Inspection on 06/02/07 for Elmbank Care Home

This inspection was carried out on 6th February 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Elmbank Care Home 26/09/07

Elmbank Care Home 17/11/05

Elmbank Care Home 21/07/05

Elmbank Care Home 08/03/05

Elmbank Care Home 14/06/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Byars Care Home

St Marys Nursing Home

Jubilee Villa Care Home

Bramble Lodge

Parkmanor Residential Home

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

CARE HOMES FOR OLDER PEOPLE Elmbank Care Home 35 Robinson Road Mapperley Nottingham NG3 6BB Lead Inspector Jayne Hilton Key Unannounced Inspection 6th February 2007 10:00 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 Elmbank Care Home DS0000026433.V323506.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 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. Elmbank Care Home DS0000026433.V323506.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elmbank Care Home Address 35 Robinson Road Mapperley Nottingham NG3 6BB 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) 0115 962 1262 0115 952 3726 Elmbank Nursing Home Limited Isabel Mantle Care Home 35 Category(ies) of Learning disability (4), Old age, not falling registration, with number within any other category (35), Physical of places disability (2) Elmbank Care Home DS0000026433.V323506.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Within the total number of beds a maximum of 2 bed maybe used for the category Physical Disability (PD 50 ) Within the total number of beds a maximum of 4 beds maybe used for the category Learning Disability (LD 50 ) One bed may be used in the category LD(E) to specifically accommodate a named person referred to in Variation application dated 29.06.04. This person is aged 67 years on admission. One bed may be used in the category Learning Disability to accommodate the named person referred to in the variation application dated 23/09/05. This person was aged 47 years on admission. (LD 1 named) One bed may be used to accommodate the named person named in V36722 dated 17 November 2006. 17th November 2005 4. 5. Date of last inspection Brief Description of the Service: Elmbank is registered to provide a service for up to 35 service users in single and shared rooms, some with ensuite facilities. The premises are an extended residential house in Mapperley, close to a shopping area and four miles from Nottingham city centre. Both nursing and care staff are provided. The home is accessible for wheelchair users and there are accessible gardens. A lift provides access to the first and second floors. Information on the fee levels was not provided for this inspection. Elmbank Care Home DS0000026433.V323506.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted by two Regulation Inspectors and was unannounced. The focus of inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. This inspection took place over 7 daytime hours. The main method of inspection used was called ‘case tracking.’ This involves selecting three residents and looking at the quality of the care they receive by talking to them, examining their care files and discussing how support is offered to them by staff members. Many of the people who live at this home have a very limited ability to understand and communicate. Therefore many judgements in this report are from observation and reading residents’ records and documents. The residents who were “case tracked” were not able to help by giving an opinion about the care provided. Due to time spent on some specific areas of concern one resident who could express an opinion was interviewed and others were communicated with throughout the inspection process. Five members of staff, the manager, two relatives and three service users were spoken with as part of this inspection, documents were read and medication inspected to form an opinion about the quality of the care provided to residents. Prior to completing this visit the inspector assessed the homes previous inspection reports, the service history including any complaints and adult protection referrals. A Pre-inspection questionnaire had not unfortunately been completed by the registered manager prior to the inspection. Eight completed residents satisfaction questionnaires were also received prior to this inspection. Elmbank Care Home DS0000026433.V323506.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Picture Symbols have been sited around the home to assist service users to locate the various rooms and ‘All About Me’ books are used to assist communication between service users with a learning disability and staff. Elmbank Care Home DS0000026433.V323506.R01.S.doc Version 5.2 Page 7 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. Elmbank Care Home DS0000026433.V323506.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Elmbank Care Home DS0000026433.V323506.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users needs are assessed prior to moving to the home. There was no evidence that they have been informed in writing that the home can meet their individual needs or of a contract. The home does not provide an intermediate care service. EVIDENCE: Four service users assessments and care plan documentation were viewed. Information pertaining to the level of fees charged was seen in the files but there was no specific Contract document, Terms and Conditions or copy of confirmation in writing that the home could meet the needs of the service user. Information obtained from service users and/or relatives indicated that Contracts had not been provided. Elmbank Care Home DS0000026433.V323506.R01.S.doc Version 5.2 Page 10 The pre inspection questionniare had not been completed by the manager prior to the inspection and this is required by regulation. Information about fees was therefore not obtained for this report. It is recommended that service users and visitors are informed about how they can access a copy of the most recent inspection report. An appropriate pre-assessment tool is used prior to admission, which identifies religious needs, however the documenation needs to be expanded to enusure that the cultural and diversity needs of service users are fully addressed. Extended Community Care assessments were viewed in care plans where applicable. Attention is needed that dates are always recorded on the preassessement documentation. The format for care planning is very complex and consists of a detailed assessment sheet which then informs staff of the service users needs and how they will meet them. The system is not very service user friendly but staff reported that they found the system useful. A relative confirmed that the manager had talked through the care plan and thay they were happy with its contents. The documents contain detailed medical terminology and references and are not easy to follow for medically untrained readers. Elmbank Care Home DS0000026433.V323506.