Inspection on 05/12/07 for Elm Lodge

This inspection was carried out on 5th December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 27/03/07

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 Sally Gill Key Unannounced Inspection 09:10a 5th December 2007 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.V350691.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 DS0000066153.V350691.R01.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 dee.yates@hotmail.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.V350691.R01.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). 27th March 2007 Date of last inspection Brief Description of the Service: Elm Lodge is registered to provide accommodation and care for up to fifteen older people with a dementia type illness. Dr Vidya Vishwas Sapatnekar owns the business and the Registered Manager, Dolores Yates has day-to-day control. The home is a large detached property with accommodation on two floors. There are nine single bedrooms of which three have ensuites and three double rooms. Bedrooms are situated on the ground and first floor. All rooms have a wash hand basin. Access is provided by a stair lift although steps are still involved. In addition there is a lounge and another small seating area with doors leading to the garden, a separate dining room, two walk-in shower rooms and a bathroom (not assisted). At the rear there is an attractive enclosed garden mainly laid to lawn with established borders and seating. There is wheelchair access to the ground floor. There is a small parking area at the front of the building, which can be accessed from the road; additional parking is also available on the road itself. The home is situated approximately 15-minutes walk from Eastbourne town centre and its amenities including the train station. A bus stop is located just outside the home. The staff compliment consists of a registered manager, two deputy managers, senior health care assistants and health care assistants. Staff work a rota that includes a minimum of two staff on duty day and night. Currently charges are £410.00 to £650.00 per week. Additional charges are made for some hairdressing. Elm Lodge DS0000066153.V350691.R01.S.doc Version 5.2 Page 5 Previous inspection reports are available from the provider or can be viewed and downloaded from www.csci.org.uk. Elm Lodge DS0000066153.V350691.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was carried out over a period of time and concluded with an unannounced visit to the home between 09.10am and 2.45pm. The registered manager assisted throughout. Residents, relatives and staff were spoken to. Observations included interactions between residents and staff. Fourteen people were living at the home on the day of the visit. Surveys were sent to the home to distribute to residents, relatives and health and social care professionals. Feedback received was entirely positive. The care of two residents was tracked to help gain evidence as to what its like to live at Elm Lodge. Various records were viewed during the inspection and parts of the home were viewed. The Annual Quality Assurance Assessment (AQAA) was completed by the home and has been used to inform this report. The home has purchased the neighbouring house and has plans to extend through and increase the numbers of people it can accommodate subject to approval. What the service does well: Everyone spoken to is happy with the care provided at Elm Lodge. Residents said ‘I have always been happy here’, ‘there are lots of party’s’, ‘my family are happy as everyone is so kind to me’, ‘carers are lovely’ and ‘I am always happy’. Relatives felt the home organises family and social things e.g. fireworks, Christmas buffet and activities for the residents every day very well. Comments included they ‘recognise people as individuals and therefore respect individual needs’, ‘my X is well looked after they are treated with respect and is shown much warmth and affection. Elm Lodge feels like a home’, ‘the care given at Elm Lodge is really fantastic they really do care for the patients in their charge. Also the food is beautiful and so much of it’, ‘the staff are brilliant. They are so patient and appear to have all the time in the world. I can honestly say the staff do a wonderful job and are always smiling’, ‘I don’t think a care home could be much better than Elm Lodge as I consider it to be the nearest you could get to living in your own home’ and ‘its in a league of its own’. Relatives said they are always kept informed about their family member and feel part of what goes on in the home. Elm Lodge DS0000066153.V350691.R01.S.doc Version 5.2 Page 7 People can be confident that staff are well trained in subjects relating to residents needs and also their health and safety. People benefit from an atmosphere, which is lively, full of warmth, inclusive and very caring from the manager right through the staff team. What has improved since the last inspection? What they could do better: Improve the protection of people by obtaining more detailed information during recruitment. Make further minor improvements to the medication system to fully protect people. Please contact the provider for advice of actions taken in response to this Elm Lodge DS0000066153.V350691.R01.S.doc Version 5.2 Page 8 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.V350691.R01.S.doc Version 5.2 Page 9 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.V350691.R01.S.doc Version 5.2 Page 10 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, 5 & 6 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives have the information needed to make a decision as to whether this home is right for them. The homes decision to offer a place is based on an assessment of needs. EVIDENCE: People receive information about the home prior to admission so they can make an informed decision whether to move in. The manager advised that usually during