Inspection on 04/09/07 for Elm Lodge

This inspection was carried out on 4th September 2007.

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

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

Other inspections for this house

Elm Lodge 14/04/08

Elm Lodge 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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Elm Lodge 4a Marley Close Greenford Middlesex UB6 9UG Lead Inspector Clare Henderson Roe Key Unannounced Inspection 4th September 2007 10:20 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.V347863.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.V347863.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 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.V347863.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. 11th June 2007 Date of last inspection Brief Description of the Service: The home has been purpose built to meet the National Minimum Standards for Older People. It is situated in a residential area of Greenford, and is easily accessed via public transport and the A40. There are shops within reasonable walking distance to the home. The home comprises of 5 units, each of which can accommodate 15 residents. All bedrooms are single with en suite toilet, wash hand basin and shower facilities. Each unit has a communal sitting/dining area with a kitchen area plus a separate quiet/activities room. Four of the units are registered to provide personal care and one unit is registered to provide nursing care. Each unit is individually staffed. The home accommodates service users placed by the Borough of Ealing. With regard to the fee rates for the home, the Major Projects Manager for Ealing Council has provided the following information: Elm Lodge was developed under the Governments Private Finance Initiative and capital costs are met in this way. Ealing Council pays a Unitary Charge, which covers all the services the Council receives from Ealing Care Alliance. It covers the costs of care and the provision of facilities management services to the day care service and accommodation. It is not possible to separate these out to identify how much each residential care and nursing care placement costs. The fee payable to the Council by residents who fund themselves in full is £495.00 per week for residential care. The fee payable to the Council by residents who fund themselves in full is £612.00 per week for nursing care. Deducted from that will be the free nursing care amount of £125.00 (high) and £83.00 (medium and low). Elm Lodge DS0000061258.V347863.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of 26 hours was spent on the inspection process, and was carried out by 3 Inspectors, one of which was a CSCI Pharmacist Inspector who examined the management of medications. The Inspectors carried out a tour of the home, and service user plans, medication records & management, staff rosters, staff records, financial & administration records and maintenance & servicing records were viewed. 18 residents, 20 staff and 3 visitors 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 service users, representatives/visitors and health & social care professionals have also been used to inform this report. At the time of inspection an Acting Manager, 2 Heads of Nursing and 1 Head of Care present. These people are referred to as ‘the management’ in this report. What the service does well: Prospective residents are fully assessed prior to admission plus the home obtains copies of Social Services and associated healthcare professionals assessments to ascertain if they can meet the assessed needs. Staff care for residents in a gentle, courteous and professional manner, respecting their privacy and dignity. The home has an open visiting policy and visiting is encouraged. Visitors spoken to said that they are made welcome and positive feedback was also received on the CSCI questionnaires. Advocacy services are available and this is to be further explored for residents without anyone to act on their behalf. The meal provision is good and varied, meeting the individual preferences, cultural and religious needs of the residents. Copies of the complaints procedure are displayed throughout the home and systems are in place to manage complaints effectively. The home has been purpose built to a good standard, providing the residents with a pleasant and homely environment to live in. Staffing levels were appropriate to meet the assessed needs of residents and these are kept under ongoing review. There was good teamwork and staff commented that they were happy in their work and had been supported to improve practices overall. Staff receive training to include induction training plus mandatory training and updates and training in topics relevant to the diagnoses and needs of the residents. The management are aware of the need to increase the ratio of staff with NVQ in care level 2 or the equivalent to 50 and are working towards this. There are robust procedures in place for staff recruitment and these are followed. Residents personal monies are being well managed on their behalf and are securely stored. There are good procedures and practices in place for the management of health & safety in the home. Elm Lodge DS0000061258.V347863.R01.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.V347863.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.V347863.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. 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 persons needs. EVIDENCE: The home has a comprehensive pre-admission assessment document that provides a good picture of the resident and their needs. This is completed for all prospective residents, and one viewed had been well completed. The home also obtains a copy of the needs led assessment undertaken by social services. Elm Lodge DS0000061258.V347863.