CARE HOMES FOR OLDER PEOPLE
Elm House 43 Cambridge Road Southport Merseyside PR9 9PR Lead Inspector
Mrs Claire Lee Unannounced Inspection 09:00 23 August 2006
rd X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Elm House DS0000017232.V295779.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Elm House DS0000017232.V295779.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Elm House Address 43 Cambridge Road Southport Merseyside PR9 9PR 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) 01704 228688 Mr Peter John Berry Mrs Hilary Jane Berry Mrs Zena Carol Stretch Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Elm House DS0000017232.V295779.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. Service users to include up to 30 OP Maximum number registered to be 30, of which up to a maximum of 30 N (Nursing) and up to a maximum of 7 PC (Personal Care). The service must employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 25th October 2005 Date of last inspection Brief Description of the Service: Elm House is a privately owned care home that provides 30 single places for older people. 23 beds are for nursing care and 7 for personal/residential care. Elm House is situated close to Southport town centre, local amenities and Hesketh Park. The home has 4 floors with a passenger lift to all areas. There is a lounge with a conservatory to the front of the building and this room is also used as a dining room. There is a ramp at the front entrance and staff use a portable ramp to access the steps to the main front door. The home has car parking space and a well maintained enclosed garden at the rear. Baths and a shower are suitably adapted to assist those who are less able and residents are provided with a call system. Elm House is privately owned by Mr Berry and a new manager was appointed this summer, Mrs Zena Carol Stretch. Mrs Stretch is in the process of applying to the Commission for the registered manager’s position. Mr Berry has sought planning permission for an extension to the rear of the building for six single ensuite bedrooms and more recreational space. The overall number of beds at the home will remain unchanged as alterations are planned to the existing single rooms. This work has yet to commence however general maintenance and some decoration of the home is ongoing. The fee rate for accommodation is £448.50 - £510.00 a week. Elm House DS0000017232.V295779.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. An unannounced site visit was conducted as part of the inspection process. The site visit took place over 8 hours with one inspector and 28 residents were accommodated at this time. A number of the home’s care, staff and health and safety records were viewed and a partial tour of the building was undertaken. Discussions took place with 7 residents, 5 staff, the home’s manager and owner. During the inspection 3 residents were case tracked (their care files were examined and their views of the home were obtained). This process was not carried out to the detriment of other residents who also took part in the inspection process. Discussion also took place with a relative who was visiting. All the key standards were inspected and also previous requirements and recommendations from the last inspection in October 2005 were discussed. Satisfaction survey forms “Have Your Say About …” were distributed to a number of residents prior to the inspection and some were also left for relatives to compete at the time of the visit. Comments included in the report are taken from the survey forms and also during the site visit. What the service does well:
Residents and relatives spoke highly of the care they receive and are pleased with the staff whom they found hard working, friendly and polite. A resident said, “It is a nice home to live in and the matron is very good”. Staff were observed interacting well with residents and visitors and a homely atmosphere was evident throughout the home. Prior to admission residents’ health, social and psychological care needs are assessed by the manager and/or a qualified member of staff. The assessment information is then used to form the basis for a plan of care. Care documentation is reviewed regularly by the home to reflect any change in care provision. Reviews seen had been conducted with the resident and/or relative. Medical referrals are made when needed to other health professionals and records are made of any visits made and action taken. Elm House DS0000017232.V295779.R01.S.doc Version 5.2 Page 6 The care records viewed were organised, up to date and sufficient information was recorded to enable the staff to meet the needs of the residents. Any risks that are taken by residents such as moving about the home are clearly recorded and updated in their files. Staff confirmed that they have access to care documentation. Care staff have a handover at the beginning of each shift to provide them with the information they need to care for the residents. A relative said, “The staff tell me everything that is going on and I trust them”. The home was seen to be clean and tidy and maintenance jobs are completed daily. The bathroom on the first floor has been renovated; there is a new bath with a chair hoist with a Jacuzzi. Piped music for relaxation purposes is played when residents use this room. A member of the home’s staff and an activity coordinator provide an entertainment programme, which includes bingo; sing a long, relaxation and cinema showings. This is offered to all residents, staff respect the wishes for some residents who would prefer to stay in their rooms. The standard of meals was found to be good. The home offers nutritious meals and staff were observed asking residents what they would like for lunch. Home baking is offered and the kitchen was well stocked with fresh produce. Staff are offered training in safe working practice areas and over 50 of staff are qualified to a National Vocational Qualification (N.V.Q) Level 2 in care. Courses are also arranged for staff with regard to caring for the older person. What has improved since the last inspection?
