Inspection on 07/12/06 for Elm Lodge

This inspection was carried out on 7th December 2006.

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 16/05/07

Elm Lodge 16/12/05

Elm Lodge 18/07/05

Elm Lodge 24/01/05

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

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

CARE HOMES FOR OLDER PEOPLE Elm Lodge Cluntergate Horbury Wakefield West Yorks WF4 5DB Lead Inspector Susan Vardaxi Unannounced Inspection 09:00 7 & 11 December 2006 th th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Elm Lodge DS0000062249.V313265.R02.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Elm Lodge DS0000062249.V313265.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elm Lodge Address Cluntergate Horbury Wakefield West Yorks WF4 5DB 01924 262420 01924 262420 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) Mrs Julie Mortimer Mr Philip Mortimer *** Post Vacant *** Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17), Physical disability over 65 years of age of places (17) Elm Lodge DS0000062249.V313265.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named service user with category DE (E) Date of last inspection 16th December 2005 Brief Description of the Service: Elm Lodge Care Home is registered to provide care for 17 Older People. It is located close to the centre of Horbury, Wakefield. The home is on the local bus route and all the local amenities are easily accessible. The home is set back in its own grounds and has a large walled garden with a lawn to the front and car parking space to the rear. The home provides a large communal lounge a small quiet room with a telephone for the service users use and a dining room. The local Health Centres support the home and provide health care as required. The provider makes information about the service to enquirers when initial enquiries are made. The fees charged in December 2006 were from £359 hairdressing & chiropody are charged in addition to the fees. The provider makes information about the service to enquirers when initial enquiries are made and of the Commissions role in the service user guide. Elm Lodge DS0000062249.V313265.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit completed on the 7th & 11th December 2006 over 11 hours and included talking with service users, three relatives, 3 staff and the providers and manager. Some records were inspected; a tour of the building completed. Some surveys forms were sent to service users, their relatives and health workers to record their views of the service. At the time of this visit ten were completed and returned to the Commission. The inspector would like to thank the service users, relatives/representative and all who participated with the overall inspection process for their co-operation. The current manager was appointed at the home in April 2006, she had not made application to be registered with the Commission at the time of this visit. Some requirements have been carried forward from previous inspections and additional requirements have been made as a result of this inspection. What the service does well: What has improved since the last inspection? Elm Lodge DS0000062249.V313265.R02.S.doc Version 5.2 Page 6 A new method for recording care plans was being introduced. Care plans seen were written to a good standard and included the action required to meet individual needs. Nutritional assessments had been completed and new weighing scales purchased as required at the last visit. The manager said she had arranged for service users meals to be served at two sittings to give privacy to service users who needed assistance to eat their meal. Menus have been introduced since the last visit. New dining tables had been purchased; the environment looked pleasant and comfortable for service users to eat in. Staff spoken with were aware of the homes whistleblowing policy however, adult protection training has not been provided for all staff. A window had been replaced with a type that would provide natural ventilation in a bedroom and an automatic door-closing device fitted on a bedroom door as required at the last visit. The manager has worked to provide more training opportunities for staff and all staff are now registered to do NVQ and manual handling training. What they could do better: To ensure that the home is operating as required by the Care Standards Act 2000 the person managing the home must make application to the Commission to be registered. The medication records examined showed some discrepancies in the amount of medication in stock and the records indicating that the medication had not been administered as prescribed which could affect service users health. Some service users are unable to access the emergency call system when sitting in the communal lounges. When staff are not present in the lounge this could lead to care needs not being met and could contribute to falls. The level and deployment of staff was said by a senior carer to sometimes mean that the two staff on duty may both be caring for one service user, which means other service users have no one available to respond to their needs. There was discussion with the provider of the need to review this to ensure that service users are appropriately supervised and their needs met. The provider said she is ready to complete her fire training provided by the fire service, which will enable her to cascade the required fire training to the staff. Elm Lodge DS0000062249.V313265.R02.S.doc Version 5.2 Page 7 Staff should also be involved in fire drills to enable them to respond appropriately to the situation should a fire occur. 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 DS0000062249.V313265.R02.S.doc Version 5.2 Page 8 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 DS0000062249.V313265.R02.S.doc Version 5.2 Page 9 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 2,3,6 Service users are provided with information about the service and have the opportunity to visit the home prior to a decision being made to live there. Pre admission assessments are completed and information recorded appropriately. Intermediate care is not provided EVIDENCE: The outcomes of survey forms sent to service users by the Commission prior to the inspection showed from the ten received all had been provided with a contract. Elm Lodge DS0000062249.V313265.R02.S.doc Version 5.2 Page 10 Service users’ records checked showed that pre admission assessments are completed and a service user had visited the home prior to admission. Letters to service users confirming the home can meet their needs were seen. Elm Lodge DS0000062249.V313265.R02.S.doc Version 5.2 Page 11 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): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. 