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. Although there has been an improvement in the completion of service user plans, shortfalls identified could place residents at risk. Shortfalls in medication management and recording could place residents at risk. Staff care for residents in a courteous and professional manner, respecting their privacy and dignity. Shortfalls in identifying end of life care needs place residents at risk of not having there needs fully met. EVIDENCE: 7 service user plans were viewed as part of the inspection process. There had been a good improvement in the completion of the care plans, which were comprehensive and personalised. There was evidence of monthly reviews being carried out. There was evidence of input from residents and their representatives on the 6 monthly review documents completed in some of the service user plans viewed, plus some residents had signed to say they had read and agreed the service user plan. Risk assessments for falls were in place, however these had not always been updated following a fall. This is a Elm Lodge DS0000061258.V347863.R01.S.doc Version 5.2 Page 10 repeat finding. Some documents did not have a section to include the date of completion and this needs to be addressed. Assessments for moving & handling, continence and pressure sore risk had been completed and where a need had been identified a care plan had been formulated to show how each need was to be met. Nutritional assessments were also in place, however these had not always been updated following a change in a residents’ weight. For one resident, the records showed a marked weight loss in one month. The resident was weighed at the time of inspection and it was clear that the previous low reading had been inaccurate and the residents weight was stable. The importance of ensuring that all weight readings are accurate was discussed, plus the need to act upon any evidence of unexplained weight loss by referring the resident to the GP for assessment and referral to the dietician. Bedrail assessments had been formulated, however the document did not identify each individual reason for and the appropriateness of their use. There was evidence of input from healthcare professionals to include district nurse, GP, dentist, chiropodist, optician and community psychiatric nurse. A thorough audit of medication was undertaken in each unit in the home. It was noted that in the residential units, generally, the recording of receipts of medication, administration and disposal was much improved. Care workers still need to ensure though that they sign the Medication Administration Records (MAR) at the time of administration. A count of medicines in several original packs proved that the records were accurate. This means that residents were receiving their medication as prescribed. There was good practice in the home of keeping information on dosage changes, discharge letters etc with the MAR for reference. The doctor and practice nurse had requested that the Blood Pressure be recorded for a resident on Bow Street but no records could be located. A resident with diabetes could not administer an increased dose of insulin because the district nurse had not called to pre-fill a syringe. The home still needs to ensure that to prevent the risk of infection from blood borne diseases that lancets for professional use are used in the home when testing blood glucose. When residents went away on leave there were records of leave on the MAR. Care workers should record what medication is being give to the family as per the homes policy. Attention is needed to ensure the safe handling of medication in the nursing unit. Medication must be checked and recorded accurately when received into the home so that residents do not run out of their medication. It was not always possible to audit medication because of inaccuracies in recording. When variable doses are prescribed then the actual dose administered must be Elm Lodge DS0000061258.V347863.R01.S.doc Version 5.2 Page 11 documented. Bank staff must have thorough induction and know where to send prescriptions and how to record administration by signing a chart not ticking. If a weekly compliance aid is used and there is a dosage change it should be returned to the pharmacist for re-dispensing. If an insulin pen is not used for a resident then the GP should be requested to prescribe vials of insulin not the cartridges. The balance of buprenorphine patches was wrong in the home. Controlled drugs (CD) must be checked and recorded by two people when received into the home and any discrepancies notified to the supplying pharmacist immediately. Unwanted CD should be disposed of in a denaturing kit. Otherwise if not in use at least weekly checks of balances should be recorded. Some attention is needed in three of the units in recording accurately the minimum and maximum temperature of the fridges. Dates of opening were written on eye drops and liquid medicines but it was noted that one bottle of eye drops was still in use three days after it had expired. It was pleasing to note that the room temperature was now maintained at a suitable temperature to maintain the potency of the medication. Staff were seen caring for and speaking with residents in a gentle and courteous and professional manner and there was good interaction on the residential units. Some staff on the dementia care nursing unit were not communicating effectively with the residents and the importance of good interaction was discussed. The Management said that more training in dementia care is taking place and communication skills will be included in this. Clothing viewed had been labelled and bedrooms had been personalised. Residents were well dressed to reflect individuality and cultural respect. The care plans contained very brief reference to the end of life wishes and needs of each resident. The importance of ascertaining the wishes of the resident and their families and recording this so that the information is available and known was discussed. Training and procedures for staff in palliative or end of life care would ensure staff have the knowledge to care for residents effectively during their last days. Elm Lodge DS0000061258.V347863.R01.