Inspection on 06/07/04 for Elm Lea Residential Care Home

Care Home For Older PeopleElm Lea Residential Care Home17 Bartholomew Lane Saltwood Hythe Kent CT21 4BXAnnounced Inspection6th and 7th July 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Elm Lea Residential Care Home Address 17 Bartholomew Lane, Saltwood, Hythe, Kent, CT21 4BX Email address reuka15@hotmail.co Name of registered Provider(s)/company (if applicable) Mrs Renuka Oojageer Mr Mookesh Oojageer Name of registered Manager (if applicable) Type of registration Care Home No. of places registered (if applicable) 15 Tel No: 01303 269891 Fax No:Category(ies) of registration, with (number of places) Old age, not falling within any other category (15) Registration number H050000799 Date first registered 31st December 2003 Was the Home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 8th January 2004 YES NO 04/05/07 If Yes refer to Part CElm Lea Residential Care HomePage 1 Date of inspection visit Time of inspection visit Name of Inspector Name of Inspector Name of Inspector 1 2 36th July 2004 09:30 am Julian Graham Lisbeth Scoones ­ 7th July 2004ID Code096699Name of Inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionMr and Mrs OojageerElm Lea Residential Care HomePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementElm Lea Residential Care HomePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Elm Lea Residential Care Home. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service Provider must comply. Service Providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the Provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Elm Lea Residential Care HomePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Elm Lea is registered to provide accommodation and personal care for fourteen Older People. Ownership of the Home was transferred to Mr and Mrs Oojageer on 18th December 2003. The Registered Manager, Mrs Christina Ashton, has resigned her position as Manager. CSCI are in discussion with the owners regarding the possibility of Mrs Oojageer acting as the Manager. Elm Lea occupies detached premises with fourteen single bedrooms, all of which have ensuite facilities. Accommodation is on the ground and first floor and the Home has a shaft lift. There is a well maintained garden for Service Users use. There are two assisted baths, one on each floor. The Service Users have a choice of sitting areas, with the main lounge/dining room, a conservatory and a small quiet room for their use. The Home is located on the outskirts of a small sized town, with good access to shops, public transport and other public amenities, some of which are within walking distance.Elm Lea Residential Care HomePage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the Inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This inspection was Announced and took place on 6th and 7th July 2004. The Inspector spoke with most of the Residents on this visit, who described the staff as being very kind and helpful. One said that you just have to ask for anything you need and they will get it for you. Another said you couldnt wish for better people. The Inspector observed staff as they were going about their duties and noted a kindly, and patient approach. Residents said that the routines in the Home are very flexible, and the Inspector saw that some Residents prefer to spend a lot of time in the privacy of their rooms and are being enabled to do so. Comments regarding the food were generally very good. Three Residents said they would like the opportunity to go out from time to time and this matter was raised with the Manager. Four staff working in the Home, including the cook, were spoken with individually by the Inspector, and all presented very well. The care staff demonstrated good understanding of the core principles of care, such as promoting privacy and dignity. All confirmed that the registered persons promote, encourage and make available opportunities to attend training. Staff meetings are held from time to time, and the process of staff supervision is underway. The Inspector also spent time with the registered persons, who only took over ownership of Elm Lea around six months ago. It is evident that they are working very hard to address some shortfalls and raise standards. Problems regarding some staffing arrangements and standards of cleanliness are being addressed. The Home was very clean at the time of inspection and adequate staffing levels are being maintained. Indeed, all staff said they find there is plenty of time in the afternoons to spend chatting with Residents or engaging them in leisure and social activities. It was good to hear staff say that this aspect of their work is important to them. The registered persons are also working hard to upgrade the premises and much has been done since the last announced inspection. Risks in relation to hot radiators must be assessed, and radiators protected as appropriate. All staff have either completed or are currently undertaking NVQ training, which is creditable. Enabling staff to receive training to increase their level of skill and understanding is of benefit to the care and quality of life of Residents. The Homes recruitment process remains below standard, and must be improved. The Inspector would like to thank the Residents, registered persons and staff for their assistance, co-operation and hospitality during this inspection.Elm Lea Residential Care HomePage 6 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for action 1 4 OP3 The Needs Assessment format to be reviewed and expanded to include all the areas listed in the Standard. Thorough recruitment procedures to be operated with regards all staff working in the Home. With regards to medication: The Home has comprehensive policies and procedures for all aspects of medicine and management 31/03/04219OP2914/02/04313 (2)OP915/04/04413OP38Risk assessments regarding hot surface temperatures of radiators to be undertaken and for radiators to be suitably protected as required. Note: The risk assessment was not examined on this occasion.Elm Lea Residential Care HomePage 7 Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard 1 OP9 The Home has a metal cupboard complying with the Misuse of Drugs (Safe Custody) Regulations 1973 and a register for record keeping.CONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Met (Yes / No) NAElm Lea Residential Care HomePage 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action 1 4 OP3 The Needs Assessment format to be reviewed and expanded to include all the areas listed in the Standard. Assessment to record Residents interests. Thorough recruitment procedures to be operated with regards all staff working in the Home; Staffing records in line with the requirements of Schedule 2 to be maintained. 07/08/0427,9,19, OP29 Schedule 207/07/08Elm Lea Residential Care HomePage 9 With regards to medication: 1)The Home to have comprehensive policies and procedures for all aspects of medicine and management. 2) Risk assessments regarding Residents self administering medicines to be more detailed, and include monitoring arrangements. 3 13 (2) OP9 3) Records to be maintained regarding medication reviews, and dates recorded when 21/08/04 these are requested. 4) Criteria for administering as required medication to be detailed. 5) Handwritten details on MAR charts to be checked and signed by two staff. 6) Managers assessments of staff competence in administering medication to be recorded.413OP38Risk assessments regarding hot surface temperatures of radiators to be undertaken and for radiators to be suitably protected as required.07/09/04515OP7Care plans to be reviewed and updated to ensure they reflect all aspects of the Residents health, personal and social care needs. All contacts with healthcare professionals to be recorded. The Statement of Purpose and Service Users Guide to be amended to accurately reflect the situation at Elm Lea; and to include all matters listed in Schedule 2. All complaints, including minor complaints, to be recorded. Hazardous substances to be stored safely; COSHH assessments to be in place; fire doors which are not operated electromagnetically, to be kept shut.07/09/0465OP107/08/04722OP1607/07/04813OP3807/07/04Elm Lea Residential Care HomePage 10 917(2), Schedule 4.7OP27Staff rotas to show which staff are on duty at any time during the day or night and in what capacity.07/07/04RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * 1 2 3 4 5 6 OP24 OP19 OP15 OP10 OP8 OP12 OP7 Call bell leads to be of sufficient length. The security of the premises to be reviewed in order to prevent unauthorised access. Residents to be informed of the main meal of the day. Agreement to use intercom in a Residents bedroom to be recorded. Protocol to be devised regarding tasks to be undertaken by District Nurses. Opportunities to be given to Residents to go out for walks and for outings. Written guidelines for the role of the keyworker to be developed.* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.Elm Lea Residential Care HomePage 11 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with Service Users Individual discussion with Service Users Group discussion with staff Individual discussion with staff Discussion with management Service User survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of Service Users spoken to at time of inspection Number of relatives/significant others the Inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the Manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding Managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES YES YES YES YES NO NO YES NO YES NO YES YES YES YES NO YES NO NO 9 2 0 NO NO YES NO 10 0 06/07/04 09.30 10Elm Lea Residential Care HomePage 12 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care Homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Elm Lea Residential Care HomePage 13 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to Service Users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the Home; and provides a Service Users guide to the Home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a Home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the Homes Service Users guide. Range of fees charged From (£) 287 To (£) 350Any charges for extrasYESIf yes, please state what the extras are: 2 Key findings/Evidence Standard met? The registered persons have prepared a new Statement of Purpose. This document needs to be checked against Schedule 2 of the Regulations to ensure all matters are covered, for example, criteria for admission, range of needs and room sizes. A Service Users Guide has also been prepared, and together with the Statement of Purpose, Complaints Procedure, the result of a Service Users survey and the summaries of recent inspection reports, form a pack to provided to all new Residents. It was good to see this pack on a table in the hall. The registered persons said they will shortly be going through all these documents with a Resident, who at the time of inspection, was on her second day at the Home since admission.Elm Lea Residential Care HomePage 14 Standard 2 (2.1 ­ 2.2) Each Service User is provided with a statement of terms and conditions at the point of moving into the Home (or contract if purchasing their care privately). 3 Key findings/Evidence Standard met? The registered persons have revised and amended the Homes statement of terms and conditions, and confirmed that all Residents have been issued with one. The statement includes the overall care and service to be provided, room number, terms and conditions of occupancy and so on. As fees vary, the registered person said space would be inserted in the appropriate paragraph to record the fee payable. The registered person said additional services not covered by the fees are detailed in the Service Users Guide. Standard 3 (3.1 ­ 3.5) New Service Users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective Service User, his/her representatives (if any) and relevant professionals have been party. 