Inspection on 27/03/07 for Elm Lodge

This inspection was carried out on 27th March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 05/12/07

Similar services:

Springfield House

The Shelley

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Elm Lodge 107 Enys Road Eastbourne East Sussex BN21 2ED Lead Inspector Robert Pettiford Key Unannounced Inspection 27th March 2007 09:25 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 DS0000066153.V334011.R03.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 DS0000066153.V334011.R03.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elm Lodge Address 107 Enys Road Eastbourne East Sussex BN21 2ED 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) 01323 419257 01323 722257 deeyates.elmlodge@yahoo.co.uk Dr Vidya Vishwas Sapatnekar Mrs Dolores Maria Yates Care Home 15 Category(ies) of Dementia - over 65 years of age (15) registration, with number of places Elm Lodge DS0000066153.V334011.R03.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Service users should be aged sixty-five (65) years or over on admission. The maximum number of service users to be accommodated is fifteen (15). Only service users with a dementia type illness to be accommodated. To accommodate one named service user under the age of sixty-five (65). Date of last inspection Brief Description of the Service: Elm Lodge is registered to provide residential and social care for up to fifteen people with a dementia type illness. The home is a large detached property siturated in a residential area of Eastbourne within walking distance of the town centre and public transport, including the railway station, with GP and dental suregeries accessible. It is on two floors with nine single rooms, three with en suite facilities, and three double rooms. Access is provided by a stair lift. There is a lounge, separate dining room and a small seating area to the rear of the building with access to a large attractive garden that residents and staff use when weather permits. There is also a small parking area at the front of the building, that can be accessed from a very busy road, additional parking is also available on the road itself. The range of fee’s charged for services provided range from £400 to £650 per person. Elm Lodge DS0000066153.V334011.R03.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection that took place on the 27th March 2007. The Inspector agreed and explained the inspection process with the two deputy managers present during the inspection. Documentation and records were read. Time was spent reading a sample of written policies and procedures, reviewing care plans and records kept within the home. The focus of the inspection was to assess Elm Lodge in accordance with the Care Home Regulations 2001 and the National Minimum Standards for Older Persons. In some instances the judgement of compliance was based solely on verbal responses given by those spoken with. The inspector spent time speaking with some of the service user’s and two relatives of service user’s who lived at the home, which gave him a good opportunity to discuss the quality of care within the home and activities enjoyed. Several comment cards were received from relatives which indicated satisfaction in the quality of care within Elm Lodge. What the service does well: What has improved since the last inspection? It was evident through the inspection process that the manager is now taking appropriate steps to review and improve the standards of care within the home. Elm Lodge DS0000066153.V334011.R03.S.doc Version 5.2 Page 6 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 DS0000066153.V334011.R03.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 DS0000066153.V334011.R03.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): 3,5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service user’s can feel on the whole confident that their needs will be fully assessed and that they will be offered a trial period before moving in to the home. EVIDENCE: The service consults the assessment information to see if they can meet the prospective service user needs before they make the decision to accept the application for admission and offer a placement. Evidence showed that prospective service users have a needs assessment carried out before they are admitted to the home. The manager was requested to review the assessment process as some minor amendments were needed with regard to including an assessment of their daily living skills and ensure this follows through to the care plan. Elm Lodge DS0000066153.V334011.R03.S.doc Version 5.2 Page 9 The manager confirmed that all service users were offered a trial period of four weeks to ensure they are happy to remain and that the home can meet their needs. Elm Lodge DS0000066153.V334011.R03.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’s can feel confident on the whole that they will have good outcomes with regard to quality of care. However their health and care needs are not fully documented within the care planning system. Service user’s can not feel fully confident that their wellbeing will be protected by the home’s policy and procedures with regard to the handling and administration of medication. Service users can feel assured that they will be treated with respect and dignity and their rights to make decisions about their lives is respected and they have the opportunity to be consulted on, participate in, all aspects of life within the home as they wish or their capacity allows. EVIDENCE: Elm Lodge DS0000066153.V334011.R03.S.doc Version 5.2 Page 11 The inspector viewed and discussed with the manager the care records relating to several service user’s at the home. In the care plans viewed there was insufficient detail and guidelines in respect of the support needed to fully meet service users needs. The care plans were regularly updated but did not evidence fully the support needed and the desired outcome. Assessments were in place that did not follow through to the care plan. They were also found to be incomplete and of variable quality. Whilst it was accepted through discussions with service user’s they were happy with