Inspection on 25/09/06 for Elm Park Lodge

This inspection was carried out on 25th September 2006.

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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Elm Park Lodge 07/12/05

Elm Park Lodge 28/07/05

Elm Park Lodge 11/01/05

Elm Park Lodge 09/09/04

Similar services:

Townley Road, 2-3

Foxley Lane (121a)

Tudor Lodge

Stacey Street Nursing Home

Delrose House Ltd

Clovelly House Residential Home Ltd

Abbey Road [53]

Cherry Tree House

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

CARE HOME ADULTS 18-65 Elm Park Lodge 2-4 Elm Park Road Finchley London N3 1EB Lead Inspector Tom McKervey Key Unannounced Inspection 25th September 2006 09:30 Elm Park Lodge DS0000010435.V303574.R01.S.doc Version 5.2 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 Park Lodge DS0000010435.V303574.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 Adults 18-65. 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 Park Lodge DS0000010435.V303574.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elm Park Lodge Address 2-4 Elm Park Road Finchley London N3 1EB 020 8349 2388 020 8346 3288 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) Mr Kam Choy Lim Mr Kam Choy Lim Care Home 27 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (27) of places Elm Park Lodge DS0000010435.V303574.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 4 specific service users who are currently resident in the home and are over 65 years of age can reside in the home. This condition will need to be reviewed when any of the service users vacate the home. 7th December 2005 Date of last inspection Brief Description of the Service: Elm Park Lodge is a privately run care home which is registered to provide care and support for a maximum of twenty seven younger adults who have a mental disorder. The home is authorised, as a condition of its registration, to accommodate four residents who are over the age of sixty-five. Prior to November 2003, the service consisted of Elm Park Lodge, a large three-storey detached house, and The Lindens next door, which accommodates four residents in two flats. Both properties are now registered as one home, i.e. Elm Park Lodge. The bedrooms, all of which are single, are located on three floors. There are three communal lounges on the ground floor, one of which is for smokers. A conservatory is used as an arts/crafts room. There is a space at the front of the home for car parking, and there is a large, very attractive garden and patio at the rear of the premises. The stated aim of the home is to maintain the quality of life for service users by promoting their independence, dignity, rights, privacy, choice and welfare. The fees for the service range from £445 to £775 per week. Copies of this report and the homes Statement of Purpose are available from the manager of the home. Elm Park Lodge DS0000010435.V303574.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out as part of the Commission’s inspection programme and to check compliance with the key standards. The inspection was completed in a period of seven hours and thirty minutes. The proprietor/manager was present throughout the inspection and fully cooperated in the process. A tour of the main home and adjoining “Lindens” was carried out as part of the inspection, and ten residents and four staff were spoken to. There were no visitors to the home during the inspection. The inspection process also included an examination of residents’ case files and other documents relating to the management of the home. What the service does well: What has improved since the last inspection? Residents’ care plans are more comprehensive to cover physical as well as emotional needs. Elm Park Lodge DS0000010435.V303574.R01.S.doc Version 5.2 Page 6 There is a better system for logging complaints. The extractor fan in the smoking lounge has been repaired, which improves the comfort of the residents. A meeting was held with residents who smoke to encourage them to give up the habit. New proforma have been developed for the one-to-one supervision of staff. Three bedrooms and one of the lounges have been redecorated. What they could do better: Although the majority of residents enjoy a good range of activities, there was no evidence of more one-to-one support from staff being provided for those service users who are withdrawn. Such support could prevent them from becoming more mentally unwell. It is a requirement that a record be maintained of all visitors to the home. This is for the purposes of health and safety and security for staff and residents. As part of a healthy diet, fresh fruit should be always available in both sections of the home. All staff are required to receive at least six sessions of supervision a year. A thorough fire risk assessment of the home must be carried out and an emergency plan prepared in case of a major incident affecting the safety of residents and staff. Where a medical diagnosis is recorded in residents’ care plans, a description of how the condition affects the person should be provided to enable staff to better understand the resident’s behaviour and responses. Further attempts should be made to encourage and support residents to give up smoking. A procedure should be drawn up to support residents who may be able to selfmedicate. This is a reasonable objective for people who are aspiring to more independent living. Elm Park Lodge DS0000010435.V303574.R01.S.doc Version 5.2 Page 7 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. Elm Park Lodge DS0000010435.V303574.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Elm Park Lodge DS0000010435.V303574.