Residents have been issued with a contract stating terms and conditions of residency. A number of resident’s financial records were seen and these were maintained to a satisfactory standard. The home’s emergency lighting is checked monthly in house and a record is kept. Elm House DS0000017232.V295779.R01.S.doc Version 5.2 Page 7 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. Elm House DS0000017232.V295779.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Elm House DS0000017232.V295779.R01.S.doc Version 5.2 Page 9 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3 (Intermediate Care – Standard 6 is not provided at Elm House) The quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents are provided with a contract and pre admission assessments help ensure that the home can meet their individual needs. EVIDENCE: Although Standard 1 was not assessed a number of residents stated that they had received the home’s brochure (Service User Guide) which they found helpful. Residents are now issued with a contract stating terms and conditions of residency. Contracts seen included the current fee rate and these details were clearly laid out. This means that residents have the information they need about the service they will receive and how much it will cost them. Residents with private means are informed of the nursing banding (high, medium and low) following a determination of their care needs by the primary care trust. Residents who were case tracked confirmed that they had signed an agreement with the home and contract details were viewed in their files. One
Elm House DS0000017232.V295779.R01.S.doc Version 5.2 Page 10 contract did not include the resident’s room number and this information was added at this time. A resident said, “Elm House is a nice home” Case tracking confirmed good practice. The manager completes a pre admission assessment to ensure the home can meet residents’ health, social and emotional care needs. Assessments seen had been completed in detail with regards to health, personal and social care and this information had been used to form the basis for the plan of care. A resident who has recently arrived from another care home said, “I am really settled. My family helped choose the room and I am very comfortable”. It was noted that some assessment documents did not record religious beliefs. This was brought to the manager’s attention and rectified. A resident receives regular visits from her church, which she was pleased with. The dependency needs of residents are reviewed monthly and assessments completed by social workers, hospital and community were on file. Elm House DS0000017232.V295779.R01.S.doc Version 5.2 Page 11 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 The quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents’ health, personal and social care needs are addressed in care plans and residents were observed to be treated with respect and dignity. Medications practice should be improved to protect the welfare of residents. EVIDENCE: Residents have an individual care file and 3 files were viewed as part of the case tracking process. Residents accommodated at this time all had nursing needs; there were no residents assessed as needing residential (personal) care. The care files are accessible for staff, they are organised and the information is easily read. Care documentation seen had also been reviewed regularly to ensure it was accurate and reflected any change in care or treatment. Care plans record individual care associated with daily living and any condition that may affect the well being of the resident. This was discussed in relation to a resident with a neurological condition who attends the hospital on a regular basis for appointments and physiotherapy. A resident with diabetes had undergone a diabetic review. This was conducted by the home to ensure their condition was being monitored. Residents have their nutritional
Elm House DS0000017232.V295779.R01.S.doc Version 5.2 Page 12 needs monitored and are weighed regularly. Residents interviewed stated that they could see their GP when they want and the home arranges appointments on their behalf. Records indicated that a number of health professionals visit the home and a resident said, “When attending hospital a carer always goes with me”. General risk assessments including manual handling instruction are in place for residents who are at risk of falling or who require assistance with their mobility. Risk assessments for nutrition and care of resident’s skin had also been completed. Through discussion with a number of staff and general observation it was evident that staff have a good knowledge of the residents’ individual needs. This knowledge means that residents can be confident that they will get support from people who understand the care provision required. With regards to personal hygiene residents are help with bathing. A comment received raised a query regarding infrequency of showers or baths for residents. This was passed to the manager’s attention and the resident reassured that this would be addressed. Residents made the following comments regarding the care given by staff. “The staff are very good” “The staff are around to help” “Staff do not rush me, I get a thorough