Inspection on 07/03/06 for Elm Tree Close

This inspection was carried out on 7th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Elm Tree Close 29/07/08

Elm Tree Close 22/08/07

Elm Tree Close 06/09/06

Elm Tree Close 11/10/05

Elm Tree Close 03/03/05

Elm Tree Close 28/09/04

Elm Tree Close 18/03/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Elm Tree Close Elm Tree Avenue Frinton On Sea Essex CO13 0AX Lead Inspector Kathryn Moss Announced Inspection 7th March 2006 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.V277820.R01.S.doc Version 5.1 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.V277820.R01.S.doc Version 5.1 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.V277820.R01.S.doc Version 5.1 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) 11th October 2005 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 31 residents living in the home. Elm Tree Close DS0000017811.V277820.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection that took place on the 7/3/06, lasting eight and a half hours. The inspection process included: discussions with the manager, conversations with 6 staff, 5 residents, and 2 relatives; an inspection of communal areas and laundry; and inspection of a sample of staff and resident records. 15 standards were inspected, and 5 requirements and 11 recommendations have been made. Information on key standards not covered on this inspection can be found in the report of the unannounced inspection that took place on the 11/10/05. What the service does well: What has improved since the last inspection? Domestic staffing levels had significantly improved since the last inspection, enabling the home to consistently maintain higher standards of cleanliness. Staff had worked hard to develop activities within the home, and service users reported a noticeable improvement in the range and quantity of activities taking place. A large ‘day room’ is now available to residents (formerly part of the old day centre) providing them with a space where they can meet with residents from other Bungalows, and participate in a wider range of activities than can easily take place in the Bungalows. The registered provider had recently introduced a form for manager’s to use to assess how they were meeting the National Minimum Standards: this was a good tool, and should help managers and staff become more familiar with the Standards. Elm Tree Close DS0000017811.V277820.R01.S.doc Version 5.1 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.V277820.R01.S.doc Version 5.1 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.V277820.R01.S.doc Version 5.1 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 Information about the home is available to prospective service users. EVIDENCE: It was noted that the home’s Statement of Purpose on display in the hallway had been updated to show the name and details of the new manager. A revised copy of the home’s Service User Guide was submitted to the CSCI after the last inspection. Elm Tree Close DS0000017811.V277820.R01.S.doc Version 5.1 Page 9 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 and 9 Residents’ personal care needs appeared to be well met at the time of this inspection, but documentation (care plans) did not satisfactorily describe all of the assistance required by staff to meet key care needs. Medication practices were well maintained and protected residents, but some recording issues required further action. EVIDENCE: A small sample of care plans were reviewed with the manager on this inspection. These showed improvement since the last inspection, with the files viewed now containing an appropriate range of care plans (i.e. relating to the person’s key needs), and with evidence that these had been regularly reviewed and some good review notes recorded. In some cases the care plans contained sufficient information about the action required by staff to meet a specific need, and had some relevant information recorded by staff. However, in many instances the care plans only indicated that a person needed assistance (e.g. with eating, personal care, inability to self-toilet, etc.) but still did not describe the specific action required by staff to meet that person’s need, or what the person could do for themselves. It was noted that staff had sometimes used a separate blank care plan format to record some useful Elm Tree Close DS0000017811.V277820.R01.S.doc Version 5.1 Page 10 additional information relating to a number of different needs: this may indicate that the constraints of the current care plan formats made it difficult for staff to know where to record certain information relating to how to meet residents’ specific needs. Review notes contained some good observations on service users’ needs. There were also instances where review notes showed significant changes in the person’s abilities or needs over time, but where the actual care plan had not been updated to reflect the new action required. It was recommended that new care plans be developed when needs change significantly, to ensure details of current action required is available staff. Where pressure area preventative care was required, care plans were present on two of the files viewed (not present on the third file), but