Inspection on 07/05/08 for Elm Residential Care Home

This inspection was carried out on 7th May 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Elm Residential Care Home 01/05/09

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 Elm Residential Care Home 7 Elm Close Bolsover Nr Chesterfield Derbyshire S44 6EA Lead Inspector Bridgette Hill Unannounced Inspection 7th May 2008 02:50p Elm Residential Care Home DS0000070897.V363849.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 Residential Care Home DS0000070897.V363849.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 Residential Care Home DS0000070897.V363849.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elm Residential Care Home Address 7 Elm Close Bolsover Nr Chesterfield Derbyshire S44 6EA 01246 826230 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) elm_house@msn.com Jaywantee O`Farrell Vacant Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Elm Residential Care Home DS0000070897.V363849.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care Home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home fall within the following categories: Learning Disability - Code LD The maximum number of service users who can be accommodated is: 4 New service registered under current ownership on 21st December 2007 2. Date of last inspection Brief Description of the Service: Elm House is a small residential home, offering 4 places for adults with a learning disability. Situated in a residential cul-de-sac, the accommodation is a large detached family house. It is spacious and comfortable, with a good sized and private garden and patio area. The home is occupied by the providers and provides an extended family style of environment where the residents can join in very much as if it were their own home. The home is close to the town centre of Bolsover with its range of facilities, and more locally there are small general stores for immediate needs. Good links have been developed with local care professionals, and residents are encouraged to maintain community links with the social contacts and organisations they had prior to their admission. Fees are £358.64 per week. Extra charges are made for hairdressing, chiropody, magazines and newspapers. Elm Residential Care Home DS0000070897.V363849.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. This was an short notice visit which focused on assessing all key standards. The visit was one where short notice was given as residents spend time at day centres and activities therefore the day was prearranged to ensure residents could speak to us about what it is like to live at the home. The inspection took place over 6 hours over two days. As part of this visit a thematic inspection relating to safeguarding and recruitment practices was completed. To complete this a range of questions was asked of the Manager, staff and residents. As part of the inspection a sample of service users care files and a range of documents were examined. The communal areas were viewed and some residents were happy to show us their bedrooms. During the visit opportunity was taken to have discussions with management, and service users. Since being registered the Providers has sent us the Annual Quality Assurance Assessment (Aqaa) and surveys have been returned to us from 2 residents and 2 relatives. A letter from a relative was also given to us during the visit. The Registered Provider Jaywantee O’Farrell was present during the visit. What the service does well: What has improved since the last inspection? Elm Residential Care Home DS0000070897.V363849.R01.S.doc Version 5.2 Page 6 This is the first inspection of the service under the current owners. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Elm Residential Care Home DS0000070897.V363849.R01.S.doc Version 5.2 Page 7 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 Residential Care Home DS0000070897.V363849.R01.S.doc Version 5.2 Page 8 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents are given opportunities to visit and make a positive decision about moving into the home but only basic contracts are in place so they may be unaware of the conditions of their residency. EVIDENCE: There have not been any new residents admitted since the last inspection. All current residents have according to the Annual Quality Assurance Assessment been at the home for at least two years. The two surveys received from current residents indicated that residents were asked if they wanted to move into the home and information about the home was given to them. The Annual Quality Assurance Assessment completed by the Provider indicated that a new service user assessment tool has been introduced and a Service User Guide and Statement of Purpose are available at the home and that these had been simplified. These were seen at the visit on a notice board in the kitchen which was accessible to residents. One resident told us that they knew the information was there but had not chosen to read it. Not all residents could read but information was not available in alternative formats. Elm Residential Care Home DS0000070897.V363849.R01.S.doc Version 5.2 Page 9 The Annual Quality Assurance Assessment also stated that opportunities for new residents to visit the home on an overnight basis and to have a meal at the home would be routinely offered. The Annual Quality Assurance Assessment told us that a copy of the last inspection report was in the home; this was to be found in the entrance hallway. In care files there were brief terms and conditions contracts but these were insufficiently detailed as to the fees payable, who was responsible for payment of fees and the notice periods that were applicable. Elm Residential Care Home DS0000070897.V363849.