wash” Residents spoken with felt their privacy was respected and that staff were sensitive and kind in their approach. Residents interviewed said that they receive their medications on time and generally the medicine charts evidenced staff signatures following administration. A few gaps were noted for one particular medicine and this was brought to the manager’s attention. Medicine charts seen evidenced the receipt of medication in the home and a record was seen for the disposal of medications. The home must also ensure any changes in medication is re written on the medicine sheet rather than altering the original entry. A resident who was case tracked was being offered support to care for their own medications and had signed a disclaimer for this purpose. The home should however complete a risk assessment to ensure the resident is able to administer their medications safely. A lockable draw for their safe keeping should also be provided in the room. Elm House DS0000017232.V295779.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,and 15 The quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents are able to exercise choice and control over their lives and are offered a choice of wellbalanced and nutritional meals. EVIDENCE: The home had a very pleasant friendly atmosphere and staff were observed chatting with residents in the lounge and on a one to one basis. The home now has a varied social programme, which is organised by a member of staff (who is employed on the care team) and an activities lady who visits twice a week. A cinema showing has been planned for later this month and staff confirmed that bingo is a favourite. Staff take residents out for walks to the park and a resident stated, “Up until recently I was going out most days in a taxi and like to be independent”. The member of staff responsible for activities is ordering cards, balls and games in a larger size to suit the needs of the residents. The hairdresser was visiting at the time of the inspection and the ladies are offered regular manicures. Several residents stated that they were aware of the activities offered by the home but would prefer not to join in. Staff respect this wish.
Elm House DS0000017232.V295779.R01.S.doc Version 5.2 Page 14 Throughout the afternoon visitors were seen popping in meeting their family member in the lounge or their bedroom. A relative said, “The staff never mind when we visit”. The home offers Holy Communion, which enables residents to continue to practice their faith. Menus were varied and nutritionally balanced. The home does not have a dining room and therefore meals are served on individual tables to residents in the lounge or in their own rooms. Residents interviewed confirmed that they were happy with the quality and quantity of the food they received. A resident said, “The food is generally good and served hot”. Staff were observed assisting residents with their lunch in an unhurried manner. Stock cupboards evidenced a good supply of dry goods and there was fresh fruit and vegetables on the menu. Fridge, freezer and hot meal temperatures had been recorded in line with environmental health requirements and the cleaning schedule was up to date. Elm House DS0000017232.V295779.R01.S.doc Version 5.2 Page 15 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents and relatives have confidence that their concerns will be dealt with. Abuse policies and procedures are in place to protect the residents. EVIDENCE: The home has a complaint procedure, a copy of which is displayed in the main entrance hall. Residents interviewed were aware of who to speak to if they had a concern and expressed the view that the manager would sort things out quickly. During the last 12 months the manager has investigated 9 complaints and the complaint log evidenced any action taken. A member of staff interviewed was aware of the complaint procedure, a copy of which is provided during induction for new staff. The home has policies and procedures to protect the residents and staff have received training in abuse awareness. Sefton’s Adult Protection Policy is also kept at the home. Staff interviewed were able to discuss the concept of abuse and were aware of the Whist blowing Policy. Recruitment practices are discussed under the section, Staffing. Elm House DS0000017232.V295779.R01.S.doc Version 5.2 Page 16 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,22,23,24,25 and 26 The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Some improvements have been made regarding the decor and replacement of furnishing and fittings to provide residents with comfortable surroundings. EVIDENCE: Elm House is large detached property set in its own grounds. Mr Berry has sought planning permission for an extension to the rear of the building for six single ensuite bedrooms and more recreational space. The overall number of beds at the home will remain unchanged as alterations are planned to the existing single rooms. This work has yet to commence however the home are hoping to start the work within the next few months. Residents and relatives will be advised of the start date. A number of bedrooms have been decorated and furnished to a good standard however there are still areas, which need
