Inspection on 14/04/08 for Elm Lodge

This inspection was carried out on 14th April 2008.

CSCI found this care home to be providing an Adequate service.

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 04/09/07

Elm Lodge 11/06/07

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 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Elm Lodge 4a Marley Close Greenford Middlesex UB6 9UG Lead Inspector Rekha Bhardwa Key Unannounced Inspection 11:15 14 & 15th April 2008 th 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.V360131.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.V360131.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elm Lodge Address 4a 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 pamela.small@servitehouses.org.uk 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.V360131.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. 4th September 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 residents 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.V360131.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an unannounced inspection carried out as part of the regulatory process. A total of 25 hours was spent on the inspection process, and was carried out by 1 Inspector. The Inspector carried out a tour of the home, and service user plans, staff rosters, staff records, financial & administration records and maintenance & servicing records were viewed. A CSCI Pharmacist Inspector carried out an inspection of the medication management on 14/04/08 and the findings of this visit have been incorporated into this report. 21 residents, 15 staff, 2 visitors and one healthcare professional were spoken with as part of the inspection process. The pre-inspection Annual Quality Assurance Assessment (AQAA) document completed by the home, plus comment cards from residents, representatives and staff have also been used to inform this report. A random unannounced inspection of the home was undertaken on 19/3/08. Outstanding requirements from that visit have been incorporated in this report. At the time of the inspection one unit was empty due to the residents moving to a new Servite home. There were no issues identified in respect of equality and diversity during the course of the inspection. What the service does well: The Manager Designate has been in post since November 2007. She is well aware of the work that is required to bring the home up to a good standard and has plans in place to address this. Prospective residents are assessed prior to admission. Staff care for residents in a caring and professional manner, respecting their privacy and dignity. Information regarding advocacy services is available. The home has an open visiting policy and visiting is encouraged. The food provision is good with choices available to meet the preferences of the residents. The home is purpose built and well maintained. The home was clean and fresh throughout and infection control is being well managed at the home. Staffing levels had been increased in line with the assessed needs of the residents. A training programme is in place. Residents personal monies held on their behalf by the home are being well managed. Some comments received from residents living at the home and visitors include: ‘The home has improved over the past few months.’ ‘I would Elm Lodge DS0000061258.V360131.R01.S.doc Version 5.2 Page 6 recommend Elm Lodge to other relatives looking to place a loved one in a care home’. ‘It is like a family and everyone is friendly and caring’. ‘The home celebrates a variety of festivals across faiths and cultures’. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Elm Lodge DS0000061258.V360131.R01.S.doc Version 5.2 Page 7 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.V360131.R01.S.doc Version 5.2 Page 8 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 fully assessed prior to admission, thus the home ensures they are able to meet each resident’s needs. EVIDENCE: The home has a pre-admission assessment document that provides a good picture of the resident and their needs. This is completed for all prospective residents in order to ascertain if the home is able to fully meet their needs. Completed assessments were viewed on each unit and had been well completed. The home also obtains a copy of the needs led assessment undertaken by social services. Elm Lodge DS0000061258.V360131.R01.S.doc Version 5.2 Page 9 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 & 11. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service user plan documentation is not always completed in full, thus the staff are not provided with a complete picture of each resident and their needs. Although medications are generally being managed better, shortfalls in administration and recording place residents at risk. Staff care for resident’s in a gentle and professional manner, respecting peoples privacy and dignity. Shortfalls in identifying end of life care needs place residents at risk of not having their needs fully met. EVIDENCE: Service user plans were sampled on each unit. Several care plans viewed were very general and did not detail individual needs of the resident, for example, individualised personal care needs. Care plans had not always been formulated for all the residents identified needs, for example, for a resident with some weight loss. There was evidence of input from the resident and/or their representative when the service user plan was formulated. Monthly reviews had been recorded but actual updates of some areas of the service user plans Elm Lodge DS0000061258.V360131.R01.S.doc Version 5.2 Page 10 had not been carried out. One service user plan viewed on Baker Street unit was comprehensively completed. Risk assessments for falls, moving and