did not provide details of the specific equipment in use with that person. The home’s practices relating to storing and recording medication were inspected on this visit; the home’s medication policy and evidence of staff training in medication were not inspected on this occasion. Medication was stored on each Bungalow, with spare supplies kept in a central locked cupboard within the home; storage arrangements viewed on two Bungalows were secure and orderly. Medication administration records (MAR) were generally pre-printed by the dispensing pharmacist; in two instances where details of medication for a new resident had been handwritten by staff onto the MAR, the entries had not been signed by the person making the record. Medication received by the home was recorded on the MAR, and where no new supply had been received, the MAR generally showed medication carried over from the previous month; in one instance this had not been recorded, making it difficult to audit the number of remaining tablets. Medication administered was generally well completed, with only a few gaps observed, and there was a clear system for recording medication returned to the pharmacist. Bottles of eye-drops seen had all been dated on opening, and were within use-by timescales. The home had a wall-fixed safe that was used as a controlled drugs cabinet, and a controlled drugs record book (not viewed on this occasion). Elm Tree Close DS0000017811.V277820.R01.S.doc Version 5.1 Page 11 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 and 14 Residents were happy with the lifestyle and activities at Elm Tree Close. The home supported residents to exercise control over their lives. EVIDENCE: Information on a local advocacy service was available in the office, although no advocates were currently involved with any residents. However, the manager had appropriately assisted one resident to arrange for a solicitor to support them with decisions about their finances. On previous inspections it had been noted that residents were able to bring personal possessions into the home with them, and on this inspection it was reported that two residents had asked to have their rooms decorated and to choose the décor themselves, and that one of them had recently ordered a new wardrobe that had been installed for them by the maintenance person. These provided good examples of residents having choice and autonomy over their personal space. The manager confirmed that residents could see their own records, and that someone had recently asked to see their records; on previous inspections it was noted that Access to Records information was included in the Resident’s Handbook. Day-to-day choices and activities were not fully inspected on this occasion, but posters were seen displayed around the home advertising a wide range of activities taking place each week. These included seated exercises, music and Elm Tree Close DS0000017811.V277820.R01.S.doc Version 5.1 Page 12 sherry, painting, etc.; on the day of the inspection groups of residents were seen in a separate day room enjoying music and dancing, and reported that a seated exercise session had taken place in the morning. Staff had clearly worked hard to develop the activities since the last inspection, with several residents commenting on the improvement in activities available. This was good to see. Elm Tree Close DS0000017811.V277820.R01.S.doc Version 5.1 Page 13 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): None of these standards were inspected on this occasion. EVIDENCE: The CSCI has not received any complaints or concerns about Elm Tree Close since the last inspection. Elm Tree Close DS0000017811.V277820.R01.S.doc Version 5.1 Page 14 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): 19 and 26 At the time of this inspection, areas of the home viewed provided a self, wellmaintained environment, which was clean, pleasant and hygienic. EVIDENCE: On the day of the inspection the home was clean and tidy, and areas viewed were satisfactorily maintained. Only communal areas were viewed on this inspection. The manager was in the process of completing an annual development plan, which incorporated a range of objectives relating to the improvement or refurbishment of the premises; she explained that bedrooms were decorated as and when required. The home had a Home Improvements log book for maintaining a record of when rooms were decorated or furniture/equipment replaced. There were clear systems in the home for identifying and recording any maintenance work requiring action, and the home’s maintenance person carried out any repairs required. The home had been inspected by both the fire officer and the environmental health officer within the last year. Elm Tree Close DS0000017811.V277820.R01.S.doc Version 5.1 Page 15 An issue carried forward from the last inspection regarding the risk to residents from hot radiators was reviewed (reference standard 25): the manager confirmed that a risk assessment had been carried out (evidence seen), and that action had been taken to address radiators presenting the greatest risk (i.e. those in ensuite toilets). She stated that plans were in progress to fit low temperature covers on other radiators, but that this had yet to be carried