2 Key findings/Evidence Standard met? The Inspector viewed the recorded Needs Assessment in respect of a Resident admitted to the Home on the day before this inspection. The form does not cover all the areas listed in the Standard as required from the last inspection. For example, there is no record of this persons history of falls. The Manager said that the information was recorded over the telephone from a Care Manager. The Manager agreed to visit prospective Residents in their own home or in hospital wherever possible, in order to carry out a thorough assessment. It was very good to see that part of the Homes assessment includes a section entitled Summary of Background information, which covers matters such as special memories and would like to..... A brief care plan has been drafted for this new Resident, which the Manager said would be built upon as needs become better known. Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the Homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the Home. 3 Key findings/Evidence Standard met? The Manager said that arrangements are made for Residents to receive any specialist services they may need. All contacts with healthcare professionals must be recorded. See Standard 8. All staff have either completed or are in process of undertaking NVQ training to enable them to have the skills and knowledge to provide the care to meet Residents needs.Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective Service Users are invited to visit the Home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 3 Key findings/Evidence Standard met? The Manager said that prospective Residents are offered the opportunity to visit the Home prior to moving in, so they can meet some of the staff and Residents. The Resident most recently admitted to the Home, for example, came for tea. The Manager said that prospective Residents could stay overnight or for a more extended stay if they wished. Emergency admissions are not made, the Inspector was told.Elm Lea Residential Care HomePage 15 Standard 6 (6.1 - 6.5) Where Service Users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable Service Users to return Home. 9 Key findings/Evidence Standard met? Intermediate care is not provided.Elm Lea Residential Care HomePage 16 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The Service Users health, personal and social care needs are set out in an individual plan of care. Service Users make decisions about their lives with assistance as needed. Service Users, where appropriate, are responsible for their own medication, and are protected by the Homes 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.Standard 7 (7.1 ­ 7.6) A Service User plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each Service User and provides the basis for the care to be delivered. 2 Key findings/Evidence Standard met? A sample of care plans was viewed on this occasion, and there was evidence that they are being reviewed on a monthly basis. Risk assessments are also in place, and these too are reviewed regularly. The Manager has prepared a new Resident case file system, in which assessments, care plans, and other important information can be easily located and accessed. The Inspector saw that some of the Residents care needs are being recorded in the care plans, and these in the main are well written and give instruction to staff as to how these needs are to be met. It was good, for example, to see in one Residents care plan, reference to the need for staff to enable the Resident to choose what clothes she puts on in the mornings. Some needs, however, are not being reflected in the care plans. For example, one Resident needs assistance with toileting, and there was no reference to any continence programme in place. Social and leisure needs, could also feature more prominently in the care plans. The use of terminology was also discussed with the Manager.Elm Lea Residential Care HomePage 17 Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains Service Users health and ensures access to health care services to meet assessed needs. No. of incidents where Service Users have been taken to Accident and Emergency during last 12 months No. of Service Users with pressure sores at time of inspection (from information taken from care notes) 1 03 Key findings/Evidence Standard met? There was evidence to show that the Home is promoting and maintaining Residents health. The Inspectors were told, for example, that a District Nurse is visiting a Resident with leg ulcers twice a week. There needs to be a record of any agreements for nursing tasks delegated by the District Nurse for staff to do. A written protocol regarding delegated tasks is a recommendation of this report. The Manager said there is contact with specialist healthcare professionals as appropriate, and which include the continence advisor and diabetic nurse. Equipment for the promotion of tissue viability is available, and includes sheepskins, propad mattresses and cushions and recliner chairs. The continence nurse is coming to the Home next week to train staff in the use of continence aids. The optician is visiting the week after this inspection, the Inspector was told. Nutritional assessments were seen in the kitchen. The Inspector saw in one care plan that the oral hygiene needs of the person were identified. Not all contacts with healthcare professionals are being recorded, and this was discussed with the Manager. Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and Service Users are able to take responsibility for their own medication if they wish, within a risk management framework. 