handling, continence, nutrition and pressure sores had been formulated. For one resident who had had a fall the falls risk assessment had not been updated. For another resident who required bedrails a bedrail assessment was in place however this did not clearly identify the reason why the bedrails were being used. Consents for the use of bedrails had been obtained. Risk assessments for other risks identified, for example, smoking were in place. For residents on the units providing personal care only any nursing needs are addressed by the District Nurses. Pressure relieving equipment was seen in use in the home but specific equipment in use for the individual resident had not been clearly identified in the service user plan. Records viewed indicated that the dietician had been contacted where there was evidence of weight loss. Moving & handling assessments had been carried out. The equipment in use to aid with moving & handling was not clearly identified in some cases. There was evidence of input from healthcare professionals to include GP, tissue viability nurse, dietician, chiropodist, optician and dentist. Relatives and representatives commented in the surveys that they are informed of any concerns regarding their relative. The CSCI Pharmacist Inspector carried out a medication inspection on 14/04/08. An audit of medication was undertaken in each unit in the home. It was noted in most units that overall, the recording of receipts of medication, administration and disposal was satisfactory and correlated with medication taken from the monitored dosage system. Care workers still need to be reminded that they sign the Medication Administration Records (MAR) at the time of administration. In one unit loratidine had not been signed the morning of the inspection and the previous morning. The record was completed at the time of the inspection. In another unit ferrous sulphate was given but again not signed as given. If a resident refuses medication e.g. procyclidine then it should be recorded as such with the appropriate endorsement. A count of medicines in several original packs in all the units also proved that the records were accurate. Variable doses were recorded accurately and in two units there was evidence of dosage changes being recorded accurately and signed and dated by the GP. This means that residents were receiving their medication as prescribed. There was concern that the previous good practices of keeping information on dosage changes; particularly discharge letters, with the MAR for reference was not consistently being followed. On Bow Street unit it was difficult to track down the current dose of warfarin for a resident. Completed anticoagulant books must be archived so that only the current record is available for evidence. When the hospital changes the dose of a medicine then there must Elm Lodge DS0000061258.V360131.R01.S.doc Version 5.2 Page 11 be evidence of this new dosage in the home. It was noted that the Medication Administration Record and the GP prescription and labels did not correlate for one resident. This is to be the subject of a separate investigation by the Designate Manager as it was not possible to determine whether the resident was receiving the correct dose of medication. At the time of this report the outcome of the investigation had not been received. A statutory enforcement notice is being considered over concerns around areas in the safe handling of medication in the home. The home kept records of visiting healthcare professionals. The outcome of these visits should always be fully recorded as in Baker Street unit so that the audit trail can be maintained It was pleasing to note that insulin was no longer being pre-drawn up for the week. District nurses were administering twice daily the prescribed dose of insulin in a residential unit. To prevent the risk of infection from blood borne diseases there was good practice throughout the home of using lancets for professional use, when testing blood glucose. Care plans for the two of the insulin dependent diabetics were inspected and there was evidence of robust risk assessments and monitoring. One resident was self-medicating and the risk assessment had been updated in February 2008. Controlled Drugs were inspected in the home. Balances were correct. Attention is needed in ensuring that balances are recorded as zero when destroyed and that no gaps are left in entries. Controlled drug registers are legal records under both the Misuse of Drugs Act and the Care Standards Act and all staff must be aware of the current legislation. Storage of medication in the home was secure. Room temperature in two units was slightly on the high side. If the temperature is rising then the airconditioning units must be used so that the potency of the medication is not affected. In one unit the minimum and maximum temperature of the fridge was still not being recorded. Medication was well organised and tidy in all but one unit. In this unit the issue of adequate storage should be considered. It was noted that waste medicines were now being returned to the pharmacist and not collected as previously, by a licenced waste carrier. Elm Lodge is a care home with nursing and under the Waste Regulations all the waste is regarded as clinical waste and must be destroyed according to the regulations. The supplying pharmacist had provided training in the new monitored dosage system Staff were seen to be speaking with residents in a courteous manner. Residents clothing is individually labelled. Several of the bedrooms viewed Elm Lodge DS0000061258.V360131.R01.S.doc Version 5.2 Page 12 were personalised. Residents’ preferences in respect of personal care givers to include gender was clearly recorded. For some residents care plans were in place for death and dying. The Manager Designate reported that she was in the process of gradually introducing these throughout the home. Facilities are also available for relatives to stay at the home should they wish to stay close to their loved one in their final day. Elm Lodge DS0000061258.V360131.