out. The home’s laundry room was away from areas where food was stored or prepared, and contained washing and drying machines, a sink for hand washing clothing, and a hand wash basin; a sluice sink was available in a separate adjacent sluice room. The laundry person showed an awareness of infection control processes, and confirmed that protective clothing was available to her, and that there were systems in place for identifying and segregating any soiled items. It was noted that the washing machines only had hot wash cycles capable of either 60°C or 95° washes, and this was discussed in relation to the need to wash items soiled with body fluids at a temperature of at least 65°C to minimise risk of infection. The laundry person confirmed that soiled items such as sheets and underwear would be washed at 95°C, but was concerned that some items of soiled clothing might suffer from being washed at 95°C. The manager was advised to seek the advice of the Health Protection Agency on this. The home appropriate written guidance on infection control in care homes. Elm Tree Close DS0000017811.V277820.R01.S.doc Version 5.1 Page 16 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, 28, 29, 30 At the time of this inspection, sufficient numbers of staff were on duty to meet residents’ needs. Staff recruitment practices included appropriate checks to protect residents. Relevant training was provided to ensure that staff were trained to do their job; evidence of NVQ training did not yet sufficiently demonstrate that care staff had achieved the required qualifications. EVIDENCE: Rotas viewed showed that agreed staffing levels (8 in the mornings, 7 afternoon/evenings and 3 at night) were generally being satisfactorily maintained. It was noted that some care staff were sometimes working three long days a week (i.e. 7am to 9pm), and there were occasions when staff were working two successive long days. On most days there were at least three staff working a long day (on some days, four or five staff working long days), resulting in several hours during the day when the staff team was one person short due to staff taking breaks. Although staff chose to work long shifts or extra hours, this must be closely monitored by the manager and registered provider to ensure that the health and welfare of staff and service users is not affected. The manager reported that further staff recruitment was in process, and expected that this would minimise the need for any staff to work more than two long days per week. Staff turnover since the last inspection had been low, and staffing levels in the home had generally improved. In particular, there had been a significant improvement on domestic staffing levels, which is commendable. Elm Tree Close DS0000017811.V277820.R01.S.doc Version 5.1 Page 17 The files of three new staff were viewed with regard to evidence of recruitment practices. Two of the files contained good evidence of all checks required by regulation having been carried out prior to the person starting work. The third file contained an application form with an incomplete employment history: it was not clear from the application form whether the person’s last period of employment involved work with children or vulnerable adults, and although two personal references had been obtained there was no evidence of a last employer reference. The registered provider had recruited this person on behalf of the home: the manager checked with the head office, but no further information was available for this person. All three staff had started work on the basis of a POVAfirst check: the manager was advised that new staff should only start work prior to receipt of a full CRB check in exceptional circumstances, and was given information on the Department of Health POVA guidance regarding supervision arrangements for any new staff who start work prior to the receipt of a full CRB check. The manager stated that new staff underwent a comprehensive induction in the home, including time spent with the manager going through employment issues and procedures in the home, a week spent supernumerary to the staff team for inexperienced care staff, and a care practices checklist completed under the supervision of a senior carer over the first six weeks. Although it had been noted on previous inspections that the home had a workbook for new staff to complete that covered the TOPSS (now ‘Skills for Care’) induction units, the manager stated that this was not currently in use as it was being revised. It was suggested that the previous TOPSS induction could have been continued until the replacement was available, as this meant that some new staff had not completed an induction linked to the TOPSS units. The home maintained individual staff training profiles (records), kept in a central file and archived on personal files at the end of each year. These were well maintained, although it was noted that there was not yet a training record in place for some new staff, although they had completed some training. The manager stated that she also intended to develop a recording system to show an overview of current core training for all staff, to assist in monitoring when staff training was due. Records for existing staff showed a good range of training