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are provided with a plan of care, which is reviewed, but improvement is needed in the documentation and monitoring of care to ensure all service users needs are fully met. Service users are satisfied with the care they receive and their privacy is respected. Service users are protected by the homes policies and procedures for medication management. Good practice recommendations are made to further improve outcomes for service users. EVIDENCE: Three care plans were examined and found to contain action plans for various needs leading from areas identified in assessments. There was evidence that plans were regularly reviewed and plans were amended as a result of changes, but there was some confusing information and the plans difficult to follow and track through. Elmbank Care Home DS0000026433.V323506.R01.S.doc Version 5.2 Page 12 Daily progress diaries are not used but care plans are evaluated and updated on a daily basis. Service Users heathcare needs appear well addressed but there were gaps identified for example, not all care plans examined had Chiropody input documented and several days gaps were noted in a bowel chart for one service user, with no recorded actions by staff. Health screening and nutritional charts are implemented as needed. On discussing a nutitional care plan with staff members it was noted said that the service user did not like taking nutritional suppliments but there was no reference in the care plan that suppliments were being offered . Authorsiation is gained for the use of bedrails but the paperwork does not inform the reader of the potential risks of use of bedrails and this is recommended. Falls are monitored but as the documentation is condensed and so detailed any amendments made, are in small writing. There was evidence of appropriate referral to outside professionals such as the tissue viability nurse and Community Psychiatric Services. Input by dental services was recorded for the supply of dentures but the maanger reported that it hasbeen difficult to find a dentist able to visit the home for routine check ups and fillings etc and where service users are not mobile or well enough to travel to a surgery this is impossible. The manager is advised to approach the Primary Healthcare Team in relation to accessing dental services for the home. The manager agreed that improved cross referencing of information would improve the format plan of care documentation and that a workshop for staff on care planing and the new system would improve outcomes for service users. Service users and their relatives commented that they were happy with the care delivered. Continence care and pressure area care appeared to be well managed. The systems in place for the management of medication were satisfcatory, however The Bristish National Formulary was out of date, a new one sould be obtained. The storage temperatures of medication should be monitored. Service users spoken with mostly felt respected by staff, who were described as very caring. Some issues were raised about rough handling by staff on occasions and this was raised with the manager to deal with appropriatly. Staff were able to demonstrate that they pomote privacy in their practice. Elmbank Care Home DS0000026433.V323506.R01.S.doc Version 5.2 Page 13 Elmbank Care Home DS0000026433.V323506.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social religious and recreational interests. Relationships with relatives and friends are encouraged. A varied, balanced diet is offered and service users are happy with their meals. EVIDENCE: An activities worker was employed on three days each week, but was not present during this inspection. In her absence care staff provide some activities. Appropriate sing-along 40’s music was playing in the lounge and most service users were joining in with this. Two service users attend a day centre on some days. Relatives were welcome to visit at all times and they were welcome to have meals. Details of friends and family were included on service users files. Service users with a learning disability have all about me books to aid communication. The manager reported that she and the activities co-ordinator are setting up a new programme of activities and a record of participation will be kept which is good practice. Elmbank Care Home DS0000026433.V323506.R01.S.doc Version 5.2 Page 15 Service users expressed satisfaction with the level and range of activities provided. The manager reported that they are also looking into providing more trips out in the future. Most meals were taken in the dining room, though some service users were served individually in lounge areas or bedrooms. Menus had been revised since the last inspection but were still at the printers. Service users were served with faggots or fish on the day of the inspection and records evidenced that service users regularly had a choice of two main course meals. A newly employed cook was in post and service users and relatives reported satisfaction with the meals and said drinks were provided at frequent intervals or when they requested. Elmbank Care Home DS0000026433.V323506.