2 Key findings/Evidence Standard Met? The Home has made a number of improvements in this area as required from the last inspection, and this is commended. Storage has improved and a fridge has been purchased. The registered persons confirmed that the office in which the fridge is kept is locked when not in use. Records are being made of medicines received and administered. The pharmacy has the Homes record of medication returned, and this matter was discussed. Medicines for internal use are kept separate from medicines for external use. A list of specimen signatures is in place. There was no apparent overstocking. The medication policy and procedures remain in need of expansion as required from the last inspection. On this visit, further requirements are made, which are detailed in the Statutory Requirements section of this report.Elm Lea Residential Care HomePage 18 Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that Service Users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 3 Key findings/Evidence Standard met? Staff fairly new to the Home said that the core principles of care, including the promotion of privacy and dignity, are covered in Induction Training. Residents spoken with said that their dignity is respected when staff assist them with any personal care. The registered persons expressed their confidence that staff treat Residents with respect and that rights to privacy are upheld. A portable phone is available for Residents to make calls in private. Some have phones in their rooms, and telephone points are available in all rooms. The Inspector saw that Residents preferred term of address is noted in care plans. All the Residents were looking nicely dressed and well presented. Standard 11 (11.1 ­ 11.12). Care and comfort are given to Service Users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 3 Key findings/Evidence Standard met? The Inspector visited the Home a short while ago, at a time when a Resident was dying. A friend of this person was able to visit regularly, and along with the Deputy Manager was with the Resident when she died. The Manager said that the Resident was made comfortable, with regular turning, fluids and oral care, and was in no pain. The District Nurses visited each day. Policies and procedures on death and dying are in place and were reviewed recently. The Manager said that she tries to find out Residents wishes regarding arrangements after death on admission, although the difficulties at times in obtaining this information were recognised.Elm Lea Residential Care HomePage 19 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit Service Users expectations, preferences and capacities. 3 Key findings/Evidence Standard met? Residents were asked by the Inspector whether the routines in the Home are flexible, and he was assured that they are. He was told that there are no restrictions, for example, regarding the times of rising and retiring. The registered persons and staff confirmed this. One Resident, for example, prefers to lie in in the mornings, and comes downstairs at around midday. It was very good to hear staff say that engaging Residents in conversation and activities is an important part of their job, and it was apparent that staff are trying to enable Residents to have a more interesting day. Staff confirmed that there is plenty of time for them to engage Residents in activities in the afternoons. Two or three of the comment cards, however, and received prior to the inspection, referred to there not being enough activities. Records are being made of activities provided, which include musical exercises (and Karaoke), beauty workshops, war memories and singing, and so on. Bingo has been tried, but did not prove popular. Three Residents told the Inspector that they would like to go out more, and this was brought to the attention of the registered persons. Two Residents who spend most of the day in their rooms, said they see little of staff during the day. Staff said that they do go up and chat with these Residents. It is advised that this matter is reflected in the Residents care plans, and monitored by their keyworkers. There is a church service held in the Home every month. Standard 13 (13.1 ­ 13.6) Service Users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with Service Users preferences. 3 Key findings/Evidence Standard met? The Inspector spoke with some relatives during the course of the inspection, who confirmed they are made welcome when they visit. Residents confirmed that this was the case, too, and said they can receive their visitors in private if they want to. There is not much in the way of involvement in the Home by local community groups at present. The registered persons said that they are looking into the possibility of volunteers, and are aware that they would need to undergo the same checks as staff.Elm Lea Residential Care HomePage 20 Standard 14 (14.1 ­ 14.5) The registered person conducts the Home so as to maximise Service Users capacity to exercise personal autonomy and choice. 