Inspection on 20/04/06 for Elmbank Residential Care Home

This inspection was carried out on 20th April 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

Elmbank Residential Care Home 17/12/08

Elmbank Residential Care Home 04/12/07

Elmbank Residential Care Home 23/10/06

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Elmbank Residential Care Home Elmbank Woodham Road Woking Surrey GU21 4EN Lead Inspector Helen Dickens Unannounced Inspection 18th April 2006 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 Residential Care Home DS0000066669.V288701.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. Elmbank Residential Care Home DS0000066669.V288701.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Elmbank Residential Care Home Address Elmbank Woodham Road Woking Surrey GU21 4EN 01483 765984 01483 765984 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) Elmbank Residential Care Home Ltd Mrs Chinder Kaur Saggu Care Home 14 Category(ies) of Dementia - over 65 years of age (4), Old age, registration, with number not falling within any other category (14) of places Elmbank Residential Care Home DS0000066669.V288701.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th January, 2006 Brief Description of the Service: Elmbank is a detached property in a residential area of Woking. One of the proprietors is also the registered manager and operates the business with an employed staff team. The home provides 24 hour care and accommodation for 14 older people, up to four of whom may have dementia. Twelve of the bedrooms are single and one is used as a double room. There are no en suite facilities but each room had a hand basin. There is a communal lounge, conservatory and dining room. The home has its own garden which is accessed from inside the home. There is car parking to the front of the home and in the side road. Elmbank Residential Care Home DS0000066669.V288701.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 6 and a half hours and was the first key inspection to be undertaken in the Commission for Social Care Inspection year 2006/07. The inspection was carried out by Helen Dickens, Link Inspector for the service. Mrs. Saggu, Proprietor and Registered Manager, and Deputy Manager, Jean Izzard, represented the establishment. A partial tour of the premises took place and four residents and two staff were interviewed. A number of files, documents and records were examined as part of the inspection process. The inspector would like to thank the residents, staff and proprietor for their time, assistance and hospitality during this inspection. What the service does well: What has improved since the last inspection? What they could do better: On the day of the inspection, three Immediate Requirements were made, all of which were related to similar issues raised at the last inspection. Details are contained in the main report. Elmbank Residential Care Home DS0000066669.V288701.R01.S.doc Version 5.1 Page 6 Cleanliness in some parts of the home needed to be improved. The proprietor said the care plans were overdue for review due to a transition to a new careplanning format. Initial assessments on two residents contained insufficient information to produce a suitable care plan. Care staffing levels need to be reviewed as care staff are doing most of the domestic work in the home including cleaning bedrooms and toilets, and doing the laundry. Further work needs to be done on quality assurance and this is outlined under Standard 33. Some recommendations will also be made with regard to the administration of medication. 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. Elmbank Residential Care Home DS0000066669.V288701.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 Elmbank Residential Care Home DS0000066669.V288701.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): 3 Residents not admitted under social services arrangements do not have the same standard of pre-admission assessments as other residents and this needs to be addressed in order to ensure all potential resident’s needs have been properly identified. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four residents files were examined as part of the inspection process and two found to have good pre-admission assessments. These documents are crucial in devising a suitable care plan and one resident placed from out of county had an extremely thorough and detailed assessment. Two others who had not had involvement from social services had missed out on the community care assessment of need, and had only the home’s own initial assessment from which to devise a care plan. These assessments were basic and not completed in full – this would make it difficult to ensure that resident’s needs were all properly identified and then incorporated into their care plan. Elmbank Residential Care Home DS0000066669.V288701.R01.S.doc Version 5.1 Page 9 This home does not offer intermediate care services. Elmbank Residential Care Home DS0000066669.V288701.R01.S.doc Version 5.1 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): 7,8,9 and 10 Residents care plans were generally well done but needed to be regularly reviewed in order to ensure resident’s current health and social care needs were being met. Medicines are being administered with care though a few minor improvements could be made to improve the safety of the process. Residents were observed to be treated with dignity and respect. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans contained a good overview of residents needs and those residents interviewed confirmed their needs were being met by staff. Most had been reviewed in January of this year but not since and the proprietor explained this was because they were ‘phasing in’ new care planning documentation. A requirement was made in this regard. Health care needs were documented and all residents are registered with local GPs. The GPs have just reviewed all residents at Elmbank with regard to general health needs, including nutrition. One resident is currently in hospital having a mental health needs assessment. Residents at Elmbank regularly see Elmbank Residential Care Home DS0000066669.V288701.R01.S.doc Version 5.1 Page 11 the chiropodist and this was confirmed by the record of payments to the chiropodist who visits the home. One resident was identified as needing a hearing aid assessment, at their annual review in March. The home has since arranged for an appointment with the audiologist at the hospital. Medication administration is generally well organised at Elmbank and the home uses blister packs provided by a local pharmacy; the last local pharmacist’s visit to the home in June 05 made some recommendations regarding the administration of medication. As per one recommendation, a special medication fridge has now been