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 good. This judgement has been made using available evidence including a visit to this service. The activities provision has increased and an activities co-ordinator employed to provide residents with activities to meet their assessed needs. The home has an open visiting policy, thus encouraging people to maintain contact with family and friends. Information regarding advocacy services was available, thus peoples right to individual representation is respected. The food provision in the home is good, offering variety and choice, thus meeting peoples’ individual needs. EVIDENCE: The home has employed an activities co-ordinator who is due to start on 10/09/07. The person is experienced in this area of work and will be in charge of the activities provision for the residents. In the meantime some outings have been arranged and staff have been carrying out some activities with residents on the units. The management explained that music for reminiscence therapy has been ordered and additional equipment for activities has been purchased, with plans for more items to be bought. Feedback regarding the shortfall in the current activities provision had been received on CSCI comment cards returned and when speaking with the management it was clear that they are very aware of the importance of activities to meet residents interests and Elm Lodge DS0000061258.V347863.R01.S.doc Version 5.2 Page 13 abilities and they intend to provide a good range of activities in future. Life history information had been obtained for some residents, and care plans for activities had been completed, and are to be further personalised once the activities co-ordinator is in post and can find out more about the residents’ individual interests. The home has an open visiting policy and visiting is encouraged. Visitors spoken with said that they are made welcome at the home and are offered refreshments. Residents can choose to receive visitors in their own bedrooms or in one of the communal areas. The home has an advocate from Alzheimer’s Concern who is involved in supporting residents and relatives plus providing training for staff. They also provide individual advocacy services. The home also has access to Ealing ‘First Voice’ advocacy services and the Acting Manager said that there are some residents without a representative and that he would look into arranging advocates for these residents. One Inspector viewed the kitchen and it was clean and tidy. Kitchen records to include fridge, freezer and food temperatures, cleaning records and lists of resident meal choices for the 3 daily meals were available and up to date. The cook said that they ensure that if a resident wants an alternative to the meal options available then this is provided. The kitchen staff work hard to provide a good standard of food, meeting the religious and cultural needs of the resident groups. There was a good supply of fresh, frozen, tinned and dried foodstuffs available, and those viewed were in date. Each unit has a kitchen area where hot and cold drinks and snacks can be prepared and these are available throughout the 24 hour period. Residents spoken with expressed their satisfaction with the meal provision at the home, and one resident said ‘I look forward to mealtimes’. Staff were available to assist residents as required. One resident was being assisted with a pureed meal, and all elements had been mixed in together, and the meal looked unappetising. The importance of ensuring all meals are presented in an attractive and appetising manner was discussed with the management. On the Asian unit a menu to meet the cultural and religious needs of the residents was being provided. Elm Lodge DS0000061258.V347863.R01.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 policies and procedures in place for the management of complaints and adult protection issues, and these are followed, thus safeguarding the residents. EVIDENCE: Servite Houses has a complaints procedure and comment sheets and copies of these were freely available in the entrance of the home. The Service User Guide also contains complaints procedure information to include contact details for CSCI. On the Asian unit the complaints procedure was displayed in Hindi, Punjabi and Gujarati. The home has had 2 complaints since the last inspection and complaints are being correctly managed. The home has procedures for adult protection plus they follow the Ealing Safeguarding Adults procedures. Following the last inspection any POVA issues identified had been reported, investigated and appropriate action taken to address them. Staff spoken with were clear to report any concerns and understood Whistle Blowing procedures. Written information regarding recognising and reporting abuse was on display throughout the home. Elm Lodge DS0000061258.V347863.R01.