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 4 & 5 The quality in this outcome group is excellent. This judgement has been made from evidence gathered both during and before the visit to this service. There are very close contacts between the home and the Community Mental Health Team to ensure that residents are placed in a service that fully meets their needs. Comprehensive assessments are carried out before residents are admitted and they are encouraged to visit the home before moving in. The residents are given a copy of the Service User Guide and a contract. which explain what service is provided by the home. EVIDENCE: The case files of three new residents were examined, and the inspector asked them about their experiences of living in the home. They confirmed that they had visited the home before moving in and that the service was meeting their needs. The residents particularly mentioned the high level of competence and care shown by the staff and were able to name their key workers.The case files contained comprehensive assessments by the Community Mental Health Team, and the manager and deputy of the home. Elm Park Lodge DS0000010435.V303574.R01.S.doc Version 5.2 Page 10 Risk assessments were also carried out. There was evidence of regular reviews under the Care Programme Approach by the mental health professionals. There were several written comments by health and social work professionals sent to the inspector, praising the service. For example; “ I feel that the day manager is able to support very complex cases very well and works really well with the Community Mental Health Team. Other support workers are good and professional” “Staff and most of the residents appear to be happy. Good standard of care delivered and resident are always aware and informed of any changes. The CMHT and the home woek closely together towards the residents’ care plans”. The files also contained service contracts, which were signed by the residents. As is good practice, the residents sign to confirm that they have been given the Service User Guide for the home. Elm Park Lodge DS0000010435.V303574.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All these standards were assessed. The quality in this outcome group is good. This judgement has been made from evidence gathered both during and before the visit to this service. All residents have an individual care plan, but it would be more helpful for staff for their knowledge and in their interactions with residents, to have less medical descriptions of their mental health needs. Residents are supported to be as independent as possible within a framework of thorough risk assessment, and they are encouraged to participate in the running of the service. EVIDENCE: The care plans of the new residents were examined. Mental health and physical health issues were covered in the care plans. The care plans were being reviewed regularly, particularly during CPA meetings with the Community Mental Health Team. Elm Park Lodge DS0000010435.V303574.R01.S.doc Version 5.2 Page 12 Some care plans included the clinical diagnosis, “chronic schizophrenia”, but this is an umbrella term that covers many types of condition. There was no explanation to how this illness manifested itself. For example, whether visual or auditory hallucinations were a feature, or the person had delusions. This more detailed description would be more helpful to care staff in their interactions with residents, and a recommendation is made about this. Other areas such as social, sexual and religious needs were not addressed. Thorough risk assessments were in place to cover behaviours and activities within and outside the home. There was evidence that potentially dangerous incidents were appropriately dealt with by urgent appointments with the Community Mental Health Team. The ethos of the service is to enable and support service users to achieve as much independence as possible. The company also provides move-on facilities such as “The Lindens” next door to Elm Park Lodge, and community supported living services nearby. The success of the service is evidenced by the fact that, since the last inspection, four service users had moved on to these facilities. Elm Park Lodge DS0000010435.V303574.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 The quality in this outcome group is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. There is a good range of stimulating activities for the majority of residents, but more individual activities need to be provided for those people who are withdrawn. There is an open visiting policy with few restrictions, but all visitors to the home should sign the visitors’ book. Residents are supported to live as independently as possible. The menus offer a wholesome diet, but this should be supplemented by fresh fruit being available. EVIDENCE: Residents’ records contained examples of spending large amounts of time outside the home pursuing their own interests. This is encouraged and Elm Park Lodge DS0000010435.V303574.R01.S.doc Version 5.2 Page 14 residents say they are free to come and go as they please. They are expected to inform the staff if they wish to stay out late. Regular meetings are held between the manager, staff and residents to discuss how the service is run. The minutes of the meetings indicate that residents are able to express their views and make suggestions. There is an arts-and-crafts facilitator who provides sessions for those residents who wish to attend. This service is very appreciated by the residents and was well attended. An exhibition of their work was on display. Residents said that they found the sessions very therapeutic in enabling them to express their feelings and develop skills through art. Five residents work as volunteers in local charity shops, and there was evidence of attendance at religious services. Some household tasks are carried out by residents on a rostered basis with the support of the staff, including shopping, cooking some meals and washing up. Groups of residents regularly play football in the local park. It was noted however, that there were few individual activities for residents who were withdrawn due to their mental health problems. A requirement is made to address this issue when reviewing their care plan. Many residents said they had regular contact with their friends and relations, including spending weekends at home. However, the visitors’ book was not always signed when they visited the home. This is a requirement. All residents have a key to the front door and their rooms are protected by a key-pad entry system. Each person has a small safe to keep valuables in. A requirement was made at the last inspection for fresh fruit to be available, which the inspector was told had been complied with. However, this was not in evidence at this inspection and this requirement is restated in this report. Otherwise, the menus indicated a good variety of food was provided and the residents said they were satisfied with their meals. Elm Park Lodge DS0000010435.V303574.