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Inspection on 11/10/05 for Elm Tree Close

Also see our care home review for Elm Tree Close for more information

This inspection was carried out on 11th October 2005.

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 but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Residents particularly commented on the dedication of the staff team. Several residents told the inspector that the staff were lovely, worked very hard, and that `staff can`t do enough for you` and `are always willing to help`. Elm Tree Close provides a suitable environment for the purpose of meeting its stated aims: accommodation is all on one level, and residents are accommodated in single rooms with ensuite toilets. Residents spoken to were happy with their rooms and with the facilities provided.

What has improved since the last inspection?

Staff spoken to reported having attended several training courses over the last year, covering a range of training relevant to the needs of the home. Although the home is not registered for dementia care, several residents had developed dementia or a level of cognitive impairment since coming to live in the home, and it was good to see that the new manager and a senior carer had attended a dementia care course this year. The home has had a new assisted bath installed since the last inspection, thus improving the range of bathing facilities available to residents, and had also taken action to address some health and safety issues identified at the last inspection (re hand washing facilities in the laundry, and the maintenance of safe hot tap water temperatures).

What the care home could do better:

The main areas identified for further action related to: care plans, domestic staffing levels, and action to minimise risk from hot radiators. As these had all been issues identified at the last inspection, it was disappointing to see that they had not been addressed. In particular, although there were no concerns about the actual care being provided by staff, care plans did not provide satisfactory evidence of the action required of staff to meet people`s needs. As this has now been identified at several successive inspections the registered provider needs to address this with some urgency.