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. There are activities provided for residents with a programme in place, and residents specialist needs are also catered for. Further work is required in this area to ensure that all care staff implement activities with residents. The home has an open visiting policy, thus encouraging residents to maintain contact with family and friends. Information regarding advocacy services is freely available, thus ensuring the residents’ right to independent representation is respected. The food provision in the home is good, offering variety and choice, thus meeting the resident’s individual needs. EVIDENCE: The home employs a full-time activities person. All care staff working in the home also implement activities. The activity programme is displayed throughout the home and in the main entrance. Each unit has an activities room and a supply of activities equipment in place this includes exercise equipment, musical tapes, board games and arts and crafts. One relative commented to the Inspector whilst the activities equipment is available this was not always being used by the care staff and that on several occasions little or no activities take place. We also observed this. The activities co-ordinator has a detailed action plan of the activities that are to be introduced by the Elm Lodge DS0000061258.V360131.R01.S.doc Version 5.2 Page 14 home. A group of residents are running the mobile shop with the assistance of the activities co-ordinator. We viewed some completed activity files for residents. The activities co-ordinator stated that eventually all residents will have a completed file. Input is received from various religious representatives, and the home can arrange input to meet the needs of residents from different religious and cultural backgrounds. The home has an open visiting policy and visiting is encouraged. Residents can choose to receive visitors in their own bedrooms or in one of the communal rooms, as they so wish. Information regarding advocacy services was displayed in the main entrance of the home. The home has contact with Age Concern, Alzheimers Concern and Ealing ‘First Voice’ advocacy service. The kitchen was viewed and this was clean and tidy. The kitchen records were complete and up to date. Good supplies of foodstuffs were available and there was evidence of stock rotation. Since the last inspection there have been some additional work surfaces that have been installed with a new cooker and oven. The home also has a temporary dry store, which is located outside of the kitchen. Concerns had been raised about the access to this area in poor weather. The Regional Manager for the catering company stated that a canopy for this area had been ordered. There is a choice offered at mealtimes and menus are displayed on each unit. The Nurse on the nursing unit reported that all residents are offered a choice of meal and that these choices are recorded. It was not clear how the residents likes and dislikes are assessed and how this information is passed to the kitchen. Drinks and snacks are available throughout the 24 - hour period. Each unit has a kitchenette where essential supplies are available. Lunch was viewed during the course of the inspection and residents who required assistance were being assisted in a sensitive manner. We were informed that the home is able to provide the diets that meet the cultural needs of residents. An Environmental Health Inspection took place in October 2007 and a report of this visit was available. Elm Lodge DS0000061258.V360131.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 adequate. This judgement has been made using available evidence including a visit to this service. The home has policies and procedures in place for the management of complaints and adult protection issues, and these are not always followed, thus not safeguarding the residents. EVIDENCE: The home has a clear complaints procedure and this is on display in each bedroom and on the notice boards. The complaints record book was viewed and there had been 2 complaints since the last inspection. Two anonymous complaints forwarded by CSCI to Servite Houses in January 2008 had been investigated, however a response to the complaint had still not been received by CSCI. It is noted that an email containing positive comments about the progress of the home under the present Manager was also received by CSCI. Policies and procedures are in place for adult protection and the home also follows the Ealing Safeguarding Adults procedures. The Manager Designate informed the Inspector that there had been 17 POVA referrals since the last inspection. She also stated that there had been extensive POVA training for all staff working in the home. We noted that for one resident who had been identified as having some bruising there was no evidence that this had been followed through and an explanation recorded regarding the occurrence of this. The importance of investigating thoroughly any injuries sustained by a resident was discussed with the Manager Designate. Elm Lodge DS0000061258.V360131.