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All of these standards were assessed. The quality in this outcome group is good. This judgement has been made from evidence gathered both during and before the visit to this service. Residents are able to provide for their own personal care with the support of staff. There is very good liaison with the Community Mental Health Team and G.P to ensure that the residents’ psychological and physical health needs are met. A procedure for self-medication should be prepared for residents who may be able to administer their oral medication. Specialist advice should be provided for those residents who wish to give up smoking. The residents’ wishes in the event of their death, are known to the staff. EVIDENCE: All of the residents are able-bodied and provide for their own personal care needs, though occasionally they may need reminding by the care staff. Elm Park Lodge DS0000010435.V303574.R01.S.doc Version 5.2 Page 16 There was evidence of frequent appointments with members of the Community Mental Health Team, including CPA meetings, for emotional and psychological support. Several residents are seen in the home and in clinics by Community Psychiatric Nurses if they require regular injections of medication. Other healthcare appointments were documented, for example with the G.P, hospital, dentist and optician, and the residents’ weights were checked monthly. As noted in the last inspection, most of the residents smoke. The manager said that he held a meeting with these residents to discuss providing support to give up the habit, but there was a poor response. The requirement is restated to invite a specialist adviser to discuss this subject with the residents, and to have appropriate literature about the danger of smoking available. Residents’ medication was being stored properly and when medication was not given, the reason was documented appropriately in the administration of medicines records. There was no procedure in place for residents who might at some stage, be able to self-medicate. Given that the service prepares service users to be independent, this would be a reasonable project. A recommendation is made for a procedure to be drawn up for self-medication. Residents’ wishes in relation to their death are recorded in their case files. Elm Park Lodge DS0000010435.V303574.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 The quality in this outcome group is excellent. This judgement has been made from evidence gathered both during and before the visit to this service. The residents and their relatives speak highly of the service. There is an appropriate complaints procedure in place and residents say they are aware of how to raise concerns if they need to. There are good systems in place to protect residents from abuse. EVIDENCE: The complaints book showed that complaints were recorded properly and were dealt with appropriately. Response times to complainants were within reasonable timescales. The deputy manager is an accredited trainer on the subject of adult protection and she has a programme of training the staff in this subject during their induction. Staff who were interviewed, were aware of their responsibilities regarding potential abuse of residents. A large number of written comments were sent to the inspector from residents and their relatives, the majority of which expressed a high level of satisfaction with the care in the home. Elm Park Lodge DS0000010435.V303574.R01.S.doc Version 5.2 Page 18 This is a synopsis of a letter to the inspector by a relative. ” I am so grateful to the management and staff for their support of my brother. His life skills were assessed without him feeling threatened in any way and he was fully informed and involved at every stage. He is now able to manage his day to day affairs with confidence”. Elm Park Lodge DS0000010435.V303574.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 & 30 The quality in this outcome group is excellent. This judgement has been made from evidence gathered both during and before the visit to this service. The home is generally well maintained, and the residents have comfortable rooms that promote their independence. There is a good standard of cleanliness, but the mat in the entrance needs cleaning or replacing. EVIDENCE: A tour of the main home and The Lindens annexe was carried out. Generally the home was well maintained and was comfortably furnished. The large garden was well maintained and contained new pieces of garden furniture. One of the residents had made a substantial, attractive bench for the patio. Elm Park Lodge DS0000010435.V303574.R01.S.doc Version 5.2 Page 20 Since the last inspection, the water in the Lindens annexe had been adjusted to be sufficiently hot for residents to have a bath or shower, and the extractor fan in the smoking lounge was operating properly. In the Lindens, there was a problem in Flat 1 where the toilet door did not close properly. The window in the landing needed a curtain or blind to preserve privacy. Both of these matters were immediately attended to by the maintenance person during the inspection. Four residents permitted the inspector to see their bedrooms. They had comfortable furniture and were tastefully decorated. Each bedroom is protected by a coded entry system, the code being known only to the individual and the staff. Each resident is provided with a safe for keeping valuables in. A requirement is made to clean or replace the mat in the entrance hall. Otherwise, the home was clean and there were no offensive odours present. Elm Park Lodge DS0000010435.V303574.