CARE HOMES FOR OLDER PEOPLE Elm Tree Close Elm Tree Avenue Frinton On Sea Essex CO13 0AX Lead Inspector Kathryn Moss Unannounced Inspection 11th October 2005 09:30 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 Tree Close DS0000017811.V258502.R01.S.doc Version 5.0 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 Tree Close DS0000017811.V258502.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Elm Tree Close Address Elm Tree Avenue Frinton On Sea Essex CO13 0AX 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) 01255 677747 01255 679926 Southend Care Limited Manager post vacant Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Elm Tree Close DS0000017811.V258502.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 40 persons) Date of last inspection Brief Description of the Service: Elm Tree Close is a purpose built home for older people, situated in a residential area of Frinton, close to the town centre. Accommodation is all on one level and the home is divided into five separate units, joined by connecting corridors. Each unit has a lounge and dining area, and all service users are accommodated in single bedrooms with ensuite bathrooms. A separate central area is used as a day centre, and is run independent of the residential home, although some events are shared with the home (e.g. outside entertainment). The home is registered to provide residential care for 40 Older People (over the age of 65), and provides 24 hour personal care and support. It has appropriate aids and equipment (e.g. mobile hoist, assisted bathing facilities, hand rails, etc.) to assist residents with limited mobility. There are currently a few existing service users at Elm Tree Close who have developed dementia since coming to live in the home, but the home is not registered to admit people with dementia. The home is owned by Southend Care. The registered manager recently resigned, and the newly appointed manager is Mrs Brenda Garrett. On the day of the inspection there were 33 residents living in the home, with a further person admitted on the day of the inspection. Elm Tree Close DS0000017811.V258502.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on the 11/10/05, lasting eight hours. The inspection process included: discussions with 2 senior carers, 3 carers, a cook and a housekeeper; discussions with 7 residents; the viewing of communal areas and specific premises issues arising from the last inspection; and inspection of a sample of staff and resident records. 15 standards were inspected, and 6 requirements and 5 recommendations have been made. There were 34 people in residence in the home on the day of the inspection. The residents and visitors spoken to were all very positive about the staff team and about the care provided at Elm Tree Close, with one resident saying “ I give them 150 ….. a gold star!” What the service does well: What has improved since the last inspection? Staff spoken to reported having attended several training courses over the last year, covering a range of training relevant to the needs of the home. Although the home is not registered for dementia care, several residents had developed dementia or a level of cognitive impairment since coming to live in the home, and it was good to see that the new manager and a senior carer had attended a dementia care course this year. The home has had a new assisted bath installed since the last inspection, thus improving the range of bathing facilities available to residents, and had also taken action to address some health and safety issues identified at the last inspection (re hand washing facilities in the laundry, and the maintenance of safe hot tap water temperatures). Elm Tree Close DS0000017811.V258502.R01.S.doc Version 5.0 Page 6 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. Elm Tree Close DS0000017811.V258502.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Elm Tree Close DS0000017811.V258502.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 and 5. Standard 6 is not applicable at Elm Tree Close. Written information about the home (a ‘brochure’ pack) is available to prospective residents; this does not currently contain all information required by regulation. Staff from the home meet prospective residents prior to admission to assess their needs, and to ensure the home can meet these needs. The home has the skills and facilities to meet the needs of the client group to whom it aims to provide a service. Prospective residents and their representatives are able to visit the home prior to admission to assess its suitability. EVIDENCE: The home’s statement of purpose was seen displayed in the hallway: it was noted that this had been updated since the last inspection, as requested, but needed further revision following the recent change of manager. During the inspection, there was evidence of a ‘brochure’ pack that was given to prospective residents, but this did not appear to have been amended after the last inspection to cover all the issues required in a ‘Service User Guide’, as detailed in Regulation 5 and Standard 1. Elm Tree Close DS0000017811.V258502.R01.S.doc Version 5.0 Page 9 A new resident was being admitted to the home on the day of the inspection: there was evidence that a care management assessment had been obtained by the home, and also that an assessment had been completed by a representative from the home pre-admission; these records were available to staff on the day of admission. A senior carer spoken to stated that the home encourages prospective residents to come and visit the home first, and that staff will assess their needs on this visit. If the person is unable to visit, someone from the home will visit the person to carry out an assessment. The senior carer was very clear that the home would not admit someone if they felt they could not meet their needs. The new resident was briefly spoken to and said that she had a nice room and felt that she had been made welcome. Another resident who had only recently come to live at Elm tree Close was equally positive about their experience of settling into the home, and also felt that they had been made welcome. Staff spoken to during the inspection had attended training that was relevant to the needs the home was meeting (e.g. moving and handling, infection control, continence, prevention of falls, dementia care, etc.). The home’s layout, facilities and equipment are suited to its purpose. Elm Tree Close DS0000017811.V258502.R01.S.doc Version 5.0 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 10 Residents’ care needs appeared to be being well met at the time of this inspection. However, written care plans were not satisfactory and did not reflect the action taken by staff to meet individuals’ needs. Staff treated residents in a respectful and dignified way. EVIDENCE: The files of three residents were viewed during this inspection. One file, of a person who had been admitted to the home five weeks previously, did not contain a completed assessment form or any care plans. The manager confirmed that this was not acceptable and would be looked into at once. The other two files contained a limited range of standard format care plan forms covering issues such as medication, risk of falls, recreational activities, sleep, social contact with family, etc. However, neither file contained care plans to address the individuals’ significant personal care and health needs – e.g. washing and bathing, oral hygiene, continence, toileting, skin care, communication, feeding, mobility, etc. The manager was advised that this needed to be addressed. For care plans seen, there was clear evidence that these had regularly been reviewed. Elm Tree Close DS0000017811.V258502.R01.S.doc Version 5.0 Page 11 Residents spoken to were all happy with the way staff supported their needs, although, as noted above, staff support with personal hygiene needs was not reflected in care