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Care plans in place were accurate in the detail but were not complete in detailing how all residents assessed needs were being met. EVIDENCE: Two resident care files were examined at this visit. The care plans in place were ones which had been written prior to the new owner taking over although these had been reviewed. The format for care plans to be written on was limited and gave little space to record the care needs and what care staff should give. Some gaps were evident these being where the residents took medication and where there were some identified risks evident such as challenging behaviours. There were therefore no detail of how staff were to meet these needs. Residents knew about their plans of care but there were no records to evidence that they were encouraged or supported to be involved in the care planning process. Elm Residential Care Home DS0000070897.V363849.R01.S.doc Version 5.2 Page 11 The Annual Quality Assurance Assessment indicated that the day to day support of residents enabled staff to have a good understanding of residents needs. This was evident through discussions with staff. A good knowledge of their likes and dislikes was displayed. Some risk assessment formats were in the file these included nutrition and Moving and handling. A dependency assessment was also in place and regular reviews of these were documented. Where there were some limitations for example where residents needed to be accompanied when out these were recorded. The Annual Quality Assurance Assessment also told us that there has been linking of care plans to risk assessments and healthcare records are documented. There were risks however which were identified as part of reviews that were not included in the care plans that were available. Residents told us that they went to bed at times of their choosing, chose their own clothes and were able to have a bath when they wanted to. They spoke positively of the staff at the home. Elm Residential Care Home DS0000070897.V363849.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. There are opportunities given to service users for them to enjoy varied lives in and outside of the home, they can therefore develop skills, confidence and independence. EVIDENCE: Residents described to us to active daily lives with visits to various day centres and activities of their choosing. The types of day care appeared to be reflective of the resident’s preferences and what they enjoyed. Residents described some of the day activities as ‘work’ where they got paid. Some residents had been on holiday with staff from the day centres. Residents told us that a holiday arranged from the home was also being considered. Residents told us they had opportunities to go out from the home with the staff to shops, out for pub lunches and to local parks. Residents told us that they were going out more since the home had been under new ownership; a letter Elm Residential Care Home DS0000070897.V363849.R01.S.doc Version 5.2 Page 13 from a relative supported this. Where residents had the ability to they went out unaccompanied and used local transport. Not all residents had relatives who they were in contact with but where they had residents were supported to spend time with their families on leave overnight or by telephone. One resident told us they wrote and sent cards to their relatives. Some relatives also supported residents to go to the doctors or opticians. One relative survey and subsequent discussion told us that the relative felt they were kept well informed of events from the new owner and was happy with the care the resident received. The Annual Quality Assurance Assessment indicated that there were good records at the home of activities and family involvement. The Annual Quality Assurance Assessment recorded that there scope to develop residents meetings and the key worker system. The Annual Quality Assurance Assessment recorded that there were healthy food options offered and weight checks of residents were completed. Records confirmed that residents were weighed monthly. The residents at the home were largely self-caring and told us that they were able to bathe without assistance. The care plans reflected this but identified where sometimes prompts and encouragement were needed. Whilst no residents at the home needed a special diet when spoken with the staff appeared t have a good knowledge of the residents likes and dislikes. At the teatime meal during the visit the residents were offered a choice of main meal and had varying vegetables/salad with these according to their choice. Residents told us they liked the food at the home. Residents could also make themselves a drink when they wished. When at day centres residents sometimes took packed lunches from the home, there were no records kept to indicate what had been provided and as packed lunches are not always kept chilled this is an area where risks are higher. Elm Residential Care Home DS0000070897.V363849.