the assessment visit prospective people can examine the statement of purpose and service user guide documents which contain information outlining the facilities and services available at Elm Lodge. A copy of the last inspection report is also given at this time. People spoken to confirmed that they had sufficient information prior to moving in. In order for the home to make a judgement as to whether they are able to meet someone’s needs an assessment is undertaken by two staff. This usually Elm Lodge DS0000066153.V350691.R01.S.doc Version 5.2 Page 11 happens in the prospective persons own home. A new format has been introduced which gives a fuller picture of the persons needs and includes an assessment of daily living skills. These are held on file and form part of the care plan. Copies of any professional assessments have also been obtained to aid decision-making. Families confirmed that they and their relatives were able to visit the home prior to admission to get a feel of the place. One relative confirmed that they felt they had sufficient information in order to make a decision as to whether this was the right home for their relative. Another said my X chose the home but I think we’ve landed on our feet here. Staff confirmed that everyone is offered a trial period of four weeks to ensure they are happy to remain and that the home can meet their needs. Intermediate care is not provided. Elm Lodge DS0000066153.V350691.R01.S.doc Version 5.2 Page 12 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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The health and personal care, which a resident receives is based on their individual needs. Care plans have improved although further work on these and risk assessments could evidence the quality of care received. Minor improvements are needed to the medication system to fully protect residents. The principles of privacy, respect and dignity are put into practice. EVIDENCE: People confirmed that those who live in the home have their care and social needs met. However the development of person centred planning could enhance this. The home has introduced a new format for care planning. Two care plans were examined. Together with the assessment these give a fuller picture of the person including health, personal and social care needs and also the person’s end of life wishes. When a person moves into the home the first week is a continuation of the assessment and their skills and abilities are monitored closely both day and night. However record keeping does not reflect the detail given in verbal accounts by staff. Elm Lodge DS0000066153.V350691.R01.S.doc Version 5.2 Page 13 Some training has been completed in delivering person centred care and the manager advised that the home now feels they have the vision as to what this really means. Further training is planned. The home are involving a professional to advise them as the care plans develop. A person centred approach puts the person in the driving seat by finding out what they want from their lives. They are fully involved and care plans clearly show how ‘I’ (the person) wish to be supported and what their goals and aspirations are, they do not talk about the person and they are in a language/format that the person can understand. The home is using life histories, observation and family contact to aid person centre planning although other methods of communicating with people were discussed. Within care plans there is some good information regarding people’s skills and abilities with clear direction to staff of how to ensure these are maintained such as a person cleaning their teeth but this detail is not always consistent. At times the persons objective and the actions get muddled. Staff complete individual daily notes, which could better, reflect practice and that care needs within the care plan are being met. Care plans contain risk assessments to safeguard people. However not all risks are assessed such as some elements of medication management which could leave people at risk. In some cases the actions to minimise risks recorded did not fully reflect all the steps actually in place. Key workers are in place and are aware their role is to build up special relationships with people and at times work on a one to one basis. They also complete a monthly report although one seen lacked a clear picture of the person. Relatives feel that they are kept fully informed about their family members health and care. People have access to all health care professionals both within the home or community to ensure that their health needs are met. Staff and families support people to attend appointments. Relatives said that referrals are made quickly when staff have concerns. Advice and guidance from professionals is followed through into practice to ensure problems are resolved and good outcomes are achieved for people. Separate health care records are now maintained within the care plan to enable better monitoring and to more easily document the outcomes for each visit. Minor improvements are needed to the medication system to fully protect people. A new trolley has been purchased which allows storage and administration to take place safely and conveniently to the person. The trolley was tidy although for safety internal and external medications should be storage separately. One person is self administering some of their medication, which is great, but this must be risk assessed to ensure safety, as should the storage of prescription creams in some bedrooms. The Medication Administration Record (MAR) charts were viewed and showed that there was appropriate use of signatures and codes. Most handwritten entries were Elm Lodge DS0000066153.V350691.R01.S.doc Version 5.2 Page 14 signed and witnessed. Written instructions to staff are in place for PRN medication although would benefit from any authorisation needed before administration to be recorded. All staff that administers medication