plans. Daily care records were well maintained, with clear details of care given and reflecting issues relating to the person’s health and well-being. Care records showed contact with health care professionals, and health needs appeared to be appropriately responded to by staff. Records showed food eaten, weights, and personal cleansing and bathing. Issues relating to continence were not specifically discussed on this inspection; there were no care plans to show how these needs were being addressed on the files viewed. No residents had pressure areas at the time of this inspection, although staff reported that some residents, through frailty and immobility, were at risk. Files contained risk assessments relating to risk of developing pressure areas; however, where someone was at risk, there were no care plans present detailing the preventative action required of staff. Staff reported that residents who were at risk had pressure relief mattresses on their beds; this was not inspected on this occasion. Residents were happy that staff respected their privacy and dignity in the way care was provided. People’s preferred name was recorded on their care plans. The home has a pay phone available in a quiet hallway area, but residents reported that they were able to receive in-coming calls on the home’s phone in each Bungalow, and one resident spoken to had their own phone in their room. Residents were dressed appropriately in clothing that was clean and personal. All residents had single rooms. Elm Tree Close DS0000017811.V258502.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 15 Residents spoken to were happy with their lives at Elm Tree Close; the home provided opportunity for activities. Residents were able to maintain contact with family and friends, and this was supported by the home. A choice of balanced and varied meals were provided to residents. EVIDENCE: Evidence of was seen of residents making choices about daily routines, including where to spend their day, meals, activities, when to get up or go to bed, etc. Residents spoken to were happy with their lives at Elm Tree Close, and a staff member spoken to showed a good understanding of the importance of promoting choice and independence. The home’s assessment form had a section to record ‘social and family history’: on two of the files viewed a small amount of information was recorded; on a third file no information had been recorded. Some information on likes and dislikes was also recorded on a ‘lack of recreational activities’ care plan, but these did not contain any information on the action required by staff to encourage or assist the person to occupy their time and receive stimulation. The manager was advised to ensure that staff obtain and record as much information as possible about a person’s past history and interests. Elm Tree Close DS0000017811.V258502.R01.S.doc Version 5.0 Page 13 The home had a good four weekly activities programme, with suggested activities both morning and afternoon each day. A senior carer is responsible for monitoring and changing the activities programme, based on feedback received from staff, and ideas from residents (through residents’ meetings). All staff are responsible for offering and encouraging activities: on the day of the inspection, a carer was observed encouraging a resident to do a word puzzle in the morning, and in the afternoon residents in another unit reported that they had played dominoes, and two residents reported that they had recently enjoyed a some video and music sessions in the day centre. Activities offered and participated in were recorded on individual activity notes: records viewed showed regular entries, although many of these reflected passive activities (e.g. ‘sitting in lounge’, ‘watching TV’) rather than interaction with staff or others. However, some of these were for individuals who had less ability to participate in planned activities, and these did show where someone had been offered an activity but had refused it. The manager stated that outside entertainment is booked every few months, and that the home also has regular social events to which families are invited (e.g. summer BBQ, Halloween party planned, etc.). Residents reported that they could receive visitors at any time, as evidenced from the visitors’ book. They could also maintain contact with family and friends by telephone, and were able to receive incoming calls on the home’s telephone in each Bungalow. Residents spoken to reported being happy with the food provided, and no complaints were voiced. Several of them commented on there being good variety and choice. Lunch viewed in one bungalow on the day of the inspection looked and smelt appetising, and residents confirmed that they were enjoying it. Kitchen staff spoken to felt that supplies of food were satisfactory in quantity and quality, and that they were able to make changes to the Southend Care set menus to suit the preferences of the residents and to make them seasonally appropriate. Records were kept of the meals served each day, and these showed a good range of balanced meals. The cook described how the dietary needs of residents with diabetes were catered for, and confirmed that she had updated her food hygiene training this year. Elm Tree Close DS0000017811.V258502.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Residents were aware of who to speak to if they had a complaint, and felt able to do so. The home had appropriate policies and procedures for protecting residents from abuse; staff showed awareness of the action to be taken if they had evidence or suspicion of abuse. EVIDENCE: The home’s complaints policy was seen displayed on in the home; service users spoken to seemed aware of who to speak to if they had a concern, confidant to raise concerns, and said that the new manager regularly came round the home and was approachable and easy to talk to. The home had a complaints record book, and in the last year there were records of four complaints that had been raised and addressed. Training records showed that most staff had now attended training in the Protection of Vulnerable Adults (POVA), but about eight staff (including domestic staff) had yet to do this training. Of four staff spoken to, three confirmed that they had attended POVA training this year; the fourth said that they were booked to attend this in the next few months. The new manager was not aware whether any other staff were booked onto forthcoming training. Staff spoken to were clear about the need to report and record any concerns observed, and were also aware of the home’s Whistle Blowing policy. The senior carer on duty had received a booklet on Abuse Awareness, but had not seen the home’s POVA policy and procedure and did not know where to locate this: There was no copy of this in the seniors’ office with other key policies and procedures. The new manager located a copy of this policy, and was advised that this should be made available to staff. Elm Tree Close DS0000017811.V258502.