3 Key findings/Evidence Standard met? Residents said they are able to make a range of choices in their lives, including times of rising and retiring, whether they want to spend time in their rooms, what clothes to wear and so on. One Resident said she would like to return to the routine of having a bath on a certain day of the week. The Inspector discussed this with the Manager, who said the Residents choice on this matter is now being respected. No Resident is currently handling their own financial affairs, as relatives do this, the Inspector was told. Where it was appropriate for Residents to receive advocacy services, the registered person said he would contact Age Concern for advice. It is advised that information regarding local advocacy services is obtained, to enable access to these services should it become necessary. Standard 15 (15.1 ­ 15.9) The registered person ensures that Service Users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? Comments received from Residents were generally very positive regarding the food provided. The Home operates a four-week menu, and the menu for the day is displayed in the dining room. Not all Residents get to see it, however, and several told the Inspector that they would like staff to let them know what the main meal of the day is. The Manager agreed to arrange this. The Inspector was told that alternatives can be provided if required, and records are made when this occurs. The cook said that fresh vegetables are provided each day, and that all meals are home cooked. There was a choice of three juices at lunch time, and in addition to the regular teas and coffees throughout the day, fluids were seen in the lounge and bedrooms. The Inspector shared the main meal of the day with the Residents , which was meatballs in tomato sauce followed by bread and butter pudding. The meal was unhurried, with staff being attentive to Residents needs. Residents were asked whether they would like any more. Bowls of fresh fruit were seen, and the cook said that this is always available for Residents. The cook has completed NVQ Level 2 in catering, and is commencing Level 3.Elm Lea Residential Care HomePage 21 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the Home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 2 X X X X 2 100 2 Key findings/Evidence Standard met? A Resident told the Inspector that she had a made a complaint to the registered person. Whilst this is being dealt with appropriately, it has not been recorded. It is a requirement of this report that all complaints, including minor complaints, are recorded. Records must include the nature of the complaint, any action taken and the outcome. The Homes Complaints Procedure forms part of the admission pack and is also displayed in the Home. The Procedure will need to state that complaints can be referred to CSCI at any stage.Elm Lea Residential Care HomePage 22 Standard 17 (17.1 ­ 17.3) Service Users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 0 Key findings/Evidence Standard met? Not inspected.Standard 18 (18.1 ­ 18.6) The registered person ensures that Service Users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The Home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists YES 03 Key findings/Evidence Standard met? Staff who were interviewed were very clear that all allegations or suspicions of abuse must be reported to Social Services and CSCI. There is a clear policy and procedure on abuse which includes whistle blowing. Policies on physical and verbal aggression were not examined on this occasion; nor was the Homes policies and practices regarding handling Residents monies.Elm Lea Residential Care HomePage 23 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the Home is suitable for its stated purpose; it is accessible, safe and well maintained; meets Service Users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? The Inspector remains satisfied that the layout and location of the Home is suitable for its stated purpose. Since the last inspection, many parts of the Home have been upgraded, and this is commended. These include the lounge and dining room, and hallway. Covers have been fitted to some of the radiators in communal areas. Much work has also been carried out in the garden area too, and the registered persons said that they are hoping that this work will be finished before the end of the summer. Owing to problems with a computer, the registered persons were not able to show the Inspector the upgrading programme. An Environmental Health Officer visited in September 2003, and reported that the premises met statutory requirements. Standard 20. (20.1 ­ 20.7) In all newly built Homes and first time registrations the Home provides sitting, recreational and dining space (referred to collectively as communal space) apart from Service Users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each Service User. 3 Key findings/Evidence Standard met? The Home appears to have sufficient sitting and dining room space, with a choice of sitting areas from which to choose, including the main L-shaped lounge/dining room, a smaller quiet room and conservatory. The conservatory is a room in which people wishing to smoke can do so. Outdoor space is available. See Standard 19 with regards the garden.Elm Lea Residential Care HomePage 24 Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of Service Users. 3 Key findings/Evidence Standard met? There is just one toilet downstairs. On a previous inspection the Inspector was told that all bedrooms have ensuite facilities and that the separate staff toilet can be used by Residents in necessary, by that there has never been the need to do so. There is an assisted bathroom on both floors, which meets the Standard.Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of Service Users. 0 Key findings/Evidence Standard met? Not inspected in detail on this occasion; and it was not confirmed whether an assessment of the premises has been undertaken. Residents are able to access all parts of the Home and a shaft lift is available. Grab rails are in toilets, bathrooms and corridors. A call bell system is in place. A call bell in one room has recently been repaired, but still requires boxing in. The registered persons need to ensure that call bell leads are long enough to enable Residents to access them when sitting in their chairs. The registered person said an extension has been ordered.Elm Lea Residential Care HomePage 25 Standard 23 (23.1 ­ 23.11) The Home provides accommodation for each Service User which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing Homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite YES NO NO 14 14 0 0 10 4X X 0 03 Key findings/Evidence Standard met? The relaxing of the individual room space standards has allowed the Home to meet this Standard.Elm Lea Residential Care HomePage 26 Standard 24 (24.1 ­ 24.8) The Home provides private accommodation for each Service User which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the Service User. 3 Key findings/Evidence Standard met? Not inspected in detail on this occasion.Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of Service Users accommodation meet the relevant environmental health and safety requirements and the needs of individual Service Users. 0 Key findings/Evidence Standard met? Not inspected in detail. The risk assessment regarding hot radiators was not examined, although it was noted that some radiators were very hot to the touch and not protected.Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 3 Key findings/Evidence Standard met? Recent complaints regarding the cleanliness of the premises appear to have been addressed. No offensive odours were noted. The Inspector checked bathrooms and toilets, communal parts of the Home for cleanliness, and also some bedrooms, and these were clean and hygienic. See Standard 27 regarding domestic arrangements now in place. The laundry was clean and has an impermeable floor finish. Liquid soap and paper towels were in place. To minimise the risk of cross infection, it is advised that paper towels are provided in staff toilets. It was noted in a previous inspection that the washing machine has a sluicing facility. Separate washing baskets were seen in the laundry for individual Residents.Elm Lea Residential Care HomePage 27 StaffingThe intended outcomes for the following set of standards are: · · · · 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 Homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the Service Users, the size, the layout and purpose of the Home, at all times. Number of staff /hours in respect of Service User needs based on guidance recommended by Department of Health. Personal Nursing Care No. Service Users High No. staff hours 0 X X needs allocated No. Service Users Medium needs No. Service Users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff 2 10 227 No. staff hours allocated No. staff hours allocated No. of staff hours provided X X 232 X X X0 10 12 Key findings/Evidence Standard met? Information provided to the Inspector is that in addition to the person in charge and the cook, there are two care staff on duty during weekdays. One of the care staff undertakes domestic duties for three hours during the mornings. The recorded staff rota, however, is unsatisfactory, however, in that it does not provide details of who undertakes the domestic duties (and also the cooking in the absence of the cook) and when. It is a requirement of this report that this issue is properly addressed. The registered persons also agreed to record all the times they are in the Home. Now that additional hours have been provided for domestic duties, these staffing numbers appear sufficient, given the dependency levels as detailed by the Manager of Residents currently living in the Home. Elm Lea Residential Care Home Page 28 Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered Manager and/or care Manager, and in care Homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 3 33 2 Key findings/Evidence Standard met? The Home is well on the way to meeting this Standard by 2005, and is to be commended for its approach towards enabling staff to qualify. The Deputy Manager has NVQ Level 3 and a senior staff member has NVQ Level 2 and is to start Level 3. Other staff members are either studying for Level 2 or due to commence the training in September 2004.Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of Service Users. 1 Key findings/Evidence Standard met? Thorough and robust recruitment procedures are not being followed in the Home. Two staff files were examined by the Inspectors, and a number of shortfalls were noted. There were significant gaps in the application forms, indicating a need for much more thorough checking. A health declaration form was not completed, and two written references are not consistently being taken. The confidentiality form was not signed. There were no copies of the interview form, confirming an interview was held and the outcome; and no copy of the persons Job Description. Documents required by Schedule 2 of the Regulations, such as a photo, copies of birth certificate and passport, were not in place. It is strongly recommended that a recruitment checklist is devised to enable the Home to ensure that all matters relating to recruitment are addressed and in place. The policy on recruitment is in need of reviewing. This should include the dates references and CRB checks are applied for and returned. The policy on recruitment is in need of reviewing. It is advised that all staff receive a copy of the GSCC Code of Conduct. The Manager confirmed that staff do not work unsupervised until all checks are returned and are satisfactory.Elm Lea Residential Care HomePage 29 Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the Home and meet the changing needs of Service Users. 3 Key findings/Evidence Standard met? As referred to elsewhere in this report, a positive approach towards training is being pursued. A training matrix and staff training and development programme are being produced, and individual staff training files introduced. The programme includes statutory training. Training needs are being identified in staff supervision, the Inspector was told. Records in support of this were not seen. Staff undergoing induction training are currently holding their induction record. A blank one was viewed and looked comprehensive. It is advised that the Home checks with TOPSS whether it meets the standard.Elm Lea Residential Care HomePage 30 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 Homes record keeping policies and procedures. The health, safety and welfare of Service Users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered Manager is qualified, competent and experienced to run the Home and meet its stated purpose, aims and objectives. 