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents are supported to access a range of healthcare services to ensure their health needs are met. The medication needs of residents are not supported by care plans and robust policies and procedures to ensure residents received their medicines. EVIDENCE: The Annual Quality Assurance Assessment recorded that there are regular clinical reviews in place for residents and there is a team of multi agency professionals who offer advice, guidance and training. The Provider reported a good supportive relationship with Care Managers and reviews had been documented by the multi agencies involved in the care of residents. Residents spoken with were aware of the reviews and that they could look at their care plan if they wished to and copies of the latest reviews were in care files. The care plans in place contained details of GP’s, opticians and dentists. Residents told us about recent appointments they had been. Sometimes staff took residents to appointments, which were usually community based, but some residents were supported by their family to access healthcare services. Elm Residential Care Home DS0000070897.V363849.R01.S.doc Version 5.2 Page 15 The storage and administration of medicines was examined at this visit. No reference was made in the Annual Quality Assurance Assessment as to how this was undertaken. No residents at the home looked after their own medicines, some residents did not take any medication. The provider/manager is a registered nurse and the other regular staff member has completed medications training. A list of specimen staff signatures was available as well as a drug reference book and leaflets from the medication that residents took. Medications were locked away with separate storage for controlled drugs. The storage for controlled drugs did not however meet the current standards. The Provider Informed us on 19th may 2008 that a new cupboard had been ordered through the supplying pharmacist. The medication administration records were complete and correct with balances of drugs received in being documented. A returns book was available for any items returned to pharmacy. The balance of controlled drugs was checked against the records and found to be accurate although some accounting errors were evident earlier in the record. The care plans in place did not describe the support that residents required in order that they received their medication. The policy and procedure for medications was descriptive of the practice in place and had omissions such as how to order and dispose medicines. The bedroom doors were fitted with a safety type lock and the Provider/Manager said that some residents did have the keys but did not always choose to lock the door. Elm Residential Care Home DS0000070897.V363849.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Systems for complaints and allegations are in place but not robustly developed and detailed enough to ensure that concerns from residents will be handled consistently. EVIDENCE: As part of this inspection a thematic probe was completed regarding safeguarding. This involved asking the Manager, staff and residents a number of questions relating to safeguarding. Staff and residents were spoken with and the policies, procedures examined to look at how residents were safeguarded. Residents told us the named staff they would approach if they were frightened and said they felt that their worries would be acted on. They were also aware of alternative people outside of the home they could speak to with any concerns. The Annual Quality Assurance Assessment told us that there were clear complaints and Safeguarding Adults procedures in place. It also told us that the home had recorded that induction and training for Safeguarding Adults could be better. The improvements noted on the Annual Quality Assurance Assessment told us that Safeguarding Adults training and revised policies were in place. The procedure in place in the home was not explicit in referring to locally agreed Safeguarding Adults procedures and there was not a copy of the local procedures and reporting cards in the home. The Provider/Manager was also Elm Residential Care Home DS0000070897.V363849.R01.S.doc Version 5.2 Page 17 not wholly clear on the process of referring staff to the Pova list. A whistle blowing policy was available although the Provider/manager was initially unclear if there was one. The Annual Quality Assurance Assessment told us that the home considers they listen and act on resident’s views. It told us that in the past 12 months there were no complaints received, this was confirmed at the visit. The complaints procedure in the home did not contain any timescales to tell residents/complainants how quickly their concerns would be dealt with. The address of the Commission for Social Care Inspection also needed amending to ensure residents had access to the correct address. The two relatives surveys we received told us that relatives did not know how to make a complaint or raise concerns. The residents told us on their surveys that they did know how make a complaint. Elm Residential Care Home DS0000070897.V363849.