. YA41 17 Ensure records in respect of each resident are up to date and in good order as specified under Schedule 3. Resident’s rights and best 31/10/08 interests must be safeguarded. Ensure other records to be kept in the home as specified under Schedule 4 are up to date, and in good order. 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 YA6 Good Practice Recommendations It is recommended that residents and their relatives are DS0000006423.V371397.R02.S.doc Version 5.2 Page 27 Elliott Residential Care Home 2. YA6 3. YA23 4. YA36 5. YA34 encouraged to be involved in the development, and then signing of support plans. The daily recording sheets should be updated to include more detail about the residents changing needs. This information can be included in the residents 6 monthly review, with agreed changes recorded and actioned. Residents will be assured safety and protection where managers are kept up to date with good practice guidance. The Inspector suggested Alerter training via the local adult protection team. To ensure resident’s needs are met by appropriately trained staff. Staff training records should include:- an identified training plan for individual staff, including domestic staff, with statutory training and timescales. To ensure residents are supported and protected. The staff recruitment records should be held together to include all the required information: Two written references obtained before making an appointment. A Protection of Vulnerable Adults (POVA) and Criminal Records Bureau Check (CRB). An application form Elliott Residential Care Home DS0000006423.V371397.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Elliott Residential Care Home DS0000006423.V371397.R02.S.doc Version 5.2 Page 29 Elliott Residential Care Home DS0000006423.V371397.R02.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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