Inspection on 22/01/07 for Elm Lodge

This inspection was carried out on 22nd January 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Elm Lodge 14/04/08

Elm Lodge 04/09/07

Elm Lodge 11/06/07

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 Lead Inspector Clare Henderson Roe Key Announced Inspection 10:00 22 & 23rd January 2007 nd 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.V321440.R02.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V321440.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elm Lodge Address 1 Marley Close Greenford Middlesex 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 elmlodge@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.V321440.R02.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. New Registration 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 service users. 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.V321440.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection carried out as part of the regulatory process. A total of 26 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 16/01/07 and a separate report is available. The requirements and recommendations from that inspection have been incorporated into this report. 12 service users, 10 staff and 4 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. It must be noted that 56 service users were admitted to the home on the first day of opening, not allowing for a timely approach to admissions to the home. The Registered Manager has managed this difficult situation effectively, however some of the shortfalls in this report have resulted from a lack of time to complete admissions fully and to assess the suitability for use of some areas of the home, for example, the main kitchen. What the service does well: Information regarding the home and the services provided is freely available, with plans to translate these documents into Hindi, Punjabi and Urdu. Prospective service users are assessed prior to admission to ensure the home is able to meet their needs. Service users are involved in the formulation and review of the service user plans. Staff care for service users in a gentle, courteous and professional manner, respecting their privacy and dignity. The home has an open visiting policy and visiting is encouraged. Information about advocacy services is available. The food provision is good, offering service users choice and variety, and catering for service users religious and cultural needs. Visitors spoken with said that they are made welcome at the home. There are robust systems in place for the management of complaints and POVA. The home is a new build and the accommodation provision is of a good standard. With the exception of dementia care training, staff had received training and there is further training planned to maintain staff knowledge and skills to care for the service users effectively. Staff recruitment processes are robust. The Registered Manager has the qualifications and experience to manage the home effectively, which she does. Staff commented that the Registered Manager is very supportive. Monthly audits are carried out to monitor the homes progress, plus staff and service user meetings take place. In addition the home has a system for quality assurance and the Registered Manager is due to implement this in the near future. Systems are in place for the management of service users monies, and secure facilities are in use. Elm Lodge DS0000061258.V321440.R02.S.doc Version 5.2 Page 6 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.V321440.R02.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.V321440.R02.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): 1, 3, 4 & 5. 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. Service users and their representatives are provided with the information they need to make an informed choice about the home. Service users are fully assessed prior to admission to the home, to ascertain that the home is able to meet their needs. Staff had not all received training in dementia care, thus they did not all have the specialist knowledge to care for service users fully with such a diagnosis. Service users and their representatives are encouraged to visit the home prior to admission, thus giving them the opportunity to make an informed choice. EVIDENCE: The home has a Statement of Purpose and Service User Guide. These had been updated with any relevant changes. Copies are available on each unit and in the reception area, and are freely available on request. The Registered Manager said that the documents are to be translated into Hindi, Punjabi and Elm Lodge DS0000061258.V321440.R02.S.doc Version 5.2 Page 9 Urdu. Copies of the Service User Guide are provided to all enquirers and prospective service users. The majority of service users have transferred to the home from two Local Authority Homes. Pre-admission assessments have been completed for new service users admitted to the home. Overall these were detailed and gave a good picture of the service users and their needs. Social Services needs led assessments were also available. The home provides care for service users with general care needs and also for those with dementia care needs. Some staff have received dementia care training, however it was clear that not all staff had received this training, and the need to ensure all staff working with service users with dementia are appropriately trained to do so was discussed. The home has an Asian unit and the staff are able to communicate effectively with service users and understand how to meet their cultural needs. A specific Asian Menu is prepared daily for the service users, and is also available to service users on other units should they so wish. Service users on this unit were dressed appropriately to reflect their culture. Service users and representatives spoken with confirmed that they had been given the opportunity to visit and view the home prior to admission, in order for them to make an informed choice. Elm Lodge DS0000061258.V321440.R02.