has received training, which has recently been updated. Medication is logged into and out of the home. There was a relaxed atmosphere within the home. Interaction between staff and people observed during the visit was warm, friendly and supportive and often with the use of good humour. Some issues were discussed with the manager who agreed to address these directly including the storage of plastic bags in toilets and some ensuites, a part frosted glass door to a bedroom and some communal toiletries in a shower room. Elm Lodge DS0000066153.V350691.R01.S.doc Version 5.2 Page 15 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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Social, cultural and recreational activities meet people’s expectations. People receive a varied, wholesome and healthy diet with an emphasis on home cooking. EVIDENCE: People who live in the home enjoy a relaxed lifestyle. Routines are flexible and individual choices and preferences are respected. People said they could choose when to get up or go to bed, where to eat their meals and how to spend their day. Staff advised that activities usually take place during the afternoon and people are encouraged to take part. Arrangements have been made to work with a consultant to deliver person centred activities to people. This will also involve training the staff and looking at ways of communicating with people to help match activities to peoples’ individual interests and abilities. Relatives and staff confirmed that activities include music and movement, dancing, dominoes, art and crafts and skittles. A relative confirmed that the local church singers come in. One relative said ‘they are very good at recognising Elm Lodge DS0000066153.V350691.R01.S.doc Version 5.2 Page 16 seasons by that I mean Halloween, fireworks night (with fire works in the garden) and a summer garden party. These are also opportunities for relatives to meet each other and all the staff. Once the weather is nice the residents are out making the most of the lovely gardens. The staff here has energy, which is stimulating for residents’. One person is able to access the local community and attends a day centre three times a week. Staff have also sourced a local outreach activity group and hope that some people will be able to attend with staff support. Several people go our regularly with families and friends. Relatives confirmed that they are always made to feel welcome and offered tea and biscuits or homemade cake. One relative said I feel I have become part of the scene. Another said everyone is very friendly and they keep us informed about what’s going on. There is a choice of communal areas where people can have a chat in addition to peoples own bedrooms. There are four weekly menus in place which is not a choice menu but alternatives are available such as salads or an omelette. A person said ‘the food is very good but you always get someone who will moan’. People enjoy meals, which are home cooked and reflect traditional English food. Fresh meat and vegetables are delivered regularly from local shops. Special diets are well catered for including diabetic and those requiring a liquidised diet. People have the option of where they can take their meals some using the dining room and others prefer their room. Both hot and cold drinks were readily available for people throughout the visit. Elm Lodge DS0000066153.V350691.R01.S.doc Version 5.2 Page 17 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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People have access to a robust complaints procedure, feel confident to voice any concerns and are protected from abuse. EVIDENCE: People are aware of the complaints procedure, which is displayed within the hallway of the home. This has been updated to include the new address of the Commissions local office. The manager advised that no formal complaints have been received for sometime but a record would be maintained. Relatives felt confident to complain but added there’s really nothing to complain about. People felt confident that should they have any concerns the manager would resolve any issues. One relative gave an example of where they are not entirely happy with their relatives room and said a plan has been put in place with the manager and owner to address this in the near future. The owner and manager both confirmed this would be addressed. Any concerns that are highlighted in the quality assurance questionnaires are responded to individually and action taken to address them. People who live in the home are protected from abuse through good policies and procedures. All staff has received training in safeguarding adults. A staff member spoken to knew how to report abuse both inside the home and also to Elm Lodge DS0000066153.V350691.R01.S.doc Version 5.2 Page 18 external agencies. Staff all have protection of vulnerable adults (POVA) and Criminal Record Bureau (CRB) checks in place before staff are recruited. Elm Lodge DS0000066153.V350691.R01.S.doc Version 5.2 Page 19 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, 23, 24, 25 & 26 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People benefit from a safe, comfortable and homely environment, which continues to be improved. EVIDENCE: People who live in the home benefit from the pleasant homely environment. Work has gone into improving the environment for people living there with good results since the last inspection. Two bathrooms have been completed refurbished. This means that people now have two walk-in shower rooms and one bathroom. The manager advised that at present people prefer to have a shower. A new stair lift has been installed which enables people to turn away from the top of the stairs before getting off making it safer. Two bedrooms have had new carpets. A new industrial washing machine and tumble dryer have been purchased to make the laundry more efficient. Further Elm Lodge