the standards of care received and relatives had a high opinion of the home and the service provided documentation suggested otherwise due to lack of information and detail. No evidence was available that service user’s where possible were involved in drawing up personal care plans in the documentation and that they are consulted in reviewing and amending such care plans. The care planning system needs to be reviewed and introduce a centred planning approach to the care plans which will have a holistic model as its base. The care planning approach for all service users needs move away from a task orientated base to one with includes social and personal goals including hopes and aspirations. The care plan should further evidence that equality and diversity issues have been considered with evidence that any needs are being supported. The inspector viewed a sample of care records and specific health care records relating to several service user’s. Records viewed confirmed that service user’s had access to a range of health care inputs as and when required and as part of regular health checks. The documentation seen confirmed that all Service users have a Doctor and visits from other health professionals are arranged and enabled. The health care issues of the residents were seen recorded in the daily record. It was recommended that visits to health professionals is documented separately on its own page to enable the home to more easily document the outcomes for each visit. Risk assessments sampled were not detailed with regard to identifying the risk and the control measures needed to minimise risks. The deputy managers present recognised this and are committed to ensure that all service users have comprehensive risk assessments to minimise risk. Management of risk needs to take into account the age, specialist needs of people who use the service, balanced with their aspirations for independence and choice. Where limitations are in place, the decisions have been made following consultation with the service user, relative where appropriate and social services care management. Elm Lodge DS0000066153.V334011.R03.S.doc Version 5.2 Page 12 The inspector visited the home at 9:25AM. During the inspection the inspector noted that service user’s were seen making choices about their lives and were seen to be part of the decision process. A relaxed atmosphere was noted with the service user’s interacting with staff. The inspector also had the opportunity to speak with two relatives who expressed a great deal of satisfaction with the care offered and given. They felt that the home offered an inclusive family atmosphere and that the manager was receptive to their comments and suggestions. The inspector viewed the storage arrangements and some records including Medication Administration Record (MAR) sheets, and the protocols for the administration of “PRN/As Required” Medication. MAR sheets. The manager confirmed that all staff that dispense medication have received appropriate training. No service users currently manage their own medication and the home currently uses the Boot’s MDS system (Medicines are packed into separate compartments allowing the service user to be given the correct medicine, at the correct dose, at the correct time.) Several areas of concern were seen and brought to the managers attention. Namely:Medication /supplies were stored inappropriately in a cabinet that was too small in the opinion of the inspector. It was recommended that the home consults with the Community Dispensing Pharmacist for advice with regard to storage and consider purchasing a medication trolley to allow for better storage and easier access. Prn or as required medication protocols were not available for all as required medication. In that they were not written up. Medication that had been prescribed was being given in an altered dose for one service user. It was recommended that the home ensures that it has evidence available to confirm that this has been authorised by the service user’s General Practitioner. The home was requested to confirm in writing that medication is administered stored and disposed of as required by the above regulation and that safe procedures are in place to protect service users from a risk of harm. The home needs to ensure that the recording and administration of medication follows The Royal Pharmaceutical Society guidelines (amended June 2003) Elm Lodge DS0000066153.V334011.R03.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. Service user’s’ social and recreational interest and needs are well provided for with a wide range of activities organised and are supported to maintain contact with family and friends, which ensures they continue to receive stimulation and emotional support. The dietary needs of service user’s are well catered for and their views and opinions are sought regarding the choice of meals served. Service user’s feel confident that they are enabled to exercise choice and control over their lives. EVIDENCE: The home offers a full programme of activities. This included Musical movement, quizzes, word games, board games, reminiscence and many other activities. Various other social events are arranged with families being invited. The home has an open day and summer fair. Relative’s and service users spoken with expressed satisfaction with regard to activities and opportunities for choice and participation. Elm Lodge DS0000066153.V334011.R03.S.doc Version 5.2 Page 14 Family and friends are made to feel welcome within the home are very much seen as priority in maintaining emotional health and know they can visit the home at any time. Staff always make time to talk to visitors and share information with the agreement of the resident. The design of the home provides seating areas within the communal areas of the home where residents can entertain their visitors, in addition to the privacy of their own room. It is clear that the home encourages individuals and groups from the community to visit the home. Service user’s are encouraged to exercise choice and control over their lives where possible, staff were willing to assist if necessary. Service user’s confirmed they could bring personal items on admission. The majority of the residents said the food was of good quality and that they had a choice. Three full meals plus supper and snacks were available every day with drinks readily available. Evidence was seen that the residents were offered a choice at every meal and that it was well balanced and nutritious. The inspector viewed the menus, which offered a selection of fruit and vegetables on a daily basis. Specialist diets could be provided when advised by health care professionals or service user’s. Elm Lodge DS0000066153.V334011.R03.