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, 24 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is purpose built and well maintained, and bedrooms are personalised, thus providing a clean, homely and safe environment for residents to live in. Procedures are in place for infection control and these are practiced, thus minimising the risk of infection. EVIDENCE: The home was purpose built and has been open for a year. At the time of inspection the builders were present and carrying out ‘snagging’ repairs that had been identified and listed. The units have been well decorated and furnished and provide a very homely environment. There were no fire safety issues noted at the time of inspection. The kitchen has been reviewed and plans drawn up to improve the layout in line with health & safety. Bedrooms are bright and several viewed had been personalised, giving a homely feel to them. En suite facilities include a toilet, wash hand basin and Elm Lodge DS0000061258.V347863.R01.S.doc Version 5.2 Page 16 shower facility. Residents spoken to were very pleased with their rooms and the facilities provided. For residents on the nursing unit, height adjustable beds had been provided. Assisted bathing facilities are available on each unit. One Inspector viewed the laundry. This was clean and tidy and it was clear that the staff were taking great pride in their work, to ensure residents personal clothing is being well cared for. Protective clothing to include gloves and aprons were available on each unit and staff were clear of the importance of effective infection control. Two bedrooms were malodorous and this emanated from the carpets. This was discussed with the management with a view to replacing the carpets with alternative flooring suitable to meet the residents individual needs. The home was clean and tidy throughout. Elm Lodge DS0000061258.V347863.R01.S.doc Version 5.2 Page 17 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. Training provision is good, 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: At the time of inspection staffing levels on each unit were appropriate to meet the assessed dependencies of the residents. The Acting Manager explained that staffing is kept under review and where a need for additional staff is identified this is actioned. Three residents were currently requiring 1:1 care to meet their needs. The home does use agency staff, and endeavours to have long-term agency staff in order to provide continuity of care to the residents. The management reported that there has been an effective recruitment drive with new nurses, senior carers and carers being employed, and awaiting employment checks to be completed. The home was clean and tidy and appropriate numbers of housekeeping, catering and ancillary staff were on duty to meet the needs of the home. The Inspectors were informed that a receptionist is available from 8am to 9pm every day and this has reduced issues with visitors having to wait to be admitted to the home, plus telephone calls are being much better managed. Staff were courteous and there was a happy atmosphere throughout the home. Elm Lodge DS0000061258.V347863.R01.S.doc Version 5.2 Page 18 The AQAA evidences that 13 staff have either attained NVQ level 2 or above in care or are currently undertaking this training. This is below 50 of the care staff and the management were aware of the importance of having 50 of the care staff trained as soon as is practically possible. One Inspector viewed 3 sets of staff employment records. The paperwork for staff employment is sent out and collated at head office, and the lists available in the home did evidence that all required checks had been carried out. Some of the health questionnaires were not seen and the Head of Care said that these are given out with the Criminal Records Bureau check documentation and would have been received by head office prior to the person being employed. Evidence of these checks being completed should be available in the home. The home has an induction programme that incorporates the Skills for Care Common Induction Standards. The management confirmed that these are given out to all new employees, with some adaptations made for the nursing and ancillary staff. There was evidence of increased training provision in both mandatory and other topics relevant to the needs and diagnoses of the residents. The need for increased training for staff had been identified on one of the CSCI questionnaires and the management said that this had already been identified and was being addressed. Elm Lodge DS0000061258.V347863.R01.S.doc Version 5.2 Page 19 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 good. This judgement has been made using available evidence including a visit to this service. The current management arrangements for the home are effective and the staff concerned have the experience to manage the home appropriately. Systems for quality assurance are in place, thus providing an ongoing process of review and feedback. Monies held on behalf of people living at the home are being well managed and securely stored, thus safeguarding them. Staff are not receiving formal supervision, thus not providing them with individual opportunities to discuss support and development needs. Overall the systems for the management of health & safety throughout the home are good, thus safeguarding people living at the home, staff and visitors. EVIDENCE: Elm Lodge DS0000061258.V347863.R01.S.doc Version 5.2 Page 20 At the time of inspection an Acting Manager, 2 Heads of Nursing and Head of Care were present at the home. Following the last inspection the Registered Provider had taken action to improve the management input for the home in order to improve standards throughout. It was clear at this inspection that the home was being effectively managed and had improved since the last inspection in several areas, however more improvements are required and thereafter the improvements must be sustained. The Acting Manager has an open door policy and staff spoken with said that he is very supportive and manages change in a constructive manner, explaining the reasons for the change and listening to the views of the staff. The Acting Manager intends to introduce a new quality assurance programme for the home to audit all aspects of the home. Currently monthly medication audits and daily MAR chart audits are carried out. Other audits seen were health & safety, kitchen safety and