7,8,9,10,11 Information in respect of service users’ health, personal and social care needs are set out in their individual care plans. Medication records indicate that medications are not always administered as prescribed. Service users privacy and dignity is protected. EVIDENCE: There were nine service users sitting in the large lounge at the beginning of the visit. They looked well groomed and comfortable and breakfast had been taken. A member of staff spoken with said five service users were up and dressed when they arrived for work at 8am and that this had been the service users’ choice/preference. This was confirmed in records seen. Elm Lodge DS0000062249.V313265.R02.S.doc Version 5.2 Page 12 The providers have developed a new care plan format which is currently being used to update all service users care needs and ensure identified needs are met. A provider said they are” aiming to store all care plans electronically.” Care plans seen had been reviewed and changes in need recorded and development ongoing. A service user’s care plan seen had been reviewed regularly. The service user was ill and on bed rest and monitoring forms were in place for fluid intake and pressure area relief. This had been well managed; a district nurse said no pressure sores were present. However further development in respect of the service user’s dietary needs is needed and this was discussed with the manager at the time of the visit. A visiting district nurse said staff were meeting the service user’s needs appropriately, she said that the manager had responded immediately when she had recommended a product to be provided to prevent the service users lips from becoming sore. The service user looked clean and comfortable in the hospital bed provided by the district nurses, the bedroom is shared with another service user, the manager said the screens in the room are placed between the beds when both service users are in the bedroom and across the door opening when the bedroom door is open. Weight checks had been completed on the records seen. Some nutritional assessments had been completed and weighing scales provided as required at the last inspection The nurse said that two service users when terminally ill had been well cared for during their illness. Comments made by a GP who took part in the Commissions survey showed that they did not have any concerns about the home and are satisfied with the care provided. Records of GP, district nurse, chiropody and opticians visits were seen on the records checked. The provider escorted a service user to an outpatient appointment another service user went to outpatients escorted by the relative at the time of the visit. Medication records and medications in stock were checked. Discrepancies were observed in the balances of some prescribed medications that are provided in sachets. The number of sachets in stock and the number of signatures on the medication records did not balance indicating that some had not been administered. This was brought to the manager and providers’ attention during the visit. The medications returned to the Pharmacist records were checked and it was seen that some medication in sachets had been returned to the pharmacist at the end of the previous medication monthly cycle indicating that these medications had not been administered correctly during that month also. Elm Lodge DS0000062249.V313265.R02.S.doc Version 5.2 Page 13 The manager said she was aware of this and meetings had been held with staff in respect of this, however this had not stopped this practice from reoccurring. The manager said she had planned to audit medication procedures, however this had not occurred up to the time of this visit. The manager said she had arranged for service users meals to be service at two sittings to give privacy to service users who need staff assistance to eat their meal. Elm Lodge DS0000062249.V313265.R02.S.doc Version 5.2 Page 14 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 12,13,14,15 Service users do not always consider that there are enough opportunities at the home for social stimulation. Family and friends feel welcome and know they can visit the home however their religious needs are not being met. Service users are generally satisfied with the meals provided. EVIDENCE: Service users views varied on the provision of activities at the home, of 10 surveys received, three considered that there were activities that they could take part in, five felt there were usually activities for them and two only sometimes. The manager said that they have been unable to arrange regular visits from the local clergy. Elm Lodge DS0000062249.V313265.R02.S.doc Version 5.2 Page 15 A list of activities were seen and discussed with the manager who said that an activities person visits the home weekly. The list included hairdressing. Some service users had made Christmas cards for their relatives. The provider said she had arrangements for service users to have physical motivation sessions on a two weekly basis. The providers said entertainers visit fortnightly and a singer visits once a month. She said in house activities include bingo domino games and group discussions when current affairs are usually the topic of discussion. It was considered from discussions with the providers and staff at this visit that the staffing levels do not enable staff to spend time motivating service users. Some service users spoken with said they are offered a choice of meal daily and can get up when they want to and this was seen recorded in their care plan. Relatives spoken with said they can visit at any time and privacy is given to their visits. The menus were seen and the meals served at lunchtime to be adequate however meals in the evening consist generally of sandwiches prepared by the cook before she goes off duty, the two carers on duty then serve the meal. New dining tables and chairs had been purchased; the environment provides a pleasant environment for service users to eat their meals in Elm Lodge DS0000062249.V313265.R02.S.doc Version 5.2 Page 16 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 16,17,18 Information provided on surveys and discussions with service users indicate that service users and their relatives/representative are aware of the homes complaints procedure. Arrangements are made for service users to vote. Staff are aware of their duty under the homes whistleblowing policy and when required make referral to the POVA list. EVIDENCE: The homes complaints procedure is currently being revised. A complaint had been made by a social care professional, which the Commission was aware of prior to the visit. The records seen showed that the providers had responded appropriately. The provider said a new method of recording was being developed and the complaint procedure revised. Of 10 surveys received from relatives 9 said they were aware of the homes complaints procedure. 