Inspection on 11/06/07 for Elm Lodge

This inspection was carried out on 11th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Elm Lodge 14/04/08

Elm Lodge 04/09/07

Elm Lodge 22/01/07

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Elm Lodge 1 Marley Close Greenford Middlesex UB6 9UG Lead Inspector Clare Henderson Roe Key Unannounced Inspection 11th June 2007 12:30 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 Lodge DS0000061258.V339601.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 Lodge DS0000061258.V339601.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elm Lodge Address 1 Marley Close Greenford Middlesex UB6 9UG 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) 020 8575 0259 0208 839 1160 Servite Houses Tracy Ann Burgess Care Home 75 Category(ies) of Dementia (30), Old age, not falling within any registration, with number other category (45) of places Elm Lodge DS0000061258.V339601.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Of the thirty (30) beds registered in the category (DE), one unit comprising of fifteen (15) beds may be used for service users with dementia requiring nursing care. 22nd January 2007 Date of last inspection Brief Description of the Service: The home has been purpose built to meet the National Minimum Standards for Older People. It is situated in a residential area of Greenford, and is easily accessed via public transport and the A40. There are shops within reasonable walking distance to the home. The home comprises of 5 units, each of which can accommodate 15 residents. All bedrooms are single with en suite toilet, wash hand basin and shower facilities. Each unit has a communal sitting/dining area with a kitchen area plus a separate quiet/activities room. Four of the units are registered to provide personal care and one unit is registered to provide nursing care. Each unit is individually staffed. The home accommodates service users placed by the Borough of Ealing. With regard to the fee rates for the home, the Major Projects Manager for Ealing Council has provided the following information: Elm Lodge was developed under the Governments Private Finance Initiative and capital costs are met in this way. Ealing Council pays a Unitary Charge, which covers all the services the Council receives from Ealing Care Alliance. It covers the costs of care and the provision of facilities management services to the day care service and accommodation. It is not possible to separate these out to identify how much each residential care and nursing care placement costs. The fee payable to the Council by residents who fund themselves in full is £495.00 per week for residential care. The fee payable to the Council by residents who fund themselves in full is £612.00 per week for nursing care. Deducted from that will be the free nursing care amount of £125.00 (high) and £83.00 (medium and low). Elm Lodge DS0000061258.V339601.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of 36 hours was spent on the inspection process. The Inspectors carried out a tour of the home, and service user plans, staff rosters, staff records, financial & administration records and maintenance & servicing records were viewed. The CSCI Pharmacist Inspector carried out a medications inspection on 12/06/07 and a separate report is available. The requirements and recommendations from that inspection have been incorporated into this report. 21 residents, 14 staff and 5 visitors were spoken with as part of the inspection process. The pre-inspection questionnaire and comment cards from service users, representatives/visitors and health & social care professionals have also been used to inform this report. On the first day of inspection the Registered Manager was on leave, however the Deputy Managers and Acting Regional Manager were present. What the service does well: What has improved since the last inspection? Elm Lodge DS0000061258.V339601.R01.S.doc Version 5.2 Page 6 There has been an improvement in the activities provision in the home, plus following the inspection an activities co-ordinator has been appointed. Additional moving & handling equipment has been purchased so that the needs of all the residents can be met. The laundry provision has caused concern, and the laundry person spoken with was very clear regarding the need to ensure personal items of clothing are well cared for and maintained in good condition. The staffing on the nursing unit has increased since the last inspection and resident’s needs are therefore being better met. There has been an improvement in the health & safety of the home, with areas such as the main kitchen and unit kitchen areas having been risk assessed and action taken to minimise risks identified. Assessment and work is ongoing to bring the main kitchen up to a good standard and provide adequate storage. Action is also being taken to improve the security within the home, and in conjunction with this, the telephone systems are also being reviewed. 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 Elm Lodge DS0000061258.V339601.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Elm Lodge DS0000061258.V339601.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 Lodge DS0000061258.V339601.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. The home does not provide intermediate care. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are assessed prior to admission to the home, to ascertain that the home is able to meet their needs. EVIDENCE: Pre-admission assessment documentation was viewed for 3 residents. In one instance where a copy of the homes assessment was seen, this had only been part completed and did not give a full picture of the persons needs. Copies of the Social Services needs led assessments were available for all 3 residents and gave a good picture of their individual needs. The importance of completing any assessments carried out in full was discussed with the Registered Manager and Acting Regional Manager. Elm Lodge DS0000061258.V339601.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 &10. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Overall the service user plan documentation was poorly completed, thus placing service users at risk of not having their needs identified and met. Shortfalls in the medication management and recording place service users at risk. Staff care for service users in a courteous and professional manner, however incomplete recording of information regarding religious dietary requirements shows a lack of respect. EVIDENCE: The Acting Regional Manager informed the Inspectors that shortfalls in the completion of the service user plans had been identified and that additional management support had been provided with a view to reviewing all the residents with relatives and key workers in order to bring all the information up to date. There was evidence of this having taken place on some units, and clear update records were available and due to be typed up into a new service user plan format. Some others had already been updated, with others due for this. Care plans had not always been completed for all identified needs. It was concerning that for 2 residents who had fallen the falls risk assessment Elm Lodge DS0000061258.V339601.R01.S.doc Version 5.2 Page 11 document had not been completed. For another resident with a falls risk assessment in place, this had not been updated following a fall. In another instance clear falls monitoring to include updates following falls was in place. The District Nurses provide any nursing input required on the personal care units. For two people with wounds, the wound assessment had not been completed or had been wrongly completed although there was evidence of wounds being present. Continence assessments had not always been completed despite the residents having continence care needs. Moving & handling assessments did not always identify the equipment to be used, for example, the type of hoist required for individual needs. Nutritional assessments had been completed, however for two people who had experienced significant weight loss it was not clear as to what action had been taken to address this. A consent document for the use of bedrails was in place, however the company are still in the process of formulating a risk assessment for their use. Bedrails must not be used unless a full risk assessment has been carried out and the appropriateness of their use clearly identified. For some people with diabetes the frequency of blood glucose monitoring had not been recorded. Information regarding peoples’ medical diagnoses was not always available, which gave cause for concern as staff were therefore not aware of specialist needs resulting from particular medical conditions. Some of the documentation had not been signed and/or dated. There was evidence of input from the GP and from healthcare professionals. One service user plan viewed gave a general overview of the persons needs, however on reading the daily record it was clear that the person had challenging behaviour and had been difficult to manage. The Inspectors were very concerned that several of the shortfalls had been identified at the last inspection and until the recent additional management input had been provided, little appeared to have been done to address the requirements regarding care planning from the last inspection. CSCI Pharmacist Inspector carried out a medication inspection on 12/06/07 and a separate report is available. The requirements and recommendations resulting from that inspection have been incorporated into this report. The abbreviation ‘MAR’ stands for medication administration record. The findings of the pharmacy inspection gave cause for serious concern. Staff were seen caring for the residents in a gentle and professional manner. Residents spoken with said that they were being well looked after at the home and that staff are kind to them. One resident was presented with a meal that contained ingredients not acceptable in line with their religious belief and the information regarding this had not been fully recorded in the service user plan. Bedrooms had been personalised and the bath and shower facilities had also been made very homely. Several comments had been received regarding the laundry care of personal clothing. One Inspector spoke with the laundry person and it was clear that they had identified the importance of ensuring that Elm Lodge DS0000061258.V339601.R01.S.doc Version 5.2 Page 12 personal laundry is well cared for and ironed and was taking action to improve the service provided. Elm Lodge DS0000061258.V339601.