Elm House DS0000017232.V295779.R01.S.doc Version 5.2 Page 17 attention and therefore this work must continue. The existing laundry room is too small and does not provide segregation of foul and clean linen. A new laundry room is planned. The home is looking to provide a relaxation room for residents and staff. The home was generally clean and residents stated their satisfaction of the overall cleanliness of the building. One resident did however comment, “Sickness and holidays and staff shortages have a bearing on this”. Bathrooms were hygienic and there were no unpleasant odours. Hot water temperatures are recorded prior to staff bathing residents to ensure the water is delivered to a safe temperature. Records seen were satisfactory. The rooms of residents whose care was case tracked had their own personal possessions and they were satisfactorily clean and well presented. A resident spoken with stated that she was pleased with the standard of furniture provided. A number of bedrooms seen had also been decorated with matching bed linen. A resident said, “My room is very pleasant”. Staff stated that the home had a good standard of equipment including sufficient hoists to assist residents who are less independent. The bathroom on the top floor has a walk in shower and the bathroom on the first floor has been fitted with piped music, a Jacuzzi bath, bath hoist and raised toilet. The bathroom in the basement is still not in use and is being used for storage space. Equipment needed by residents is stated in their plan of care and manual handling assessment. A member of staff who is also employed as a domestic carries out routine maintenance. Day to day jobs are recorded in the diary and the manager completes a check of the building to ensure all areas are safe for the residents. Emergency lighting is provided throughout the home and subject to a monthly in house safety checked and an annual maintenance contract. Records seen were in date. Elm House DS0000017232.V295779.R01.S.doc Version 5.2 Page 18 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28,29 and 30 The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. There are sufficient numbers of appropriately trained and experienced of staff care for the residents however recruitment practices are not robust to protect their welfare. EVIDENCE: The staffing rota for the month of August 2006 was seen. A registered nurse is on duty 24 hours a day and generally 6 carers are employed in the mornings and 5 in the afternoons. The home were down on care numbers during the afternoon of the site visit however staff confirmed that where possible the manager covers any outstanding shifts. The home does not have bank staff but is currently employing new care staff. At night there is a registered nurse with 2 care staff. Staff have a key worker role (a number of residents are assigned to them) and they are supported by more experienced senior carer. A resident said, ““The nursing has improved me no end and I am pleased with everything”. Registered nurses employed have a current registration with the NMC (Nursing Midwifery Council) to enable them to practice. The home’s recruitment practice remains a serious concern. It is still not robust to protect the welfare of the residents. The staff files of 3 new staff were seen and 2 employees had commenced employment prior to a POVA
Elm House DS0000017232.V295779.R01.S.doc Version 5.2 Page 19 check or CRB being received. One staff file only evidenced this information. This was raised as a requirement at the last inspection in October 2005 and this continues to put residents at risk. Recruitment practise must be robust to protect the residents. All new staff had completed a job application form and 2 references had been obtained prior to their employment. Staff are given contracts and receive an induction within the first few weeks. The manager is looking to make changes to the induction programme which she feels will be beneficial. Staff interviewed stated that when starting they had been shown round the home and also worked with a member of staff until they were familiar with the residents and the general routine. The home offers staff a training programme in safe practice areas including, manual handling, fire prevention and health and safety. Dates of these courses were evident in the staff files viewed. Planned training includes, first aid and food hygiene, which is required for a number of staff. The majority of staff handle and serve food. Other courses include abuse awareness, diabetes, care of the dying and motor neurone disease. Over 50 of staff have attained a National Vocational Qualification (N.V.Q) Level 2 in care and NVQ Level 3 is also being accessed. A member of staff said, “The matron is good at arranging courses and sorting out funding issues”. Residents interviewed generally praised the staff saying they give good care. A few residents commented that staffing numbers could fluctuate however the staff work hard and are quick to respond for calls for assistance. A relative said, “The staff are kind and thoughtful”. Elm House DS0000017232.V295779.R01.S.doc Version 5.2 Page 20 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,37 and 38 The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Residents have confidence