10 surveys received for service users showed that some could be unsure of how to make a complaint. Elm Lodge DS0000062249.V313265.R02.S.doc Version 5.2 Page 17 The providers said service users had received letters in respect of voting which would be given to the service user or if applicable their advocate. The providers said some staff had undertaken safeguarding training and training was planned for the remaining staff. Following the inspection the registered person has supplied documents showing application for safeguarding training has been made to the local authority. Staff spoken with were aware of their responsibility under the homes whistleblowing policy. The providers said they had made referrals for possible inclusion on the Protection of Vulnerable Adults register (POVA) as required at the last inspection. Elm Lodge DS0000062249.V313265.R02.S.doc Version 5.2 Page 18 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 19,20,22,23,24,25,26 Service users live a clean and comfortable environment that is decorated to a good standard. Specialist equipment is provided however service users’ safety and dignity could be compromised if they are unable to call for staff assistance when sitting in the communal rooms. EVIDENCE: The fire officer’s report for the 15th February 2006 identified that all work in relation to fire recommendations had been completed. The communal lounges and dining room were clean tidy and well decorated. Some dining and lounge furniture had been replaced since the last visit. Elm Lodge DS0000062249.V313265.R02.S.doc Version 5.2 Page 19 Communal toilets/bathrooms seen were clean and tidy. Mobile hoists and bath seats were seen. Call systems are available for service users to use, however it was observed that service users who have mobility problems are unable to access the emergency call in the lounges and dining room. A senior care spoken with said the floor is left unattended when two staff on duty to assist one service user. The manager said that service users call out if other service users need staff’s assistance. The manager said the chair lift shaft had been extended to reach ground level so that service users would be able to access the stair lift seat more easily. The manager said that handles are to be fitted on the landing walls to help service users when they get off the stair lift. A window had been replaced to provide ventilation to a bedroom as required at the last inspection. An automatic door closure had been fitted to enable service users to have the door open when occupying the bedroom. Some running hot water temperatures tested varied between 17 degrees to 45 degrees. Service users’ bedrooms seen were clean, tastefully decorated and personalised. Bed lined checked was clean and had been well laundered. A service user spoken with in their bedroom said they were satisfied with their room; the fabrics used were colour coordinated and provided a very pleasant environment for the service user to live in. A screen was seen in a shared bedroom. The laundry room was clean and tidy. Infection control and COSHH sheets were displayed on the laundry walls. The areas behind the washing machines and tumble dryers were clean as required at the last inspection. It was observed that the boilers located in the laundry room were open to the environment. The gas certificate seen showed that the ventilation in the laundry room was not adequate. These issues have been addressed fully in standard 38 of the report. Elm Lodge DS0000062249.V313265.R02.S.doc Version 5.2 Page 20 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 27,28,29,30 The current staffing levels and deployment need to be reviewed to ensure service users are appropriately supervised and their needs fully met. EVIDENCE: Staff rosters seen showed two carers are rostered to work from 8am to 10pm and two carers at night. The provider and manager are rostered as assisting the carers for three hours in the morning from 9am to noon, Monday to Friday. Night staff now work an extra hour in the morning to assist in getting service users up. The staff spoken with said that they serve afternoon meals prepared by the cook before she leaves at 5pm, they deal with the crockery after the meal and some service users are bathed in the evening. A senior carer spoken with said that the floor is left unattended when two staff are needed to assist a service user. Elm Lodge DS0000062249.V313265.R02.S.doc Version 5.2 Page 21 Accident records seen showed a number of falls and the need to audit these and the levels of staffing levels was discussed, particularly at times when service users required two staff to assist them. The manager said all staff are now registered to do NVQ level 2 qualifications. The provider, since the visit has confirmed that all staff employed receive a POVA first clearance and work within Department of Health guidelines. The provider said all staff are now registered for manual handling training provided by the local authority, all staff have first aid training, adult protection training is planned. Elm Lodge DS0000062249.V313265.R02.S.doc Version 5.2 Page 22 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 31,33,35,38 The arrangements for handling and safekeeping service users personal allowances are satisfactory. Action needs to be taken in respect of the health and safety issues identified and fire training and drills provided for all staff to ensure service users’ safety. Elm Lodge DS0000062249.V313265.R02.S.doc Version 5.2 Page 23 EVIDENCE: The manager has been in post since April 2006 and at the time of the visit the Commission had not received an application for her to be registered. A