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activities provision has improved since the last inspection with further action being taken in this area to provide residents with activities to meet their assessed needs. The home has an open visiting policy, thus encouraging service users to maintain contact with family and friends. Two advocacy services are accessed by the home, thus ensuring residents’ rights to independent representation is respected. The food provision in the home is good, offering variety and choice, thus meeting the service users individual needs. EVIDENCE: At the last inspection it was identified that the home needed an activities coordinator. This post has since been advertised twice with a good response to the second advertisement. Following this inspection the Acting Regional Manager has confirmed that an appointment to this post has been made. In the interim period a member of staff has taken on responsibility for arranging outings and activities and there had been an improvement in this area overall. Residents on one unit were playing a card game and were enjoying themselves. On the second day of inspection several residents went on an Elm Lodge DS0000061258.V339601.R01.S.doc Version 5.2 Page 14 outing to Kew Gardens and more trips have been planned. In some of the service user plans ‘life history’ documents had been completed and information was available regarding individual hobbies and interests. A reader-friendly activities programme was in place, and once the activities co-ordinator commences then more action can be taken to personalise the programmes to each unit. The home has an open visiting policy and visiting is encouraged. Visitors spoken with said that they are made welcome at the home and are offered refreshments. Residents can choose to receive visitors in their own bedrooms or in one of the communal areas. The home now has an advocate from Alzheimer’s Concern who runs a support group at the home as part of the monthly relatives meetings. They also provide individual advocacy services. The Inspectors were also informed that the home also uses the ‘First Voice’ advocacy service for Ealing. Contact details were seen on display. One Inspector viewed the kitchen. Following the last inspection action has been taken to risk assess the area and the Acting Regional Manager explained some options being considered to improve storage arrangements. The kitchen staff continue to work hard to provide a good standard of food, meeting the religious and cultural needs of the resident groups. There was a good supply of fresh, frozen, tinned and dried foodstuffs available, and those viewed were in date. Kitchen records to include fridge, freezer and food temperatures, cleaning records and lists of resident meal choices for the 3 daily meals were available and up to date. Any food allergies are recorded and the cook is informed of these. Each unit has a kitchen area where hot and cold drinks and snacks can be prepared and these are available throughout the 24 hour period. Overall the residents spoken with expressed their satisfaction with the meal provision at the home. Staff were available to assist residents as required. Elm Lodge DS0000061258.V339601.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has a clear complaints procedure in place to address any concerns raised by residents and their visitors. Procedures are in place for the protection of residents from abuse, however shortfalls in practice place residents at risk. EVIDENCE: A copy of the complaints procedure was on display on each unit. There is a complaints log and 7 complaints had been recorded since the last inspection. Some minor concerns had been responded to verbally and this had been recorded. Written responses had been made to the other complaints raised. Since the last inspection there had been 4 adult protection investigations. However, during the inspection shortfalls identified in the medication management plus an incident of unexplained bruising have identified further POVA concerns. Regulation 37 notifications had not been received for all incidents reportable under the CSCI requirements. The Ealing Safeguarding Adults co-ordinator has provided training at the home and although staff spoken to said that they knew to report any concerns, it appeared that some staff were unsure as to what events might constitute a POVA issue. Some of the residents exhibit behavioural needs, however there was no evidence of any recent training on this topic. The pre-inspection questionnaire recorded procedures are in place for the management of residents’ personal monies. Elm Lodge DS0000061258.V339601.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is purpose built, providing a safe and homely environment for people to live in. Infection control procedures are in place, thus protecting residents, staff and visitors. EVIDENCE: The Inspectors carried out tours of each unit. The Regional Manager reported that an in-depth audit of the environment had been carried out and shortfalls identified are being prioritised in line with health & safety as part of the snagging contract. Bedrooms had been personalised and there was a homely feel to each unit, with other areas such as the bathrooms being well appointed. Since the last inspection additional moving & handling equipment has been purchased to meet the needs of all residents. Action had also been taken to provide override facilities for the lighting, which was originally all on timers. This means that in the case of an emergency full lighting can be accessed. The home has a rear garden with limited seating available. Comment had been Elm Lodge DS0000061258.V339601.R01.S.doc Version 5.2 Page 17 received regarding the limited provision of suitable garden space for residents to walk and sit out in, due to the steep gradient of the majority of the garden. The home was clean and fresh throughout. There are suitable laundry facilities and procedures to meet the needs of the home. Protective clothing to include gloves and aprons was available. One Inspector spoke with one of the laundry staff who had been working at the home for 2 weeks, and it was clear that they took pride in their work and understood the importance of caring for individuals clothing correctly. It was not clear from the training records provided as to whether staff had received training in infection control. Elm Lodge DS0000061258.V339601.