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 good This judgement has been made using available evidence including a visit to this service. The home has a effective complaints system in place and service user’s and families are aware of its contents. Service user’s are protected by robust adult protection policies and procedures EVIDENCE: The home had a written complaints procedure, which was seen in the foyer. Service user’s spoken with were aware of the contents and felt free to voice their concerns. The home has received no formal complaints since the last inspection. The home had also received compliments from families regarding the level of care offered. The complaints procedure however was in need of updating to include the new address of the Commission local office and that of the local social services department. Elm Lodge DS0000066153.V334011.R03.S.doc Version 5.2 Page 16 The inspector viewed and discussed copies of the Home’s Policy for the Protection of Service user’s and staff “Whistle blowing” procedure. These include procedures for the reporting of suspicion or evidence of abuse with a format for the recording of any allegations and action to be taken. Full training is provided in abuse. More courses are planned to ensure all staff receive the training required to protect service user’s from abuse. Criminal Record Bureau Checks (CRB) have been obtained for all staff. The Registered Manager is aware of her obligations with regard to ensuring the safety of Service user’s and protecting them from abuse. Elm Lodge DS0000066153.V334011.R03.S.doc Version 5.2 Page 17 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): 19,20,26, Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Service user’s benefit from living in a home that provides for a homely environment which provides safe access to comfortable indoor and outdoor communal areas. However the standards of internal decoration were found to be of variable quality. EVIDENCE: The service provides a homely environment. Elm Lodge provides homely, comfortable individual and communal space for residents. There is a large lounge at the front of the building that can be used for activities, a large dining room in the centre and a small seating area near the kitchen next to the door to the garden. Service user’s are encouraged to bring their own possessions to the home and many have personalised their rooms with pictures and ornaments. Furniture is provided by the home if residents prefer However Elm Lodge DS0000066153.V334011.R03.S.doc Version 5.2 Page 18 fixtures and fittings and general decoration were seen to be of a variable standard / quality. The kitchen and bathrooms were found to be in need of refurbishment in the view of the inspector to ensure standards of infection control / hygiene are maintained. There are sufficient bathrooms and toilets but one or two are not in good working order and are in need of refurbishment. During the inspection it was noted that the home does not provide safety valves to regulate hot water temperatures on sinks viewed within a selection of service user’s rooms and that the washing machine did not have a sluice facility to ensure that hygiene standards meet the needs of service user’s. The home was requested to review its environmental risk assessment and consult with the Environmental Health Officer to ensure that all risk are minimised and that it meets the standards with regard to suitable washing facilities, hygiene standards in the kitchen and control of water temperatures. Elm Lodge DS0000066153.V334011.R03.S.doc Version 5.2 Page 19 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. Service user’s can feel confident that their care, social and emotional needs are fully promoted by the employment of care staff in sufficient numbers to meet their needs at all times and trained to the required standards. Service users are fully protected by the recruitment procedures within the home. EVIDENCE: The ratios of care staff to service user’s should be determined according to the assessed needs of residents. A copy of the staffing roster seen indicates that rotas have been prepared for the following month. The currently home provides two AM carers and two PM carers. The home has two carers working at night. Additionally the staff are supported by the manager whilst working on shift should the need arise. Following discussions with the two deputy managers, a review of the rota and observations made during the inspection. The inspector is of the opinion that sufficient care staff were on duty to support service users to participate in Elm Lodge DS0000066153.V334011.R03.S.doc Version 5.2 Page 20 activities, meet their personal needs and take all reasonable steps to ensure their health and safety at all times. Evidence at time of the inspection however confirmed that their immediate needs were being meet and that the service users spoken with were happy and content. Relatives spoken with confirmed this in that they felt that their relatives were adequately supported with their needs. The staff training records indicated undertaken training for staff. Staff have received all the required core training according to the evidence seen. Individual and group staff training needs had also been fully identified. Additional courses are planned to ensure that care staff are suitably trained. Out of a staff team of nine two have a NVQ Level 3 in Care, Two have a RMA (Registered Managers Award) and two staff are RGN’s (Registered General Nurses) who are registered with the Nursing and Midwifery Council. The home also