fire safety. Each morning the management meet with the senior care worker on each unit and discuss any issues, audit the MAR charts and receive handover for each resident. Any issues identified can then be effectively managed and addressed. Regulation 26 unannounced inspections are carried out on behalf of the Registered Person and reports made available. The management carry out a monthly audit from which they compile a monthly report for Ealing Care Alliance. Minutes of residents meetings were on display. The Acting Manager said that he did meet informally with representatives and other visitors as part of the day-to-day management of the home in order to provide opportunities to discuss any issues. The home holds personal monies on behalf of the residents. One Inspector viewed 5 sets of records and balances for personal monies. These were up to date and being accurately maintained. Clear records of income and expenditure are maintained and receipts are kept. Monies are stored securely. In the employment files viewed some supervision contracts and records were available. Staff had not been receiving formal supervision every 2 months and the management were aware of the need to address this. One Inspector viewed the servicing and maintenance records. The maintenance records were up to date and clearly completed. Some of the servicing record information was not available and the Acting Manager followed this up and confirmed that all servicing is taking place. Risk assessments for equipment and safe working practices were available and due to be reviewed. Individual risk assessments had been completed for each resident to identify specific risks and state the action to be taken to minimise it. Those in the kitchen were due for review and the Acting Manager said he would ascertain what is happening in the light of a new contractor taking over the catering dept. The fire risk assessment had been last updated on 29/06/07. Fire records to include fire drills were up to date. The health & safety audit had last been completed in March 2007. Staff training and updates in health & safety topics Elm Lodge DS0000061258.V347863.R01.S.doc Version 5.2 Page 21 had been planned and the management were very aware of the need to ensure all staff are kept up to date in this area. Elm Lodge DS0000061258.V347863.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 2 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 3 17 X 18 3 3 X X X X 3 X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 2 X 3 Elm Lodge DS0000061258.V347863.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 13 Requirement Risk assessments for falls must be carried out for all service users. These must be reviewed monthly and following any falls. Previous timescales of 01/03/07 & 01/07/07 partially met. There must be evidence that action has been taken to address any findings of weight loss, in order to safeguard the resident. Previous timescale of 13/07/07 not met. Where it is proposed bedrails be used, a full assessment to identify the reason for and appropriateness of their use, plus a signed consent for their use must be in place. Previous timescale of 13/07/07 partially met. Care workers must follow the procedures of the home and sign the medication administration record immediately after they have observed the medicines to be taken. Details of the medication given to residents for a period of leave should also be DS0000061258.V347863.R01.S.doc Timescale for action 01/10/07 2. OP8 17(1)(a) 14/09/07 3. OP8 13 01/10/07 4. OP9 13(2) 05/09/07 Elm Lodge Version 5.2 Page 24 5. 6. OP9 OP9 13(2) 13(2) 7. OP9 13(2) 8. OP9 13(2) 9. OP9 13(3) 10. 11. OP9 OP11 13(2) 12 12. OP26 13(3) 13. OP36 18(2) recorded. Expiry dates must be checked and medicines not used past this date. Records must be available for the resident having his blood pressure monitored because of changes in medication. Medicines including Controlled drugs must be checked and recorded accurately when received into the home. Bank staff must have an induction and be familiar with the homes procedures for ordering and administration and recording of medication. Variable doses must be recorded accurately. To prevent the risk of infection the home must use lancets for professional use when testing for blood glucose. This is a repeat requirement. Timescale of 01/03/07 and 01/07/07 not met. The minimum and maximum temperature of the fridge must be recorded in all units. 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. Action must be taken to address the malodorous rooms to provide the residents with a safe and pleasant environment to live in. Staff must receive regular formal supervision so that their progress, support and development needs can be discussed and addressed. 05/09/07 10/09/07 05/09/07 11/09/07 18/09/07 10/09/07 01/12/07 01/10/07 01/12/07 Elm Lodge DS0000061258.V347863.R01.S.doc Version 5.2 Page 25 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. 6. Refer to Standard OP7 OP9 OP9 OP9 OP15 OP29 Good Practice Recommendations That all documentation is signed and dated at the time of completion. That the home carries out at least a weekly check of balances of Controlled Drugs. That when weekly dosett boxes are used they are sent back to the pharmacy for re-dispensing when dosage changes occur. That there continues to be robust auditing of medication in the home to ensure that it is handled safely and administered as prescribed. That for the pureed meal each food item be pureed separately and presented appetisingly on the plate. Written confirmation that health questionnaires have been completed for all employees should be available in the home. Elm Lodge DS0000061258.V347863.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.V347863.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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