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 adequate. This judgement has been made using available evidence including a visit to this service. Service user plans were not always promptly completed or kept up to date and did not accurately reflect the condition and needs of the service user, thus placing service users at risk of not having their needs met. Shortfalls in the management of medications could place service users at risk. Overall staff care for service users in a gentle and courteous manner, thus respecting their privacy and dignity. EVIDENCE: Service user plans were sampled on each unit. For one service user admitted on 22/12/06, the service user plan had not been written until 19/01/07. Personal summaries had not been fully completed, and in some cases documentation had not been signed and/or dated. Care plans had been completed for identified needs, but in some cases the information was very brief and did not give a full picture of each need. It is acknowledged that in some cases staff had included a good amount of detail. Risk assessments for falls had not been formulated. With the exception of one service user, reviews Elm Lodge DS0000061258.V321440.R02.S.doc Version 5.2 Page 11 of service user plans had been carried out, and there was evidence of involvement from the service users in the care plans and the reviews. The home is using the service user plan documentation provided by Servite Houses. It was noted that some assessment documentation is not included in this package. These include continence assessments, nutritional assessments and in some cases pressure sore risk assessments. This was found to be the case on all units. Bedrails were in use for some service users on the dementia care nursing unit, however bedrail risk assessments and written consents for use were not available. Moving & handling assessment documents were available, however some of the information had not been fully completed and specific equipment to be used for moving & handling needs had not always been identified. On the nursing unit, for one service user with wound care needs, no wound assessment had been carried out. In addition it was not clear what size of wound it was, what pressure relieving equipment was in use and the pressure sore risk assessment document had been incorrectly added up and was not dated, plus no review had been carried out for some months. Overall the records for wound care did not provide a clear picture of how the wound was to be managed. The service users on this unit had not yet been assessed for nursing care payments. On the personal care units care plans did refer to input from the District Nurse, GP and other healthcare professionals. The importance of a senior member of staff being available to accompany the GP and other health care professionals as needed was discussed, and the Registered Manager said that she had addressed this with staff. There was evidence of service users being weighed monthly and more frequently if required. CSCI Pharmacist Inspector carried out a medication inspection on 16/01/07 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. Staff were seen caring for service users in a gentle and courteous manner. On the personal care units good interaction was noted between service users and staff. On the nursing unit this interaction was not apparent, and training in dementia care and communication is needed to ensure staff working on this unit understand how to communicate effectively with the service users. Some issues around the labelling of service users clothing were noted. Service users individual clothing had been labelled and the Registered Manager said that service users and their representatives are asked to ensure personal clothing items are labelled, and is working on systems to ensure all items are appropriately and discreetly labelled. Service users were appropriately dressed to show individuality, and also to respect religious and cultural needs. Service users can bring in personal belongings to the home, in line with fire safety. Comments received from service users on the CSCI comment cards indicated that service users were happy with the care provision and liked living at the home. Elm Lodge DS0000061258.V321440.R02.S.doc Version 5.2 Page 12 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 adequate. This judgement has been made using available evidence including a visit to this service. The home does not have an activities co-ordinator in place, and service users individual social interests are not being catered for. The home has an open visiting policy, thus encouraging service users to maintain contact with family and friends. Information regarding advocacy services is available, thus ensuring the service users right to independent representation is respected. The food provision in the home is good, offering variety and choice. EVIDENCE: The home does not have an activities co-ordinator in place. There is some provision for activities by way of equipment provided, however the staff on each unit have to implement the activities, and were seen doing so on some units. Some information regarding service users interests had been recorded in some service user plans, but no co-ordination had taken place to assess service users individual interests and to provide an activities programme that takes this information into consideration. The Registered Manager said that she was working to ensure some outings are arranged. For service users on the Asian unit, since their move to the home there had been a reduction in the opportunities to visit the Temple, and action is needed to address this. The home needs to employ an activities co-ordinator to ensure that the interests Elm Lodge DS0000061258.V321440.R02.S.doc Version 5.2 Page 13 and hobbies of service users are assessed and appropriate activities provided. The lack of activities provision was a point raised on several of the CSCI comment card received. The home has an open visiting policy and visiting is encouraged. Service users can choose to receive visitors in the day room or in their own rooms, whichever they wish. The Registered Manager said that she has contact details for Ealing ‘First Voice’ advocacy services, and has also contacted