2 Key findings/Evidence Standard met? One of the registered persons, Mrs Oojageer, is applying to the Commission to be the registered Manager. Mrs Oojageer is a qualified nurse, who has a number of years experience working with older people in a hospital setting. She says she undertakes regular training to update her knowledge and skills. She is planning to undertake NVQ Level 3 (RMA) or NVQ Level 5 (Executive Diploma in Management). The policy on recruitment is in need of reviewing. Standard 32 (32.1 ­ 32.7) The registered Manager ensures that the management approach of the Home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? A friendly atmosphere was noted in the Home. Staff spoken with said that staff meetings are held and that they can raise issues. Providing staff with copies of the General Social Care Council Code of Conduct was discussed with the Manager.Elm Lea Residential Care HomePage 31 Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of Service Users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the Home. 0 Key findings/Evidence Standard met? Not inspected in detail on this occasion. However it is noted that a Service Users survey has been undertaken and available in the admission pack. An Action Plan has been prepared in response to the survey, but was not discussed in detail. The registered person said a development plan has been prepared. Unfortunately this could not be viewed owing to a problem with the Homes computer. Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 0 Key findings/Evidence Standard met? Not inspected.Standard 35 (35.1 ­ 35.6) The registered Manager ensures that Service Users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the Service User. Number of Service Users subject to Power of Attorney processes Number of Service Users subject to Enduring Power of Attorney processes Number of Service Users subject to Guardianship Orders Key findings/Evidence Not inspected. Standard met? 0 5 X XElm Lea Residential Care HomePage 32 Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the Home and its induction, training and supervision arrangements are put into practice. 0 Key findings/Evidence Standard met? Not inspected in detail. However, it is noted that the staff supervision programme has commenced with senior staff taking on some responsibility for supervising junior staff. Supervision records were not viewed on this occasion. It is advised that guidelines are prepared to detail the purpose of supervision and what it should cover. Training for supervisors will also need to be considered. Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of Service Users and for the effective and efficient running of the business are maintained, up to date and accurate. 2 Key findings/Evidence Standard met? Records seen were generally in reasonable order, although this Standard was not examined in detail. As referred to elsewhere in this report, records relating to Schedule 2 of the Regulations are not fully in place. The Manager is also referred to Schedules 1, 3 and 4 regarding records needing to be kept in the Home. The Manager said that Residents are informed of the rights of access to their records, although there was no evidence in support of this. Residents case files are kept in the office, and the Manager said that this room is to be kept locked when not in use.Standard 38 (38.1 ­ 38.9) The registered Manager ensures so far as is reasonably practicable the health, safety and welfare of Service Users and staff. 2 Key findings/Evidence Standard met? The Home is in the process of developing a staff training matrix, which will indicate gaps in mandatory training, such as moving and handling, and infection control. Staff said they have recently undertaken fire training. Records relating to fire were not examined on this occasion. The Manager said she gives training to staff on Basic Life Support. The Inspector did not view Environmental risk assessments, but noted some radiators were very hot to the touch and were not protected. COSHH assessments are required for all hazardous substances in use in the Home, which also need to be kept securely.Elm Lea Residential Care HomePage 33 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Regulation Manager DateJulian Graham Suzie BurdenSignature Signature SignatureElm Lea Residential Care HomePage 34 Public reports It should be noted that all CSCI inspection reports are public documents.Elm Lea Residential Care HomePage 35 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 6th and 7th July 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleElm Lea Residential Care HomePage 36 Action taken by the CSCI in response to Provider comments: Amendments to the report were necessary NOComments were received from the Provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The Inspector believes the report to be factually accurateNOYESYESNote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 13/08/04, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESNONOOther: enter details here NOElm Lea Residential Care HomePage 37 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I, Renuka Oojageer of Elm Lea confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of Elm Lea am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons: RENUKA OOJAGEER R Oojageer Acting Manager 28/07/04Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Elm Lea Residential Care HomePage 38 - 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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