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 environment is of a good standard, thus providing a clean, comfortable and homely environment for residents to live in. Infection control procedures are in place, thus protecting residents, visitors and staff. EVIDENCE: The home is purpose built and a tour of each unit was carried out. The premises are well maintained. The Manager Designate stated that there is a programme of routine maintenance. The home does not have a dedicated maintenance person and the Manager Designate stated that there are three maintenance persons who address any issues within the Servite group of homes. The grounds were well maintained. The laundry was viewed and was clean and tidy. The laundry staff work hard to care for the residents’ personal clothing and all residents looked well dressed. The washing machines have sluice programmes for the management of soiled Elm Lodge DS0000061258.V360131.R01.S.doc Version 5.2 Page 17 and infected laundry. The bed linen and towels are colour coded for each unit. Protective clothing to include disposable gloves and aprons was available on each House. Staff had received training in infection control, with further training planned. One visitor commented that there had been improvements to the laundry service since the last inspection. The home was clean, bright and fresh throughout. Elm Lodge DS0000061258.V360131.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. Staffing levels are kept under ongoing review, thus ensuring appropriate numbers of staff are on duty to meet the needs of the residents. Overall training provision is good with the exception of NVQ training, thus providing staff with the skills and knowledge to care effectively for the residents. Systems are in place for the vetting and recruitment of staff, thus safeguarding residents. EVIDENCE: The staffing levels were appropriate to meet the needs of the residents. The Manager Designate stated that additional staff have been deployed on the dementia nursing unit to meet the high care needs of the residents. Ancillary and domestic staff are employed in numbers that meet the needs of the residents. Several comments were received in the CSCI survey regarding the use of agency staff and the turnover of staff. One comment received ‘Since Baker Street is for residents with dementia, high dependency on agency staff is inappropriate.’ The Manager Designate had identified this in the AQAA and plans are in place to recruit more permanent staff to the home. Other comments received included: ‘The permanent staff are very caring, motivated and have the appropriate skills and experience’. ‘I feel that the nursing staff are extremely good and effective’. Elm Lodge DS0000061258.V360131.R01.S.doc Version 5.2 Page 19 There was evidence that the induction training undertaken by staff met the Skills for Care Common Induction Standards and foundation training. Very few of the care staff have completed their NVQ level 2 in care training. The AQAA detailed that only 15 care staff working in the home with NVQ 2 in care or equivalent. The expectation is that 50 of care staff employed at the home are qualified to NVQ level 2 in care or the equivalent. Action must be taken to address this shortfall. A sample of staff employment files were viewed. The main staff records are held at the human resources department of Servite Houses. The files viewed contained a checklist, which should detail that all required checks have been undertaken. We noted that in some cases these were incomplete. The need to ensure that full information is available was discussed with the Manager Designate and the Responsible Individual. Training records were available. Staff spoken with confirmed that they had been receiving training. Specialist training in topics to include dementia care and other relevant subjects had been undertaken both by trained nurses and care staff. The training matrix provided by the home had not been updated and it appeared that several staff had not received moving and handling training for over a year. The need to ensure that information is kept up to date was discussed with the Manager Designate. Staff spoken with said that they had received training and felt this had given them a better understanding of the residents needs. Elm Lodge DS0000061258.V360131.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, 36 & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Manager Designate has the experience to manage the home, and is open and approachable. Some systems are in place for quality assurance, however shortfalls identified could lead to the quality of care provision not being fully monitored. Monies held on behalf of residents are being well managed and securely stored, thus safeguarding them. Systems for the management of health and safety throughout the home are poor, and shortfalls identified could place residents, staff and visitors at risk. EVIDENCE: The Manager Designate has several years experience of working with older residents. She has been in post since November 2007 and is in the process of applying for registration. The Manager Designate had several years of management experience. There is a registered nurse who is the clinical lead for Elm Lodge DS0000061258.V360131.R01.S.doc Version 5.2 Page 21 nursing in the home and a head of social care. Both posts are supernumerary. Staff spoken with said that the Manager Designate is open and approachable and has a visible presence in the home. Throughout the working day she regularly visits all the units. ‘Our Manager has a unique way of relating to staff and residents. She has been very supportive. My skills are being utilized fully with her help and the care I give to the residents and relatives has greatly improved’. The Manager Designate compiles a monthly report for Ealing Care Alliance. Regulation 26 visits are carried out on behalf of the Responsible Individual. Copies of these reports are available for inspection. Some shortfalls have been identified with the medication audits being undertaken. No audits are in place for monitoring the service user plans. There must be effective systems in place for the auditing and