Age Concern and The Alzheimer’s Society with a view to providing input and advocacy services where required for service users. Contact details for the advocacy services are to be displayed in the home. The kitchen was clean and tidy. Kitchen cleaning, temperature and food provision records were up to date. The home has a western menu, an Asian menu and an Afro-Caribbean menu, and service users are offered a choice at each meal. The lunchtime meals on each day of inspection were sampled and these were well presented and tasty. Service users spoken with expressed their satisfaction with the food. There was a good supply of fresh, frozen, tinned and dry ingredients available. The kitchen is somewhat small for a 75 bedded home, and space for food storage and preparation is very limited. No separate cooking area is available for the cook to prepare the Asian diet, and this is concerning due to the religious importance of the food preparation. It is acknowledged that the provision of the Asian unit at the home is a temporary measure whilst another unit is being built, however thought should have taken place to ensure facilities, even on a temporary basis, were fit to meet the dietary needs of all service users. It is acknowledged that the kitchen staff work hard with limited facilities to provide varied and tasty meals to meet the service users needs. Elm Lodge DS0000061258.V321440.R02.S.doc Version 5.2 Page 14 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 good. This judgement has been made using available evidence including a visit to this service. The home has clear complaints procedures in place to address any concerns raised by service users and their visitors. Procedures for the protection of vulnerable adults are in place, with additional staff training in this area planned to ensure staff are fully aware of the processes to be followed. EVIDENCE: The home has a clear complaints procedure and this is displayed on the units. All concerns are recorded and responded to. A complaints log is maintained plus a file for complaints documentation. It was clear from the records viewed that complaints are recorded and responded to in a timely manner. The home has policies and procedures in place for adult protection and also follows the Ealing Borough Safeguarding Adults documentation. Staff spoken with were clear to report any concerns and were also aware of Whistle Blowing procedures. Staff training in POVA has been planned and the Registered Manager was aware that all staff require training in this topic. The home has had 3 POVA allegations, which have been reported and managed appropriately. Elm Lodge DS0000061258.V321440.R02.S.doc Version 5.2 Page 15 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, 20, 21, 22, 24, 25 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has been purpose built to a good standard, thus providing a good quality clean, safe and homely environment for service users to live in. Communal rooms are available on each unit, providing the service users with a choice of venue. With one exception to be addressed, equipment is available for assisting service users as required, thus providing for the service users needs. Individual accommodation is personalised, maintaining a homely feel. Clear infection control procedures are in place and being adhered to, thus safeguarding service users. EVIDENCE: The home has been purpose built in line with the National Minimum Standards for Older People. There are 5 units, each built to accommodate 15 service users. Where ‘snagging’ work has been identified this has been recorded and discussed with the builders for action. The home had been inspected by Environmental Health and by the Fire Safety Officer prior to being registered. Elm Lodge DS0000061258.V321440.R02.S.doc Version 5.2 Page 16 It was noted that the bedroom doors do not have individual door closures and the Registered Manager said that she would clarify with the Fire Safety Officer the reasoning for this. Each unit has a lounge/diner with a kitchen area for preparing drinks and snacks and doing the washing up for the unit. These areas were well furbished and the décor was of a good standard. In addition to this, each unit has a quiet/activities room available. There is a modest enclosed garden for the service users use. All the bedrooms have en suite facilities, to include a toilet, wash hand basin and shower facility. The Registered Manager said that thought had gone into the provision of a variety of shower seats in order to cater for differing needs. In addition there are assisted bath, shower and toilet facilities on each unit. Each unit has a sluice room with an electronic disinfector. The home has two passenger lifts. Each unit has two stand-type hoists, however the nursing unit needs a lifting hoist to ensure service users needs could be fully met. Rails were seen in the corridors and grab rails are available in the en suite and assisted facilities. There is a call bell system in place throughout the home, and bells were being answered promptly. Storage areas have been provided on each unit. The bedrooms were spacious and had been furnished to a good standard. Divan beds were seen in the personal care units and adjustable beds in the nursing unit. All bedrooms are single with en suite facilities. Several of the bedrooms viewed had been personalised and looked homely. All rooms are centrally heated and there are individual thermostatic controls on each radiator. The radiators have low temperature surfaces. Emergency lighting is provided throughout the home. The lighting for the corridors and external areas is controlled on timers. These had originally been set incorrectly and action has been taken to address this. However, the main lighting comes on from 06:30 to 22:00, at which point it changes to night lighting, with no system to override this should there be a need for full lighting in a corridor for some reason, for example, if a service user fell in the corridor. This needs to be reviewed to ensure that lighting is satisfactory at all times. Windows have restrictors in place and hot water temperature checks are carried