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Residents live in spacious well-presented accommodation that has good quality furnishings and fixtures. EVIDENCE: The home is a spacious detached house in quiet cul de sac. The home is approximately a 10 minute walk to the local town centre. The home uses its own vehicle to take residents out but one resident does use local bus services. The Annual Quality Assurance Assessment told us that residents could have small items of furniture and belongings in their rooms and that residents could lock their door and hold the keys if they wished. All residents have their own bedroom with a sink each room had resident’s personal items and pictures/photographs that were individual to each resident. Residents told us they liked their rooms and that staff knocked before entering. Some residents spend time in their rooms watching their own television preferring their own company. The bedrooms were situated on the first floor rendering it unsuitable Elm Residential Care Home DS0000070897.V363849.R01.S.doc Version 5.2 Page 19 for anyone with significant mobility problems. There was no special equipment in the home but this was none was needed for the current residents. There were two fully tiled and well-fitted bathrooms available to residents. There is a large lounge, a conservatory which is also used as a dining room but has additional seating. The home presented as being modern and airy with good quality furnishings. The resident’s surveys we received back told us the home was always fresh and clean. The garden of the home was tidy and one resident told us that they were planting some vegetables in the garden, as this was one of the activities they liked. The Annual Quality Assurance Assessment recorded that the home provides a homely, comfortable and safe environment that is clean and hygienic. At the visit all of the home was found to be very clean, tidy and well presented. The home was fitted with domestic style fire alarms with records available to tell us systems were in place to check them fortnightly. Fire drills were held were recorded and one resident told if there was a fire they knew they needed to get out of the house. The laundry of the home is accessed by an external door outside of the home. This is fitted with two washers and two dryers. On the day of the visit laundry was drying outside. Residents told us about the arrangements in place for laundry with each resident having their own basket for soiled items. The clothing worn by residents seemed to be clean and well pressed. There were locked cupboards available for chemical cleansers. Elm Residential Care Home DS0000070897.V363849.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home has a small staff team who provide consistent and personalised care to residents. There are not recruitment procedures in place which ensure staff are suitably recruited to work with vulnerable adults. EVIDENCE: The Provider and a very small staff team support people using the service. This is usually the Provider and their husband. There are two additional staff who work at the home on an occasional basis though this is rare. Staff at the home sleep in at night and residents spoken with said they knew where to find and alert staff if they were unwell. As part of this inspection a thematic assessment of recruitment practices was completed. This involved looking at recruitment procedures and staff files and having discussions with management and staff. Some recruitment files for bank staff were in place; these predated the current owners but did not contain application forms and had only one reference. For regular staff at the home Criminal records Bureau checks were in place but no Elm Residential Care Home DS0000070897.V363849.R01.S.doc Version 5.2 Page 21 other checks such as application forms, references, photographs and proof of identity. A brief procedure for recruiting new staff was in place but this did not include all the steps that are required to ensure a robust recruitment process is adhered to. The provider/manager did not have an application form available. Additional information received from the Provider on 19th May indicated that work had begun on the application form and references had been obtained. The Annual Quality Assurance Assessment told us that robust recruitment procedures with all required checks are completed and that induction and training are in place for staff. This was however a checklist and not a skill based induction package. We looked at training records to assess if staff had the skills to care for the residents. There has been some training completed since the new owners have taken over. This included Safeguarding Adults, medication, Moving and handling and fire safety. Elm Residential Care Home DS0000070897.V363849.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40,42 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Whilst there have been a range of management issues identified the providers have responded positively by telling us within a short timescale what progress has been made to ensure the home is a safe and well managed one. EVIDENCE: Since the ownership of the home changed the registered Manager who was also the Provider has left and the Provider is now managing the home. The Annual Quality Assurance Assessment told us that the Provider is planning to complete the Registered Managers Award and is trying to find a course for this. The Provider has not yet applied to the Commission for Social Care Inspection to register as Manager of the home and it was confirmed during the discussion that they were unaware of the requirement to do this. Elm Residential Care Home DS0000070897.V363849.R01.S.doc Version 5.2 Page 23 The Provider/manager of the service was not ensuring that robust recruitment procedures were being followed and staff had