DS0000066153.V350691.R01.S.doc Version 5.2 Page 20 improvements are planned such as upgrading the last shower room and some ensuite facilities, which is needed. Also a new laundry room, which will ensure it, has readily cleanable surfaces and increasing the size of the kitchen. The kitchen was also due to have a deep clean by contractors on the night of the visit. Most areas of the home are decorated to a good standard and the other rooms are included in the development plan. There is a lounge and additional seating area where people can sit and relax. The dining room is pleasant and has doors leading to the well-maintained garden with a lawn area and seating and is enhanced by hanging baskets and flower tubs. People have been able to personalise their own rooms. They have been encouraged to bring in small items of furniture to make their rooms as homely as possible. There are sufficient adapted shower/bathrooms and toilets around the home. The home has fitted hot water safety valve to all bedrooms since the last inspection making hot water safer for people to use. The home on the day of the visit was clean and a relative said it always smells fresh. Clinical waste is handled and disposed of safely. An annual infection control audit is undertaken by the home. Elm Lodge DS0000066153.V350691.R01.S.doc Version 5.2 Page 21 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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are supported by a caring and committed staff team who are trained, qualified and understand their needs. EVIDENCE: Relatives feel the staff are charming and caring. On the day of the visit two staff were on duty during the day in addition to the deputy and manager who were also working. There is a cook and a cleaner each day. There is two staff on at night. Relatives confirmed that there is a cultural mix of staff but language is not a problem. People are protected through recruitment policies and procedures. Relatives confirmed that staff turnover is low. Two staff files were examined. The manager advised that application forms have recently been updated although they do not request a full employment history, which they must. The employer must also check out any gaps in employment history and detail an explanation to protect people. Two references are obtained and a POVA and CRB in place prior to employment. Four staff has National Vocational Qualification (NVQ) level 2, 3 or 4 and another two are undertaking NVQ. This will meet the 50 target. In addition two staff are qualified nurses. Elm Lodge DS0000066153.V350691.R01.S.doc Version 5.2 Page 22 People can be confident that staff are well trained. Staff undertake an induction, which meets Skills for Care specification and staff said they also shadowed an experienced member of staff for approximately a week. Training is well organised with a programme already in place for 2008. Staff have undertaken training in understanding dementia, Alzheimer’s, care planning, managing diversity, bereavement, continence, special diets, malnutrition and diabetes as well as mandatory training. Elm Lodge DS0000066153.V350691.R01.S.doc Version 5.2 Page 23 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, 32, 33 & 38 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of the people that live there. The health and safety of people who live in the home is promoted and protected. EVIDENCE: People can be confident that the management are committed to promoting their best interests. The manager has obtained her Registered Mangers Award (RMA) NVQ level 4. Relatives described her as dynamic, energetic, enthusiastic, warm and gives lots of affection to the residents. One said ‘she is very hands on and cares about me as well as my X. It’s a family home’. Staff feel she is hard working, supportive and one of the team. Elm Lodge DS0000066153.V350691.R01.S.doc Version 5.2 Page 24 All aspects of the home are monitored monthly using forms created by the home. These highlight any areas that need attention. A full health and safety audit is carried out every two months. The manager has an action plan to focus on areas for development. Quality assurance surveys are conducted six monthly, which include different people who use the service such as residents, their relatives, staff and health and social care professionals. Any negative feedback is addressed and individual correspondence is sent to communicate what action has been taken. Staff meetings are usually held monthly. Staff confirmed they receive regular supervision. The owner confirmed that regulation 26 visits are undertaken monthly. People who live and work in the home are protected through good policies and procedures and through safe working practices. Their health and safety is promoted by staff who are trained in moving and handling, basic food hygiene, first aid, fire safety, infection control and health and safety. Regular safety checks are carried out on equipment and installations. Elm Lodge DS0000066153.V350691.R01.S.doc Version 5.2 Page 25 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 X 3 N/A 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 3 3 2 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 3 X X 3 3 X Elm Lodge DS0000066153.V350691.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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 OP29 Regulation 19 & Schedule 2 Requirement The home must obtain a full employment history and record a written explanation where there are any gaps Timescale for action 05/01/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations Ensure internal and external medications are stored separately, written risk assessments are in place for self administration and storage of prescription cream in bedrooms Elm Lodge DS0000066153.V350691.R01.S.doc Version 5.2 Page 27 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.V350691.R01.S.doc Version 5.2 Page 28 - 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!