out regularly, with any adjustments needed being made at the time of the check. The home was clean, tidy and smelled fresh. Protective clothing to include gloves and aprons was available. Hand washing facilities were available in all areas where service users, staff and visitors might require washing their hands. The laundry room was clean and uncluttered. There are two washing machines and two tumble dryers, all industrial machines, and the washing machines have sluice programmes for disinfection purposes. The Registered Manager explained that relatives are asked to label clothing for service users. Elm Lodge DS0000061258.V321440.R02.S.doc Version 5.2 Page 17 Some issues were raised on CSCI comment cards and also by visitors spoken with regarding the inadequate ironing of clothes and also the lack of care when storing some clothing items. The Registered Manager said that she would address this. The home has infection control procedures in place. Elm Lodge DS0000061258.V321440.R02.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 of the personal care units was appropriate to meet the service users needs, however the nursing unit staffing levels needed reviewing in line with service user dependencies, and service users needs were not being fully met. Systems for vetting and recruitment practices are in place and protect service users. The majority of staff had received training, and the programme is to be reviewed and updated to ensure all staff receive training, thus providing them with the knowledge to meet the needs of the service users. EVIDENCE: The staff rosters were viewed. Several comments on CSCI comment cards had been received regarding the home being short of staff on occasion, and this has also been the subject of a complaint. The nursing unit needs to be reviewed, as it was clear both from comments received and also from the lack of time to complete tasks, to include documentation, that the unit is not being appropriately staffed to meet the assessed needs of the service users. Domestic staff were seen on each unit and the home was clean throughout. There is a maintenance man in post, plus catering and administration staff. The Registered Manager reported that 33 of the care staff have undertaken NVQ level 2, plus two staff are in the process of qualifying as registered nurses. A rolling programme of NVQ in care training is being put in place, with Elm Lodge DS0000061258.V321440.R02.S.doc Version 5.2 Page 19 5 staff recently commencing their training. The Registered Manager is aware of the need to have 50 of care staff qualified to NVQ level 2 in care or the equivalent. One Inspector viewed 3 sets of staff employment records and these included all the information required under the Care Home Regulations 2001. The Registered Manager said that she does ensure that staff have any necessary visas to work at the home. The Registered Manager reported that following their general induction and familiarisation with the home, each new member of staff receives a copy of the induction programme based on Skills for Care core standards, and this is then worked through by the member of staff and their mentor. Some new staff had not received training, and this was discussed with the Registered Manager. Some training in key areas such as moving & handling, food hygiene, First Aid, medication management and POVA had been planned and the Registered Manager said that this would be for new staff and also for any staff identified as having a training need in any of these areas. The Registered Manager also reported that training needs for the home are being reviewed to ensure staff will receive training in topics relevant to the service users and their work. Shortfalls in dementia care training have been reported under Standard 4. Elm Lodge DS0000061258.V321440.R02.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 and experience to manage the home, and does so effectively. Audits for quality assurance are in place and are to be implemented, to provide an ongoing process of system and practice review. Policies and procedures for the management of service user monies are in place, thus safeguarding service users. Shortfalls in some areas of health and safety could potentially place service users and staff at risk, and this needs to be robustly addressed to ensure the home provides a safe environment throughout for service users, staff and visitors. EVIDENCE: The Registered Manager has several years experience in home management and has completed the Registered Managers Award and also the NVQ level 4 in Elm Lodge DS0000061258.V321440.R02.S.doc Version 5.2 Page 21 care. The Registered Manager said that she does undertake periodic training in topics relevant to her role and the needs of the service users, and has completed dementia care training. Staff spoken with said that the Registered Manager is approachable and supportive. The home has been open since 08/08/06. There was evidence of areas of care being audited on a monthly basis to monitor performance in the home. The Registered Manager said that a Quality Assurance system is in place and was being implemented in the near future. Staff meetings and service user meetings take place and minutes recorded. The Registered Manager said that she did arrange a meeting for representatives and relatives but no one attended. Various ideas for facilitating communication with representatives were discussed at the time of inspection. Regulation 26 visits are carried out and the reports from these visits were available. The home holds small amounts of personal monies for service users. The individual records for these are clear and all input and expenditure is recorded. Regular balance checks are also carried out. Receipts are kept for all expenditure, and also given out for any cheques received on behalf of service users. There is a residents account with individual records kept and interest is paid. One Inspector checked the records and balances for 5 service users, and these were correct. Service users monies are stored securely, with safe facilities available. Maintenance and servicing records were sampled and those