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users and their representatives know how to make a complaint. Staff need to undertake training in abuse awareness to ensure service users are fully protected from abuse. EVIDENCE: The Complaint procedure is displayed in the home and service users and relatives said they knew how to make a complaint. A hard back book is in use to document any formal complaints although there had not been any recorded complaints since the current manager had come into post. Where concerns or issues have been raised these were observed to be documented within service users records. It is recommended that concerns and compliments be documented in the book and a template be devised to document formal complaints and responses which can be stored in a ring binder file. The manager said she was confident that she had the appropriate knowledege of the Nottinghamshire Committe for Protection of Vulnerabel Adults protocols although she would be attending training on the topic in the near future also. There have been no reported Safeguarding Adults notifications at the home. Staff however need to undertake training an Adult Protection Procedures to enusure service users are fully protected from abuse. Elmbank Care Home DS0000026433.V323506.R01.S.doc Version 5.2 Page 17 Elmbank Care Home DS0000026433.V323506.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,22,24,26, Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users live in an environment which is in need of redecoration and new carpets and there is evidence of water leak damage to several ceilings in the home. There are a number of Health and Safety issues which need to be addressed to ensure service users health and welfare are fully protected. Cleaning standards/practices and systems for infection control need to be addressed to ensure the environment is safe for service users to live in. EVIDENCE: Parts of the home are looking tired and the manager reported that a rolling programme of refurbishment was in process in the home. The dining area carpet was safe but should be considered for replacement. There was some protector mats placed under the dining tables, which may Elmbank Care Home DS0000026433.V323506.R01.S.doc Version 5.2 Page 19 pose a trip hazard to service users and it is recommended that these be risk assessed/removed. The home was clean and smelled fresh but attention is needed to ensure that spillages and splashes on wall coverings in the dining room and bedrooms and on television screens are routinely cleaned. Several areas of water leak staining and damage to the dining room and several ceiling tiles on the ground floor areas and these need to be made good. There was a plaster crack in the wall in the entrance to the cellar, which needs to be investigated and rectified. The sluice door had been left open when unattended, which may present a risk of cross contamination to service users who may wander in there. There was a broken headboard in one bedroom, which was removed during the inspection. The kitchen was noted to be clean, however attention is needed for food store cupboards/shelving and fridge/freezer doors to be included within cleaning schedules to ensure regular cleaning. In the smoking lounge the carpet was stained and the basket waste bin provided was unsuitable for use in this area. A metal bin should be provided to ensure fire safety. A wheelchair had been left in front of the patio doors in the smoking lounge, which would prevent exit in the event of a fire and this was removed at once when noted. Fire exits must be kept clear at all times. There were no window restrictors on the ground floor windows and this needs to be addressed to ensure safety and security to service users. The garden area has an unguarded pond and several un-level paving slabs, both presenting risks to service users. A suitable guard/rail needs to be fitted around the pond and the paving slabs made safe. Attention is needed to ensure that all bed linen such as valances and carpets are checked for staining when beds are stripped. In bathrooms towels and toiletries were noted to be openly stored which may pose a risk to service users. The provision /use of alcohol/anti bacterial scrubs would be a further measure for infection control. Elmbank Care Home DS0000026433.V323506.R01.S.doc Version 5.2 Page 20 Elmbank Care Home DS0000026433.V323506.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels are adequate to meet the current needs of the service users. Trained nurses and care staff are always available. Staff are supported to train and develop their skills. Service users are protected by the homes recruitment procedures however not all of the require documentation was held as required by regulation. EVIDENCE: Staffing levels were assessed as appropriate for twenty seven service users residing in the home and relatives and service users were satisfied that staff were responsive and around at all times. Catering, domestic, laundry and handyperson hours were also assessed as satisfcatory. Training records confirmed what staff said in relation to training achieved which included, First Aid, Manual Handling, Food Safety, Health and Safety Fire Safety, Infection Control, Dementia Care, Induction and NVQs Elmbank Care Home DS0000026433.V323506.R01.S.doc Version 5.2 Page 22 Training must be provided for staff for abuse awareness and for dealing with behaviours that challenge. Training should also be provided on Equality and Diversity. Four staff files were examined in relation to recruitment procedures and which evidenced good practice overall, however one file did not contain a photograph, which is required by regulation and therfore a requirement is set in realtion to this. There was evidence that staff are receive regular formal supervision. Elmbank Care Home DS0000026433.V323506.