review of all areas of care provision. The home must have in place an annual development plan. Some improvements have been noted in the reporting of untoward incidents under Regulation 37 of the Care Homes Regulations 2001. The AQAA completed for the home was brief and did not contain the information required under the Care Home Regulations 2001. The home does manage some personal monies on behalf of residents. The records for 2 residents were viewed and clear individual records of income and expenditure are maintained. All receipts are available for all expenditure. Since the last inspection the home has implemented a system for staff supervision. Records of supervision sessions undertaken were viewed. The maintenance and servicing records were sampled and those viewed were not up to date. These included no records for lift servicing, no Legionella testing since 2006 and no water temperatures being recorded for the months of December 2007, January 2008 and February 2008. No servicing certificates were available for emergency lighting and Portable Appliance Testing. A health and safety audit had been undertaken in March 2007. A review of workplace risk assessments had been undertaken in November 2007. There was no evidence that regular fire drills were taking place for day and night staff. The fire risk assessment had been updated following the additional changes to the kitchen. The London Fire and Emergency Planning Authority (LFEPA) visited the home on 18/3/08 and requirements from the Fire Officer have been made. Gaps were noted in health & safety training to include fire training and moving and handling training. The Manager Designate is aware of the need for all staff to undergo health & safety training to include updates at the required intervals. Elm Lodge DS0000061258.V360131.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 2 9 1 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 1 Elm Lodge DS0000061258.V360131.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 15,17 Requirement Service user plans must be completed promptly and the information contained therein must be up to date and accurately reflect the needs of each individual and how these are to be met. Where it is proposed bedrails be used, a full assessment to identify the reason for and appropriateness of their use, must be in place, in order that the resident is safeguarded. Care workers must be reminded to follow the procedures of the home and sign the medication administration record immediately after they have observed the medicines to be taken. If medication is refused or not given then the correct endorsement must be used on the MAR. The minimum and maximum temperature of the fridge should be recorded in all units. Previous timescale of 01/09/07 not met. That there continues to be DS0000061258.V360131.R01.S.doc Timescale for action 01/06/08 2. OP8 13 01/06/08 3 OP9 13(2) 21/04/08 4 OP9 13(2) 01/05/08 5. OP9 13(2) 01/05/08 Page 24 Elm Lodge Version 5.2 6. 7. OP9 OP11 13(2) 12 8. OP16 22 9. OP18 13 10 OP28 18 11. OP33 23(4) 12. OP33 24 13. OP38 12,23 robust auditing of medication in the home to ensure that it is handled safely and administered as prescribed. Auditing must also be targeted to complex medication regimes where there are changing variable doses to ensure that labels, instructions and prescriptions all correlate. Waste medicines must be disposed of via a licensed waste management company. The wishes of residents and their families in respect of end of life care must be discussed and clearly recorded, to ensure these wishes are met. Complaints must be investigated and responded to in accordance with the homes complaints procedure, to ensure complaints are dealt with in a timely manner. Previous timescale of 01/04/08 not met. Where a resident has an unexplained injury this must be thoroughly investigated, to ensure that the resident is safeguarded. The home must have 50 of care staff qualified to NVQ level 2 in care or the equivalent, in order that the staff have the necessary skills and knowledge to carry out their duties. The CSCI Annual Quality Assurance Assessment must be completed in accordance with the available guidance in order to provide a comprehensive assessment of the home. Effective systems for quality assurance must be in place and prompt action taken to address any shortfalls identified in order to protect the residents. Required maintenance and servicing checks must be DS0000061258.V360131.R01.S.doc 01/05/08 01/06/08 01/06/08 01/06/08 01/08/08 01/07/08 01/06/08 01/06/08 Page 25 Elm Lodge Version 5.2 14. OP38 18 undertaken and clear records maintained in order to protect residents. All staff working in the home must receive health and safety training to include moving and handling and fire training. 01/06/08 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. 2. 3. 2. Refer to Standard OP12 Good Practice Recommendations Staff should ensure that activities are facilitated daily for residents on each unit, so that there is something of interest taking place for residents to join in. Systems should be developed in order that the residents’ likes and dislikes in relation to food are recorded and made known to the catering staff. The employment checklists for all staff should be complete and up to date, evidencing that all required employment checks have been carried out. The training matrix should be kept up to date. OP15 OP29 OP30 Elm Lodge DS0000061258.V360131.R01.S.doc Version 5.2 Page 26 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. Extracts may not be used or reproduced without the express permission of CSCI Elm Lodge DS0000061258.V360131.R01.S.doc Version 5.2 Page 27 - 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. 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