viewed were up to date. Staff had received training in health and safety to include moving & handling, fire safety and food hygiene, and further training had been arranged. First Aid training is being planned for. The inspectors were concerned about the kitchen areas in each unit as these are open plan and accessible to service users. The need to carry out risk assessments for the equipment, service user access and safe working practices for these areas was discussed. In the kitchen the work surface space, hob cooking facilities and storage space are very limited and this needs to be reviewed to ensure that the facilities provided are suitable, both to cater effectively for 75 service users, and also from a health & safety perspective. It was noted that the nursing unit did not provide a secure environment for the service users accommodated therein, and in addition service users can freely access the lift and other units in the home. Three incidents of service users going missing have been identified where service users had wandered from their own units and ended up in other areas of the home, to include the day unit attached to the home, but which is not part of the home or its registration. Whilst it is acknowledged that the home is not a secure unit, the need to protect service users who wander was discussed, and risk assessments must be carried out and action taken to minimise any risks to service users. Some risk assessments for areas of safe working practices were in place. Accidents had been reported and are monitored for trends by the Registered Manager. Elm Lodge DS0000061258.V321440.R02.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 3 X 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 2 X 3 2 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 1 Elm Lodge DS0000061258.V321440.R02.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? N/A 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 OP4 Regulation 18 Requirement Staff working with service users with a diagnosis of dementia must receive dementia care training. An action plan to show how this is to be addressed must be submitted to CSCI. 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. Risk assessments for falls must be carried out for all service users. These must be reviewed monthly and following any falls. Assessments for nutrition, 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. Moving & handling assessments 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. DS0000061258.V321440.R02.S.doc Timescale for action 16/02/07 2. OP7 15 01/03/07 3. OP7 13 01/03/07 4. OP8 17 01/03/07 5. OP8 17 01/03/07 Elm Lodge Version 5.2 Page 24 6. OP8 13 7. OP8 15 8. OP9 13(2) 9. OP9 13(2) 10. OP9 13(2) 11. OP9 13(2) 12. OP9 13(2) 13. OP10 12 14. OP12 16(m) 15. OP12 16(n) 23(2) 12, 18 16. OP12 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. All documentation relating to wound care must be up to date and accurately reflect the progress of each wound. That all medicines are recorded when given. If not administered the correct endorsement must be used. That the practice of supporting residents with insulin drawn up a week in advance is reviewed with the district nurse team. That the home has a procedure for disposing of medication through their licensed waste carrier. That the home only uses lancing devices for professional use when taking samples for testing blood sugar. That home ensures that as part of their training care workers familiarize themselves with the action of medication they are administering Staff must have the skills to communicate effectively with service users, to include those with dementia care needs. 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. There must be a full programme of activities for each unit to meet the service users assessed needs. The staffing must be reviewed to include provision of an activities co-ordinator to effectively implement the activities DS0000061258.V321440.R02.S.doc 01/03/07 16/02/07 22/01/07 19/02/07 01/03/07 01/03/07 01/03/07 16/02/07 01/03/07 01/04/07 01/05/07 Elm Lodge Version 5.2 Page 25 17. OP22 13(5) 18. OP25 13(4)(c) 23(2)(p) 19. OP26 12 20. OP27 18 21. OP38 16(2)(g) 12(4)(b) 22. OP38 13(4) 23. OP38 13(4) programme for each unit. A hoist to meet the moving & handling needs of the service users must be available on the nursing care unit. The lighting provision must be reviewed to enable staff to override the timer system in the case of a situation arising that requires full lighting to be available. Adequate facilities and processes must be in place to ensure service users clothing is ironed appropriately as required. The staffing on the nursing unit must be revised and increased in line with service user dependencies. Thereafter this must be kept under review on an ongoing basis so that service users needs are being met at all times. The main kitchen must be risk assessed and action taken to address any shortfalls identified. Sufficient, suitable areas must be available for storage and preparation of food to meet the needs of all the service users. The kitchen areas on each unit must be risk assessed and action taken to address any shortfalls identified. The security within the home must be risk assessed and action taken to address any shortfalls identified, to ensure service users’ safety is maintained at all times. 01/03/07 01/03/07 16/02/07 01/03/07 01/03/07 01/03/07 31/03/07 Elm Lodge DS0000061258.V321440.R02.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. 2. 3. 4. 5. Refer to Standard OP7 OP9 OP9 OP9 OP9 Good Practice Recommendations It is strongly recommended that all documentation is signed and dated at the time of completion. That a chart is kept for all residents who are having blood glucose monitored. 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 fridge thermometer is reset after each reading That the pharmacist is requested to update the MAR and remove all discontinued items. Elm Lodge DS0000061258.V321440.R02.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West London Area 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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