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staffing levels throughout the home were appropriate to meet the needs of the residents, with ongoing review to identify any changes in dependencies that might affect staffing levels. Systems for vetting and recruitment practices are in place and protect the residents. A training programme is in place with more training being planned so that staff have the skills and knowledge to meet the needs of the residents. EVIDENCE: Following the last inspection the staffing provision on the dementia nursing unit had been reviewed and an additional carer is on duty for the daytime shifts. Overall the staffing on the other units was appropriate to meet the needs of the residents. The needs of the residents on the dementia personal care unit can vary from day to day and staff said that they would identify any staffing needs and discuss these with the Registered Manager. The pre-inspection questionnaire identifies 24 of staff qualified to NVQ level 2 or above, with further NVQ training being planned. The Registered Manager is aware of the need to have 50 of staff trained to NVQ level 2. One Inspector viewed 3 sets of staff employment records. These contained the information required under the Care Home Regulations 2001. One photograph was to be obtained and the Registered Manager was aware of this. There is a Elm Lodge DS0000061258.V339601.R01.S.doc Version 5.2 Page 19 spreadsheet for all staff that identifies all the areas to be completed so that the Registered Manager can see easily what stage each prospective employees checks have reached. The Servite Houses application form has been updated in line with any changes in relevant legislation. One Inspector viewed a training matrix provided by the Head of Care. This detailed the overall training provided in all Servite Care Homes. The Registered Manager informed the Inspector that the training matrix for Elm Lodge was yet to be typed up. One Inspector met the training and development manager for Servite Care Homes who stated that individual training needs had been identified and a training plan to address these was being drawn up. Some dementia training had already taken place and the Acting Regional Manager reported that further comprehensive training in dementia care and challenging behaviour is being planned. Further training in communication skills is also planned. Elm Lodge DS0000061258.V339601.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Registered Manager has the qualifications to manage the home, however the home is not being effectively managed, thus shortfalls are not being promptly identified and addressed. Systems for quality assurance are in place, however audits are not identifying issues, thus undermining the effectiveness of the auditing process. Resident monies are well managed, thus safeguarding their interests. The overall management of health & safety is good, thus protecting residents, visitors and staff. EVIDENCE: The Registered Manager has completed NVQ level 4 in care plus the Registered Managers Award and a certificate in Management Studies. Since the last inspection she has completed a Time Management Course. The home has two Deputy Managers, one being the Head of Nursing and one being the Head of Elm Lodge DS0000061258.V339601.R01.S.doc Version 5.2 Page 21 Care. Limited progress had been made following the last inspection, especially in the areas of medication management and the service user plans. The Inspectors felt that the home was not being effectively managed, based on the number of outstanding requirements from the last inspection report. The Registered Manager must be clear that it is her management responsibility to provide staff with the support and training to fulfil their roles effectively. The Registered Manager reported that Servite Houses are in the process of putting together a new Quality Assurance system. The audits that take place for the medication are not effective and have failed to identify shortfalls. The problems with the service user plans had only been quite recently identified despite the requirements of the last inspection report. There must be effective systems in place for the auditing and review of all areas of care provision. The Registered Manager compiles a monthly report for Ealing Care Alliance. Regulation 26 visits are carried out and the Inspectors requested that copies of the reports from these visits be forwarded to CSCI. Staff meetings, senior carer meetings and unit meetings take place, plus meetings for the residents and relatives also take place. ‘Drop-in’ clinics run by the managers are being set up to take place every 8 weeks, one for staff and one for relatives, so that any issues can be discussed and addressed. One Inspector viewed 4 sets of personal monies. The records were clear and up to date. Receipts are kept for all income and expenditure. The balances are checked monthly and signed for by 2 staff. Staff had received training in health & safety topics to include fire safety, moving & handling, food hygiene and First Aid. Since the last inspection risk assessments had been carried out for the kitchen areas and action is being taken to minimise risks identified. Servicing & maintenance records were sampled and those viewed were up to date. Risk assessments were in place for equipment and safe working practices. A full health & safety audit had taken place in March 2007 and a report