benefits from a management team are both qualified in care and management thus providing service user’s with staff who are trained to meet their needs. The home was able to evidence that all staff receive structured induction training (within six weeks of appointment) and foundation training (within six months of appointment) to Sector Skills Council specification (including training on the principles of care, safe working practices, the organisation and worker role, the experiences and particular needs of the service user group, and the influences and particular requirements of the service setting). The home showed that it undertakes a recruitment practice including submission of an application form detailing all previous work history, requests proof of identity and copies of qualification certificates, seeks two written references, and confirms work status. The home’s recruitment files were seen to include all the information as required under schedule 2 of the Care Home Regulations 2001 on information given. Elm Lodge DS0000066153.V334011.R03.S.doc Version 5.2 Page 21 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): 33,37,38 Quality in this outcome group is Adequate Service users and or their relatives cannot be fully confident that the quality of the service is monitored, and that their best interest are safeguarded by appropriate policies and procedures which are all up to date. Service user’s can not always feel confident that their health and safety is protected EVIDENCE: Quality assurance was discussed and the views and opinions of many of the service user’s sought. They confirmed a great deal of satisfaction in living within the home and felt confident that their views and opinions were valued by the staff and management. The manager confirmed that the home does Elm Lodge DS0000066153.V334011.R03.S.doc Version 5.2 Page 22 undertake quality assurance by means of asking service user’s / relatives to complete questionnaires The registered provider of the home does visit the home but does not complete what is known as a Regulation 26 visit (Statutory documented visits by the provider to monitor standards within the home). This requires the owner / provider to assess the quality of care within the home and ensure that it is meeting with the required National Minimum Standards. Such visits need to focus on outcomes for service user’s with regard to quality of care, staffing, adult protection, audits of policies and procedures and that they are followed, staff training, Activities, Health and Safety etc. along with speaking to staff and service user’s. The managers present at the inspection were requested to speak with the provider to ensure that such documented visits occur. Staff assisting with the inspection stated that they were not aware if the home had policies and procedures for all topics set out in Appendix 2 of the National Minimum Standards. The policies and procedures viewed were found to be on the whole out of date and in need of revision. Evidence seen confirmed that old and new policies were present that were in need of some degree of updating and re-organisation. One deputy manager spoken with stated that all policies would be reviewed to ensure compliance. The home has developed a health and safety policy that generally meets health and safety requirements and legislation. It is aware of the areas where they need to make improvements. The inspector viewed records relating to Health and Safety Procedures, maintenance and servicing, and risk assessments. The inspector viewed the Fire Log book, which was up-to-date. The inspector was able to evidence that checks and servicing of fire safety equipment / emergency lighting had been undertaken at the required frequency. Fire risk assessments were in place along with gas safety checks. Evidence was not available however that all of the required health and safety checks had been carried out. Electrical wiring and PAT (Portable Appliance Testing) testing tests were evidenced. The home was requested to review its health and safety procedures to ensure that all elements of safety are inspected and maintained to ensure the safety of service user’s and that the home meets with the standards. Elm Lodge DS0000066153.V334011.R03.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 3 x x x x x 2 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 2 x x x 2 2 Elm Lodge DS0000066153.V334011.R03.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15(1) Requirement The home needs to prepare a plan of care that fully identifies the support needs, how to support, regularly reviewed and all risks identified to minimize risk to health and safety. The registered person promotes and maintains service users’ health and ensures access to health care services to meet assessed needs. The registered person ensures that there is a policy and staff adhere to procedures, for the receipt, recording, storage, handling, administration and disposal of medicines. The premises to be used as the care home should be of sound construction and kept in a good state of repair externally and internally. The provider is required to carry out regular reg 26 visits as per the Care Home Regulations 2001. Such visits should audit the quality of care within the home and include, staffing, adult protection, audits of policies and DS0000066153.V334011.R03.S.doc Timescale for action 27/06/07 2 OP8 12(1) 27/06/07 3 OP9 13(2) 27/03/07 4 OP19 23(2) 27/09/07 5 OP33 26(1) 27/03/07 Elm Lodge Version 5.2 Page 25 6 OP38 12(1) procedures and ensure that they are followed, staff training, activities, health and safety or any other auditing as may be required to monitor the quality of care within the home. This should include consulting the views and opinions of service user’s and staff. The registered person shall 27/03/07 ensure that the care home is conducted so as to promote and make proper provision for the health and welfare of service users. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Elm Lodge DS0000066153.V334011.R03.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 DS0000066153.V334011.R03.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!