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,37,38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of service users by a manager who is fit to manage the home, however improved practice is required for the management of service users monies held on their behalf. The health, safety and welfare of service users is not fully promoted and protected. EVIDENCE: The manager has recently been registered with the Commsiion for Social Care Inspection and reported that she has enrolled for the Registered Managers Award. Staff, relatives and service users comemmented that the manager was approachable. The manager reported that she has only recently come into the post and is working to ensure that any idemtified issues are addressed promptly and that she has made many changes already. The atmopsphere in Elmbank Care Home DS0000026433.V323506.R01.S.doc Version 5.2 Page 24 the home was noticibly calm and staff and service users appeared happy and relaxed. There was evidence that the Responsible Individual makes regular visits to the home and produces reports on the findings of the visit as required by Regulation 26. Quality Assurance and Annual Review Systems are in place also. Evidence was collated that service user surveys are carried out. The system operates by three service users and one visitor being asked to completed questionnaires about their views of the service. The Quality Assurance Manager collates these, but there was no evidence of how the outcomes are reported back to service users and their representatives and this is therefore recommended. The system in place for handling of service users small cash amounts is not satisfactory and this requires prompt review and improvement. Each service user must have appropriate records and receipts kept for any transactions made on their behalf and any monies held. Records must be kept of all money as required by schedule 4 Regulation 17[2] There is a number of health and safety issues as identified in the inspection report in the section for assessment of the Environment and as follows: Attention is needed to ensure that cables from electrical equipment are not left trailing. The home has a fire risk assessment in place but had not put appropriate measures into place in relation to the smoking lounge. Records were viewed and confirmed that the following were in place and up to date. Portable appliance testing, gas safety certificate, Electrical circuit certificate, lift servicing, generic risk assessments, fire equipment checks, prevention of legionella and tests for water outlet temperatures. It is recommended however that where temperatures are recorded to be above 43 degrees that action is taken and a retest recorded. Accident records were viewed and well documented, however there were entries in the book from October which should have been removed under Data Protection Act 1998. Care plans are not stored securely if the clinic room is left unlocked. Elmbank Care Home DS0000026433.V323506.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 1 X X 2 X 3 X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 1 3 2 1 Elmbank Care Home DS0000026433.V323506.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO 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 OP2 Regulation 14 Requirement The Registered Person must confirm in writing to the service user that having regard to the assessment the care home is suitable for the purpose of meeting the service users needs in respect of his health and welfare. The Registered person shall ensure that the care home is conducted so as to promote and make proper provision for the health and welfare of service users in relation to documentation and evaluation of care plans. Ensure all staff receives training in Adult Protection. The Registered Person must ensure that the care home is kept in a good state of repair externally and internally. Replace and make good the ceiling tiles and damage caused by water to ceilings in the home. Repair the plaster crack on the wall in the cellar. Elmbank Care Home DS0000026433.V323506.R01.S.doc Version 5.2 Page 27 Timescale for action 06/05/07 2 OP8 12,14,15, 17 06/05/07 3 4 OP18 OP19 13,19 23 06/05/07 06/05/07 Ensure broken items of furniture are reported and repaired promptly [headboard] 5 6 OP29 OP35 17,18 schedule 4 13,17 Ensure that staff files contain all of the required documentation as required by Regulation. The Registered Person must keep a record of all money held on service users behalf as required by Schedule 4 [9] Ensure Records are stored securely and in compliance with the Data Protection Act 1998 The Registered Person must ensure that all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety. Ensure the paving slabs are made level Ensure fire exits are kept clear Ensure a safety rail/guard is fitted around the pond. Ensure the home is free of trip hazards. Ensure cables are not left trailing Ensure doors to the sluice and clinic room is not left open when not in use. 06/04/07 06/04/07 7 8 OP37 OP38 17 13 06/04/07 06/04/07 Elmbank Care Home DS0000026433.V323506.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP2 Good Practice Recommendations Keep copies of the signed terms and conditions within individual care plan files. Inform service users and relatives how they can access a copy of the most recent inspection report Expand the assessment documentation to include a wider section for the Diversity needs of service users. Review the current assessment/care plan format to make it more user friendly. The storage temperatures of medication should be monitored and an up to date British National Formulary is obtained. Formalise the system for documenting and responding to complaints, [concerns and compliments] Replace the dining room carpet and clean the carpet in the smoke lounge Review cleaning schedules to ensure all parts of the home are kept clean. [Walls, food cupboards, shelving, fridge/freezer doors, bed linen and television screens] Ensure window restrainers are fitted to ground floor windows Seek advice from a suitably qualified person such as a qualified occupational therapist to ensure the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. Ensure sluice and clinic room doors are kept secure when not in use Toiletries should not be left in bathrooms. Linen and towels should not be stored openly in bathrooms and toilets. Consider the use of alcohol/anti bacterial scrubs as additional measures to Infection Control Provide training for staff in dealing with behaviours that challenge and Equality and Diversity. Feedback to service users and their representatives the outcomes of Quality Monitoring Surveys/Reviews Where water outlet temperatures are recorded to be above 43 degrees, ensure action is taken and a retest recorded. DS0000026433.V323506.R01.S.doc Version 5.2 Page 29 2. 3. 4 5 6 7 8 9 OP3 OP7 OP9 OP16 OP19 OP19 OP19 OP22 10 11 12 13 14 15 16 OP26 OP26 OP26 OP26 OP30 OP33 OP38 Elmbank Care Home Elmbank Care Home DS0000026433.V323506.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Elmbank Care Home DS0000026433.V323506.R01.S.doc Version 5.2 Page 31 - 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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