of this was available to view. The fire risk assessment had been updated in March 2007. Fire drills to include night and day staff were taking place at the required intervals. Fire safety records viewed were up to date. The Regional Manager reported that a key pad security system has been ordered for the main entrance and also that a review of the security and communication arrangements for the home. Risk assessments are in place for any residents at risk of absconding and for other identified risks. Overall the health & safety is being well managed at the home. Elm Lodge DS0000061258.V339601.R01.S.doc Version 5.2 Page 22 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Elm Lodge DS0000061258.V339601.R01.S.doc Version 5.2 Page 23 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 OP7 Regulation 15 Requirement Timescale for action 01/08/07 2. OP7 13 3. OP8 17 4. OP8 17 A service user plan for each individual must be formulated promptly following admission and be maintained up to date. It must accurately reflect the needs of the service user and how these are to be met. Previous timescale of 16/02/07 partially met. Risk assessments for falls must 01/07/07 be carried out for all service users. These must be reviewed monthly and following any falls. Previous timescale of 01/03/07 not met. Assessments for nutrition, 13/07/07 continence and pressure sore risk must be in place for each service user. Where an assessment identifies a need a care plan must be formulated. Previous timescale of 01/03/07 not met. Moving & handling assessments 13/07/07 must be complete and accurately reflect the needs of the service user, to include any specific equipment to be used to assist with their needs. Previous DS0000061258.V339601.R01.S.doc Version 5.2 Elm Lodge Page 24 5. OP8 13 6. OP8 15 7. OP8 17(1)(a) 8. 9. OP9 OP9 13(2) 13(2) 10. OP9 13(2) 11. OP9 13(2) 12. OP9 13(2) 13. OP9 13(2) timescale of 01/03/07 not met. Where it is proposed bedrails be used, a full assessment to identify the reason for and appropriateness of their use, plus a signed consent for their use must be in place. Previous timescale of 01/03/07 partially met. All documentation relating to wound care must be up to date and accurately reflect the progress of each wound. Previous timescale of 16/02/07 not met. There must be evidence that action has been taken to address any findings of weight loss, in order to safeguard the resident. Medicines must be administered as prescribed. Enforcement action taken That all medicines are recorded when given with full initials. If not administered the correct endorsement must be used. Repeat requirement. Timescale of 22/1/07 not met That the practice of supporting residents with insulin drawn up a week in advance is reviewed with the district nurse team and PCT. Repeat requirement and on-going. That the home only uses lancing devices for professional use when taking samples for testing blood sugar. Timescale of 1/3/07 not met Repeat requirement Nurses and care workers must be competent to manage medicines safely in the home. Part of the training must be to understand the action of medication . That a robust audit is carried out DS0000061258.V339601.R01.S.doc 13/07/07 13/07/07 13/07/07 26/07/07 22/06/07 01/07/07 01/07/07 01/07/07 01/07/07 Page 25 Elm Lodge Version 5.2 14. 15. OP9 OP10 13(2) 12 16. OP12 16(m) 17. OP12 16(n) 23(2) 18. OP18 13(6) 19. OP18 37 20. OP31 10, 12 21. OP33 24 at least monthly in each unit to ensure that medication is handled safely and is being administered as prescribed .The audit must detail problems identified, action taken and follow up. That any medication stored in residents rooms is stored securely. Information regarding specific religious & cultural needs, to include dietary requirements, must be clearly recorded and respected to ensure residents’ beliefs are respected. Service users must be consulted regarding their social and leisure interests. A care plan to reflect this must be available in each service user plan. Previous timescale of 01/03/07 partially met. There must be a full programme of activities for each unit to meet the service users assessed needs. Previous timescale of 01/04/07 partially met. Staff must be aware of what constitutes a POVA issue and report it accordingly in order to safeguard residents. All incidents that occur in line with the Regulation 37 requirements must be reported without delay to CSCI. The Registered Manager must ensure that the home is being managed effectively at all times in order to protect the residents. Effective systems for auditing must be in place and prompt action taken to address any shortfalls identified in order to protect the residents. 01/07/07 01/07/07 01/08/07 01/08/07 21/06/07 21/06/07 01/07/07 13/07/07 Elm Lodge DS0000061258.V339601.R01.S.doc Version 5.2 Page 26 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 OP3 Good Practice Recommendations That all pre-admission assessments be carried out in full so that the needs of the individual are clearly identified and the home can ascertain if they are able to meet these needs. That all documentation is signed and dated at the time of completion. The home should work with the GP and pharmacist to ensure that all regular medication is prescribed and dispensed to start on the same day each cycle. That the pharmacist is requested to update the MAR and remove all discontinued items. That the home ensures medication is stored at room temperature or below. 2. 3. 4. 5. OP7 OP9 OP9 OP9 Elm Lodge DS0000061258.V339601.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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