in the overall management of the home however up to date service contacts maintained to promote and health and safety of the residents. EVIDENCE: Residents spoken with were aware of the role of the manager and were pleased with the day to day management of the home. A resident said, “The home is fine”. Mrs Stretch is the manager and she has many years experience caring for older people. Staff interviewed appreciated Mrs Stretch’s management style and stated that working conditions were good. Relaxation sessions are arranged on a Friday for the staff. Staff supervision was not assessed however a staff member said that they meet with the manager regularly to discuss the home and training needs. Elm House DS0000017232.V295779.R01.S.doc Version 5.2 Page 21 The home has quality assurance systems in place, which enable residents and relatives to give their views of the service and how it can be improved. Residents receive questionnaires to complete and care reviews are conducted with them and their relatives. None were seen at the time of the site visit and it is recommended that they be sent out over the next few months. As previously stated, Have Your Say forms from the Commission were sent out, 4 were returned and these refer to residents being satisfied with the overall service. The manager conducts regular audits of the premises and also reviews the home’s policies and procedures to ensure they comply with current legislation. A review of the recruitment policy would be beneficial to improve recruitment practices. The owner is present at the home each day however also completes a quality audit by inspecting the premises and talking with residents, staff and relatives. A copy of his report is then forwarded to the Commission. With regards to residents’ finances, 2 financial records were seen and they were up to date and evidenced expenditures for hairdressing and chiropody. The home is not responsible for any personal allowances. Residents and/or their families are billed for individual items as required. Information held at the home is generally kept up to date and in good order. Care staff and registered nurses complete a daily written entry regarding the care they provide however it was noted that on several occasions this had not been completed. This may well have been an oversight however, record keeping is an essential part of a nurses’ role to protect the welfare and provide continuity of care residents. Registered nurses should maintain accurate records for this purpose. Details were provided from the pre inspection questionnaire regading maintenance contracts for equipment and services to the home. The contracts for the gas, portable appliane testing and lift were inspected and these were in date. The hard wiring electrical certificate was dated 2005, a more recent one could not be located and this puts residents at risk. Arrangements were made to have this serviced as soon as possible. A copy of the ceftificate is to be forwarded to the Commission. The fire log book evidenced fire prevention equipment is checked annually by the home’s contractor and fire alarms are also tested weekly by the manager. The home has a fire risk assesment of the premises and fire training was last given to staff on 4th May 2006. The accident book records any untoward incidents that affect the well being of the resients, this was assessed in relation to residents who were case tracked. The manager is aware of equality and diversity when recruiting staff and is looking to introduce policies and procedures regarding this within the care setting. Elm House DS0000017232.V295779.R01.S.doc Version 5.2 Page 22 Elm House DS0000017232.V295779.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 x 3 2 Elm House DS0000017232.V295779.R01.S.doc Version 5.2 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 OP19 Regulation 23 Requirement The registered provider must decorate all areas of the home affected by general wear and tear and replace furniture and fittings where needed. A new laundry room is required. This remains an outstanding requirement from the last inspection, October 2005. All staff must have a POVA check and CRB disclosure prior to commencing employment at the home. This remains an outstanding requirement from the last inspection, October 2005. The home must have an in date hard wiring electrical certificate for the home and forward a copy to the Commission. Timescale for action 17/10/06 2. OP29 19 17/09/06 3. OP38 13/23 17/09/06 Elm House DS0000017232.V295779.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP9 Good Practice Recommendations The home should complete a risk assessment for those residents who wish to give their own medications and provide a lockable draw for their safe storage. Any change in prescribed medicines should be re written on the medicine sheet. The home should sent out questionnaires to residents and relatives to obtain their views of the service. Registered nurses should complete a daily written entry in the care files regarding the care given. The home should conduct a review of the recruitment policy. 2. 3. 4. OP33 OP37 OP38 Elm House DS0000017232.V295779.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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