completed over the last year, including: health and safety related training (see standard 38), POVA, medication, dementia, continence management, falls prevention, and bereavement training. No staff in the home were currently undergoing NVQ training: the manager stated that only 5 current staff had achieved NVQ level 2 in care or above, but that up to 10 staff recruited from outside the UK had an ‘equivalent’ qualification. There was not yet evidence to demonstrate how alternative qualifications met the NVQ criteria and content, and the need for this evidence has been discussed with the registered provider. Elm Tree Close DS0000017811.V277820.R01.S.doc Version 5.1 Page 18 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): 31, 33, 35, 38 The manager is not yet registered with the CSCI, but demonstrated appropriate knowledge and understanding of management issues within the home. The home is run in the best interests of residents, with systems in place for monitoring this. Systems for looking after service users’ monies safeguarded their financial interests. Practices in the home promoted the health and safety of residents and staff; however, not all staff were up-to-date in all areas of health and safety training. EVIDENCE: The current manager has been in post since September 2005: this is her first management post, and she is currently undergoing registration with the CSCI. At the time of this inspection she had just enrolled on a course to achieve the Registered Manager’s Award (NVQ level 4 in management) combined with NVQ level 4 in care, and hoped to achieve this in 12-15 months. Throughout the inspection she demonstrated good knowledge and understanding of service Elm Tree Close DS0000017811.V277820.R01.S.doc Version 5.1 Page 19 users’ needs, and of the management arrangements within the home. Staff and residents were positive about the manager, finding her approachable and supportive, and felt that she encouraged a positive atmosphere in the home. The manager explained that questionnaires were being given to residents, or their relatives if the person was unable to respond themselves, to seek their views on the service provided at Elm Tree Close. Key workers were to assist residents to complete these if required, and it was recommended that someone not involved with residents’ day-to-day care and the running of the home should assist with these. Responses were to be evaluated and a report produced. The manager was also in the process of developing an annual development plan for the home for 2006: this contained a number of good areas for development, including several premises issues. As some of the aims were quite general, it was recommended that it also include some specific objectives that staff could be involved in setting and achieving, focusing on direct outcomes for residents. There were a number of systems in place for auditing processes and practices within the home: a variety of records were checked during monthly visits carried out by a senior manager; accident records were regularly monitored and summarised; named staff had responsibility for recording a monthly premises checklist on each bungalow; and a National Minimum Standards self-assessment tool had recently been introduced to help the home evaluate their practices against the Standards. The home has facilities for the safe keeping of money on behalf of residents. There were secure storage arrangements for the safe keeping of this money, and records viewed showed the date and amount of all income and expenditure (with explanations), signatures of the staff dealing with the money, and the current balance of money held. Receipts were maintained for all expenditure, and in a sample checked the receipts, records and cash all balanced. The home also maintains a residents’ bank account for the safe keeping of larger amounts of money on behalf of residents: only six residents currently had money in this account, and clear records were maintained. Health and safety policies and procedures were not inspected on this occasion. Staff training records showed that most staff were up-to-date with moving and handling training; all staff in post in July 2005 had received updated fire safety training and some new staff had viewed a fire safety video, although not all had seen this. The manager was waiting to attend fire marshall training, and stated that this would equip her to deliver fire safety training within the home. Very few care staff had current food safety training, and the manager was aware that this training was needed. First aid training was not specifically discussed. There was a clear record of all checks and servicing carried out on equipment and utilities, which provided evidence that the equipment and premises were regularly maintained. The manager was advised that Gas Safety Record certificates do not show whether equipment was serviced at the time the Gas Elm Tree Close DS0000017811.V277820.R01.S.doc Version 5.1 Page 20 Safety check was carried out, and it was recommended that the engineer be asked to record evidence of this in future. There was evidence of regular fire drills, and of checks on fire alarms, emergency lighting, and fire equipment. Hot water taps used by residents are fitted with temperature