commenced in post prior to these being in place. The Annual Quality Assurance Assessment told us that there are monthly and annual reviews of the service. On discussion with the Provider/manager confirmed that there were not any formal quality assurances processes in place yet. It was reported that there were informal meetings and chats with residents but nothing was documented. Care records and other documents were stored in a lockable cupboard to ensure confidentiality. The Provider/manager has not had previous care home management experience and seemed unfamiliar with some policies and procedures at this visit. Some procedures were requested which we were told were not available but were later found in files this included the whistle blowing policy and the homes risk assessments. A range of information/guidance documents from various sources was found to be available but these had not been fully incorporated into working policies and procedures that reflected the homes practice. At the visit there was a lack of risk assessment processes and actions to limit and record risks. This included risk assessments on upstairs windows that opened wide and uncovered radiators. The Annual Quality Assurance Assessment did not have details of the service checks that had completed to ensure the building was safe. These were examined at the visit. The electrical installations at the home have been checked but portable appliances have not been tested. The Providers responded positively to discussions at the inspection with immediate actions being taken towards alleviating risks. Information from the provider received on the 19th May 2008 told us that a staff member had been booked on a PAT testing course. We were also told that window restrictors had been fitted to resident’s bedroom windows and risk assessments had been completed on radiators and valves did not allow temperatures to reach above 23°c and that regular checks and servicing would take place. Elm Residential Care Home DS0000070897.V363849.R01.S.doc Version 5.2 Page 24 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 2 2 3 3 x 4 x 5 x 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 3 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 2 35 2 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 2 x 1 2 x 2 x Elm Residential Care Home DS0000070897.V363849.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? First inspection since registration 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 YA1 Regulation 5 Requirement Service users must be provided with adequate information regarding the home which includes a Terms and conditions of residency contract in order that they can make informed choices Care plans in place must reflect all the assessed needs of the resident and describe the interventions that are needed to ensure that needs are met The medicine policy must be kept updated to ensure that staff have information on current practice, including arrangements for obtaining supplies of medication. A controlled drug cabinet which meets Royal pharmaceutical guidelines must be in place to store controlled drugs in The provider must ensure staff do not commence employment until all required checks and documentation are satisfactorily in place as detailed in Regulation 19 and Schedule 2 to ensure they are considered suitable to work with vulnerable residents DS0000070897.V363849.R01.S.doc Timescale for action 30/06/08 2 YA6 14 30/06/08 3 YA20 13(2) 30/05/08 4 YA20 13(2) 30/07/08 5 YA34 19 30/07/08 Elm Residential Care Home Version 5.2 Page 26 6 YA35 18 7 YA39 24 There must be in place a skill based induction package for new staff to ensure they have the skills to meet the needs of residents The registered person must ensure that a regular quality assurance system is in place which is subsequently supported by an action plan to ensure the service is a developing one Portable electrical appliances must be checked by a person who is competently trained to ensure they are safe to use 31/07/08 30/07/08 8 YA42 23(2)(c) 31/07/08 9 YA42 13(4) A risk assessment for the 15/07/08 radiators and window restrictors must be completed and any identified actions taken to ensure service users are not placed at any risk 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 YA17 YA22 Good Practice Recommendations Where residents take lunches out of the home records should indicate what is provided The complaints procedure should include timescales to let residents know when they can expect a response to their concerns The address of the Commission for Social Care Inspection should be changed to ensure residents can contact us if they wish to The Safeguarding Adults procedure should be reviewed to ensure it reflects locally agreed procedures to ensure allegations are handled appropriately. The provider/Manager should have the knowledge and a Elm Residential Care Home DS0000070897.V363849.R01.S.doc Version 5.2 Page 27 3 YA23 4 YA40 procedure in place to refer staff to the Pova list if required. There should be a review of policies and procedures to ensure they are up to date and reflective of practice in the home The Provider/Manager must ensure that they and their staff are familiar with the policies and procedures in place Elm Residential Care Home DS0000070897.V363849.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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. 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