letter informing the providers of their legal position in relation to this had been sent to the providers prior to this visit. The provider said the manager was planning to make application to the CRB bureau for an enhanced CRB check during the week of the visit. Records of staff meetings were seen, the provider said they are held monthly unless issues arise that need to be discussed earlier. A service users’ meeting had been held, the providers said they planned to hold more meetings in the future. The provider said that they were planning to complete quality audit surveys in the future. Some service users’ personal allowance records were checked and no discrepancies seen. Some of the homes monitoring systems records were seen at the visit, the manager had also provided information in respect of this within the pre inspection questionnaire. The fire records seen showed that fire system checks had been completed. No fire drills had been recorded up to the time of this visit. The provider said he had discussed fire procedures with all staff and was confident they would know how to respond in the event of a fire occurring. The provider said he is currently working on the fire risk assessment to incorporate the new fire regulations. A provider said they are due to complete training by the fire service that will enable them to cascade fire training throughout the staff team The latest emergency lighting contractor’s check had been completed in November 2005; the homes advisor completes checks weekly. Running hot water temperature records showed temperatures had varied between 40 & 44 degrees centigrade, those tested on the visit showed temperatures of 17-44 degrees centigrade throughout the home. The Legionella test certificate was seen for the test completed on 29 June 2006 was seen and no concerns noted. The Gas appliance check was completed in May 2006 and identified that the ventilation in the laundry was inadequate. This had not been dealt with at the time of this visit. The boilers in the laundry were open to the environment; dust had accumulated on the covers over the boilers. Discussion with the provider occurred in relation to them obtaining the advice of the Health and Safety officer and Gas contactors on the appropriate action to take in respect of these issues. Elm Lodge DS0000062249.V313265.R02.S.doc Version 5.2 Page 24 The provider said the decline in the floor levels between the hallway and dining room had been identified as a potential risk during the health and safety officer’s June 2006 inspection. This was also identified as a potential risk at previous inspections completed by the Commission. The provider said there are plans to extend the dining room and the level of the floor would be dealt with as part of the proposed extension. The provider has stated that this area is subject to risk assessment and review, and no falls have occurred. Elm Lodge DS0000062249.V313265.R02.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 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 1 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 X 1 3 3 2 3 STAFFING Standard No Score 27 1 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 X X 1 Elm Lodge DS0000062249.V313265.R02.S.doc Version 5.2 Page 26 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 OP9 Regulation 13(2) Timescale for action The registered person shall make 15/12/06 arrangements for the recording, handling, safe keeping, safe administration and disposal of medicines received into the home. • All medication must be administered as prescribed by the GP. The registered person must 31/01/07 ensure service users can access the emergency call alarm when they are sitting in the communal areas in the home if staff are not present. The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of service users: • The adequacy of care staff levels (and deployment) must be monitored to ensure service users needs are fully and promptly met: Previous timescale of 18 July 2005 and 6th January 2006 not met. DS0000062249.V313265.R02.S.doc Requirement 2 OP22 16(1) 3. OP27 18(1) 15/12/06 Elm Lodge Version 5.2 Page 27 4. OP31 Section 11 (1) of The Care Standards Act 2000. Any person who carries on or manages an establishment or agency of any description without being registered under Section 11 (1) of the Act in respect of it as an establishment shall be guilty of an offence. • The person who manages the home needs to apply through the Commission for a CRB clearance, as a forerunner to applying be the registered manager. 31/01/07 5. OP38 13(3) 13 (4)(c) The registered person must ensure that immediate action is taken to ensure the health and safety of service users. • A risk assessment must be completed and a copy forwarded to the Commission and Health and Safety officer confirming the action to be taken to prevent falls when accessing the dining room due to the decline in the floor level. The Gas contractor must be contacted to establish the action required to ensure appropriate ventilation is provided in the laundry. The Health and Safety officer must be contacted for advice in relation the boilers that are open to the environment in the laundry room and the Commission informed of the outcome. Fire training and fire drills 31/01/07 • • • Elm Lodge DS0000062249.V313265.R02.S.doc Version 5.2 Page 28 must be provided for all staff. 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 OP8 Good Practice Recommendations The registered person should discuss the dietary requirements for the named service user on bed rest with the health providers to ensure an adequate diet is provided. The provision of activities should be reviewed to ensure all service users’ social needs are met. The registered person should make arrangements for service users religious needs to be met. Running hot water temperatures should be maintained to temperatures that are comfortable for service users to wash themselves and bathe in. Meetings with service users should be held regularly to enable them to discuss the types of activities and venues for outing they would prefer and to obtain their views on the service provided. 2. OP12 3 3. OP25 OP33 Elm Lodge DS0000062249.V313265.R02.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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 DS0000062249.V313265.R02.S.doc Version 5.2 Page 30 - 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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