control valves to ensure that hot water remains close to 43°C. Internal checks on hot water temperatures (re risk of scalding from hot water taps, and of central hot water storage temperatures to prevent risk of Legionella) were being carried out, but records showed only intermittent entries and not regular checks. The manager was advised that this should be addressed. A comprehensive ‘water regulations inspection’ had been carried out at the end of 2005, and the manager confirmed that any action identified had been carried out. Accident records were maintained, and there were systems in place to monitor these (i.e. an accident summary form completed to provide an overview). The home had a general risk assessment for the home relating to safe working practices: this briefly addressed most core areas of the home, but information on risks and action was quite brief, and some issues were not covered (e.g. the use and storage of chemicals within the home). The manager had completed a comprehensive risk assessment on the kitchen, which provided a much more detailed risk assessment relating to safe working practices in that area. This was good, and it was recommend that this format could be applied to other safe working practices/areas within the home (e.g. laundry, domestic tasks, etc.). There were other risk assessments relating to specific individual risks (e.g. BBQ, an adjustable bed, etc.). The home’s risk assessment file contained a variety of documentation, some of which was no longer applicable and some of which needing reviewing. It was recommended that this file be reviewed and updated, to ensure it provides current working information for staff. Elm Tree Close DS0000017811.V277820.R01.S.doc Version 5.1 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 2 Elm Tree Close DS0000017811.V277820.R01.S.doc Version 5.1 Page 22 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 OP7 Regulation 15 Requirement The registered person must ensure that care plans describe the action required by staff to meet each individual 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 fifth time (last timescale 30/11/05). The registered person must ensure that staff sign all hand written medication details that they record on the medication administration record (MAR). The manager must ensure that minimum staffing levels are maintained throughout the day. This is particularly in relation to periods of the day when staff working long days are taking a break. The registered person must ensure that a full employment history is obtained for new staff, including written explanation of any gaps. DS0000017811.V277820.R01.S.doc Timescale for action 30/04/06 2. OP9 13 31/03/06 3. OP27 18 31/03/06 4. OP29 19 31/03/06 Elm Tree Close Version 5.1 Page 23 5. OP38 13 & 18 The registered person must ensure that staff receive appropriate training in all areas of health and safety. This is particularly with respect to food hygiene training. 30/06/06 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 OP8 OP9 OP25 Good Practice Recommendations Care plans relating to the action required where there is a risk of pressure areas should clearly describe any pressure relief equipment in use. Staff should always record on each new MAR form any medication carried over from the previous month (as well as any new medication received by the home). The registered provider should progress action to 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 for the third time. It is recommended that the registered person seeks advice from the Health Protection Agency regarding washing clothing soiled with body fluids at temperatures of less than 65°C. 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. It is recommended that the registered person take action to ensure that at least 50 of care staff have achieved NVQ level 2. It is recommended that a last employer reference always be obtained for prospective staff. The registered person should ensure that pre-recruitment information identifies any last period of employment involving work with children or vulnerable adults, in order to ensure that a reference is sought in these cases (reference Regulation 19, Schedule 2(3)). 4. OP26 5. OP27 6. 7. OP28 OP29 Elm Tree Close DS0000017811.V277820.R01.S.doc Version 5.1 Page 24 8. OP29 9. 10. 11. OP30 OP38OP25 OP38 The registered person should ensure that Department of Health POVA guidance is followed in relation to arrangements for the supervision of new staff who start work before the receipt of a full CRB check. It is recommended that the home continue to ensure that a TOPSS (now Skills for Care) based induction programme is completed by all new care staff. The registered person should ensure that regular checks are carried out (and recorded) on hot tap water temperatures and central hot water temperatures. It is recommended that the registered person ensure that risk assessments on safe working practices are sufficiently comprehensive and cover all potential risks (e.g. use and storage of chemicals), and are regularly reviewed. Elm Tree Close DS0000017811.V277820.R01.S.doc Version 5.1 Page 25 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.V277820.R01.S.doc Version 5.1 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!