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 25 and 26 The home provided surroundings that were generally safe and comfortable, but had not taken action to identify and address risks associated with hot radiator surfaces. Areas of the home viewed were clean and tidy on the day of the inspection. EVIDENCE: Not all aspects of these two standards were inspected on this occasion, as the primary focus was on requirements and recommendations arising from the last inspection. Hot tap water temperatures were not checked on this occasion: the maintenance person confirmed that new temperature control valves had been fitted to several hot taps, and that hot tap temperatures were being regularly monitored (records not inspected on this occasion). It was noted that no action had been taken regarding the uncovered, hot radiators observed in lounges, bedrooms and ensuites at the time of the last inspection: the new manager was unaware of any risk assessments having been carried out on Elm Tree Close DS0000017811.V258502.R01.S.doc Version 5.0 Page 16 these, and no evidence of risk assessments could be located. Action must be taken with regard to this. It was noted that a new hand-wash basin had been fitted in the laundry area, and that paper towels and liquid soap were available. The home had a laundry person who worked four days a week; care staff covered laundry tasks on other days. The laundry facilities were not specifically inspected on this occasion. On the day of the inspection the communal areas of the home were satisfactorily clean and tidy (individual bedrooms were not inspected), and the housekeeper was working extra hours to ensure that some carpets were cleaned. However, it was noted with concern that for some time the home had only had one housekeeper, which is not sufficient cover for the home (see Staffing section). Elm Tree Close DS0000017811.V258502.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 At the time of the inspection, sufficient numbers of staff were on duty to meet residents’ needs; however, some staff were working unacceptably long hours, and domestic staffing levels were not satisfactory. EVIDENCE: The rota for the week prior to the inspection was viewed, and it was noted that agreed staffing levels were generally being maintained (i.e. eight staff on the early shift, seven on the late shift, and three at night). A senior carer spoken to felt that these staffing levels were sufficient to meet residents’ needs at present. Although actively recruiting, the home was short staffed at the time of this inspection: staff spoken to confirmed that they were working extra shifts to cover the shortages, but were clear that this was their choice. Staff said that they normally did not work more than two long days (i.e. double daytime shifts) per week, and did not usually work successive long days. However, from rotas viewed it was noted that there had been some recent occasions where staff had worked three successive long days, and a resident also expressed concerns about some staff working ‘back-to-back long shifts’. The manager was advised that this is not an acceptable working pattern. At the time of this inspection the home only had one housekeeper: this situation had been ongoing for several months, and similar concerns about lack of domestic cover had been raised at the last inspection. The housekeeper was working six days a week and the maintenance person covered their day off (unless this was a Sunday, in which case there was no domestic cover). The Elm Tree Close DS0000017811.V258502.R01.S.doc Version 5.0 Page 18 housekeeper should be commended for the work they were doing to maintain core-cleaning activities; however, this was insufficient cover to achieve a sufficiently rigorous cleaning schedule in the home. One of the residents also commented on the lack of domestic staff: they praised the current housekeeper for their hard work, but felt that current domestic cover was far from adequate for a home of this size. It was noted that the home was trying to recruit domestic staff but, as required at previous inspections, the registered provider should make contingency arrangements for providing cover when it is known that the home will be short staffed for a period of time. Training was not specifically inspected on this occasion, but staff spoken to all reported having attended a variety of training this year, including dementia care, bereavement, ulcer prevention, prevention of falls, continence, infection control, manual handling updates, and POVA. This showed a good range of training being made available to staff. Elm Tree Close DS0000017811.V258502.R01.S.doc Version 5.0 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were specifically inspected on this occasion. EVIDENCE: At the time of this inspection, the registered manager had recently resigned from the home and the new manager had only been in post for a few weeks, and is therefore not yet registered with the CSCI. The new manager has many years experience as a senior carer in the home, and through this role has acquired knowledge and experience in most aspects of the management of the home. Throughout the inspection the manager demonstrated a knowledgeable, positive and open approach to all aspects of discussion about the home. Staff and residents spoken to during the inspection were all positive about the new manager, finding her approachable, supportive and helpful. Staff appreciated her willingness to assist them with care related tasks, and residents confirmed that the manager regularly goes round the home and felt that this gave them opportunity to see her and speak to her. Elm Tree Close DS0000017811.V258502.R01.S.doc Version 5.0 Page 20 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 2 X 3 3 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X X 2 3 STAFFING Standard No Score 27 2 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X X Elm Tree Close DS0000017811.V258502.R01.S.doc Version 5.0 Page 21 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 OP1 Regulation 4 Requirement The registered person must ensure that the statement of purpose is updated to reflect the change of manager. The registered person must ensure that the home has a Service User Guide that meets the requirements of Regulation 5, as described more fully in Standard 1. A copy of this must be supplied to the CSCI. This is a repeat requirement (previous timescale 30/4/05). The registered person must ensure that each service user has written care plans detailing the action required by staff to meet each need. This must include personal care and health care needs, as well as social and emotional/mental health needs. This is a repeat requirement for the fourth time (last timescale 30/6/05). Intervention required by staff to support people who have pressure areas, or are at risk of acquiring pressure areas, must be recorded in the plan of care. DS0000017811.V258502.R01.S.doc Timescale for action 30/11/05 2 OP1 5 30/11/05 3 OP7 15 30/11/05 4 OP8 15 30/11/05 Elm Tree Close Version 5.0 Page 22 5 OP25 13 6 OP27 18 It is required that the registered person carry out risk assessments and implement appropriate action with regard to unguarded radiators throughout the home. This is a repeat requirement (previous timescale 31/5/05). It is required that the registered provider ensure that appropriate arrangements are in place to enable the home to access additional domestic cover at times when it is known that the home will be short of domestic staff for a period of time. This is a repeat requirement (previous timescale 18/3/05). 30/11/05 31/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP12 OP18 OP18 Good Practice Recommendations It is recommended that the manager ensure that staff record fuller information about residents’ past life histories, interests and hobbies. The manager should ensure that all staff (including domestic staff) have attended POVA training as soon as possible. The manager should ensure that all staff are aware of the home’s policy/procedure for responding to evidence or suspicion of abuse, and that this policy/procedure is available to staff. The registered provider should ensure the provision of suitable low temperature surfaces or guards on radiators in all areas of the home that residents have access to. This is a repeat recommendation. The manager should ensure that staff do not work excessive hours, including too many long days per week, or successive long days, as this could put both staff and residents at risk. DS0000017811.V258502.R01.S.doc Version 5.0 Page 23 4 OP25 5 OP27 Elm Tree Close Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Tree Close DS0000017811.V258502.R01.S.doc Version 5.0 Page 24 - 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. 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