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 36 The quality in this outcome group is good. This judgement has been made from evidence gathered both during and before the visit to this service. There are sufficient numbers of competent staff to meet the residents’ needs and the staff receive appropriate training to meet those needs. Residents’ interests are safeguarded by thorough recruitment procedures. The managers need to ensure that all staff receive supervision. EVIDENCE: Elm Park Lodge DS0000010435.V303574.R01.S.doc Version 5.2 Page 22 The registered manager is supported by a deputy and an administrator. In addition to the care staff, there is a cook, a cleaner and a maintenance person. The manager and deputy are on call one week in rotation. The staff rotas showed that there is normally two staff on duty during the day in addition to the manager and deputy. There is one waking member of staff and one staff sleeps in at night. The manager is a National Vocational Qualifications assessor. Four staff have attained NVQ level 2, and the deputy manager has NVQ Level 3. The staff who were spoken to, said they were satisfied with the level of staffing provided. The records of four new staff were examined. The records contained all the information required under this standard, including references and proof of identity. Satisfactory checks had also been made with the Criminal Records Bureau, (CRB). There was evidence to show that all new staff are given a thorough induction in the home’s policies and procedures, when they start working at the home, and that appropriate training in health and safety, medication and first aid were provided. There were records to show that the majority of staff were receiving regular supervision, however, some staff have not had formal supervision yet. A requirement is made for all staff to have at least six sessions of supervision per year. Elm Park Lodge DS0000010435.V303574.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 41 & 42 The quality in this outcome group is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home is well managed and residents live in a relaxed and homely environment. Regular meetings enable residents to put forward their views about how the service is run, and there are robust procedures in place to protect their interests. The health and safety of residents and staff is generally safeguarded by regular maintenance and checks. However, an assessment of fire risks in the home must be carried out and an emergency plan must be provided. EVIDENCE: Elm Park Lodge DS0000010435.V303574.R01.S.doc Version 5.2 Page 24 The registered manager is a qualified mental health nurse and is very experienced in managing the service for many years. He has almost completed training for the National Vocational Qualification (NVQ), level 4, which is a management qualification. The deputy manager has a NVQ Level 3 and intends to undertake Level 4 training soon. Residents and staff said that they were able to make their views about the service known at regular meetings with the managers. At the time of the inspection, there was a friendly relaxed atmosphere in the home and the staff described their morale as very good. There was only one resident for whom personal money was managed by the staff. The inspector examined the record of transactions made, and was satisfied that the recorded balance reconciled with the amount of cash held. Signatures and receipts were seen for all purchases. There were records of weekly fire alarm tests and regular fire drills, and COSHH materials were safely stored. There were current certificates of safety for gas, fire and electric installations, and staff have been trained in health and safety. A current employers liability insurance certificate was on display. The manager stated that he had obtained a document that will enable him to carry out a fire risk assessment of the home and to prepare an emergency plan. It is a requirement that this is completed within the next three months for the safety of residents and staff. Elm Park Lodge DS0000010435.V303574.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 Adults 18-65 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 X 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 X 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 2 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 3 3 X 3 2 X Elm Park Lodge DS0000010435.V303574.R01.S.doc Version 5.2 Page 26 Yes Are there any outstanding requirements from the last inspection? 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 YA14 Regulation 15(2)(b) Timescale for action The registered person must 30/11/06 ensure that appropriate individual activities are provided for residents who are withdrawn. These must be in accordance with the person’s care plan. The registered person must 30/11/06 ensure that all visitors to the home sign the visitors’ book. The registered person must 30/11/06 ensure that fresh fruit is always available for residents as part of a healthy diet. This requirement is restated from the last report. The previous timescale was 28/02/06 The registered person must 30/11/06 ensure that all staff receive at least six sessions of supervision a year. The registered person must 31/01/07 undertake a fire risk assessment of the home and prepare an emergency plan for the safety of residents and staff. Requirement 2. 3. YA15 YA17 17 Sch 4(17) 12(1) 4. YA36 18(2) 5. YA42 13(4)(c) Elm Park Lodge DS0000010435.V303574.R01.S.doc Version 5.2 Page 27 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. Refer to Standard YA7 YA19 Good Practice Recommendations The registered person should document in the care plan where applicable, how particular features of mental health affect individual residents. The registered person should obtain specialist advice for residents who wish to give up smoking. The registered person should prepare residents who are able to self-medicate. a procedure 3. YA20 Elm Park Lodge DS0000010435.V303574.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA National Enquiry Line: 0845 015 0120 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 Park Lodge DS0000010435.V303574.R01.S.doc Version 5.2 Page 29 - 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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