purchased and is being used for those medicines requiring refrigeration. No residents are self-medicating and there are no controlled drugs at this home. Medication administration records (MARs) were well kept with no unexplained gaps. However, it was noticed that at least two members of staff have to really stretch to reach the top of the medicine cupboard, the cupboard itself was tidy but un-blistered medication could be better organised to prevent errors. The second medicine cupboard contained a variety of items which were not related to medicines and this should be reviewed. Residents MAR records did not contain a photograph but the proprietor said this is being reviewed. The deputy manager takes responsibility for medication and said that residents are currently identified by checking their names with them. She also said agency staff are not used and if they were, they would not be giving medication – therefore only senior staff who are very familiar with residents administer the medication. The home must ensure that their medication administration policy clearly sets out the method to be used to identify residents during the administration of medication, and that this is strictly adhered to. There were some excess stocks of medicines in the home and one resident had medication prescribed in January and March which had still not been opened; these need to be returned to the pharmacy as soon as possible. Four tablets were left on a spoon in the locked medicines cupboard and the home was advised to ensure that all medicines were kept in properly labelled containers. On the day of the inspection residents were observed to be treated respectfully and residents themselves confirmed that they were happy with the way staff dealt with them. Elmbank Residential Care Home DS0000066669.V288701.R01.S.doc Version 5.1 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): 12,13,14 and 15. Elmbank provides activities for residents and welcome family and friends into the home. Residents are enabled to exercise some choice and control over their lives and made some positive comments about the food provided at Elmbank. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a programme of activities provided and care plans highlight residents past interests. There was evidence in both the resident’s meeting notes and in the office activities folder that residents were given choices about community activities and they were currently planning a canal boat trip. A number of residents take a daily paper and one showed me that she does the crossword every day. The conservatory offers pleasant views for residents to enjoy and in the lounge area, before and after lunch, staff played music to which residents were seen to be singing along. One resident preferred to most of their time in their room, and liked to rest in bed after lunch; staff happily accommodated these preferences though they said they encouraged this resident to join the others for lunch whenever possible. Elmbank Residential Care Home DS0000066669.V288701.R01.S.doc Version 5.1 Page 13 Staff said relatives were encouraged to come to the home and the proprietor kept in touch with them by telephone on a fortnightly basis. Comments in the compliments folder showed a number of positive comments from relatives to staff at the home. The home endeavours to allow residents to have some choice and control over their daily lives and this is noted in the residents meetings as outlined above, and in speaking to residents. The home has now contacted an advocacy service which may be available to those residents who do not have relatives or friends to speak up for them. Residents spoken to commented favourably on the food at Elmbank. Lunch is served at midday but the member of staff who prepares lunch said this is what residents prefer. On the day of the inspection residents had corned beef hash prepared like a cottage pie with the mashed potatoes on top. The frozen vegetables were steamed; staff said this was the healthiest way to cook vegetables. Cake and custard were served for pudding. Staff said residents preferred food that was easy to chew and that the corned beef hash was popular. Residents said they had enjoyed their lunch and portion sizes were substantial for most residents, though a few had smaller meals. Staff confirmed this was because some residents had smaller appetites. One resident had a smaller main course in order to keep more room for her pudding which she always preferred, according to staff. A different cook is employed on Sunday when residents have a roast lunch. The home were asked in March to get advice from a dietician on their current menus and a recommendation will be made that a copy of this advice is sent to CSCI. During the visit to the home in March inspectors asked the proprietor to get the opinion of a dietician regarding the current menus. This report should be sent to CSCI. Elmbank Residential Care Home DS0000066669.V288701.R01.S.doc Version 5.1 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 Concerns and complaints are likely to be taken seriously at this home though none have been made during the last year. Staff are aware of the policy for protecting vulnerable adults but all staff need to be checked against the protection of vulnerable adults list, in order to fully protect residents. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints procedure and keeps a central log of complaints – the last formal complaint received was in 2003. Residents can also raise concerns directly with the proprietor who is in day-to-day charge of the home, or in residents meetings. All four residents interviewed confirmed they had no complaints with the home or the staff. The home has now obtained a copy of the Surrey multi-agency procedures for the protection of vulnerable adults. Staff interviewed in January knew what their responsibilities were with regard to reporting vulnerable adult issues. However, on the day of this inspection a member of staff on duty had not been checked against the protection of vulnerable adults register. An immediate requirement was made in this regard and this issue is discussed more fully under Standard 29 on recruitment. Elmbank Residential Care Home DS0000066669.V288701.R01.S.doc Version 5.1 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): 19, 25 and 26 The home is generally well maintained though a number of minor decorative matters and a review of cleaning arrangements need to be carried out in order to meet this standard in full. There were some hygiene shortfalls on the day of the inspection which will need to be addressed to fully protect residents. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is continually renewing and updating the furnishings and fittings as well as carrying out repairs. Since the last inspection all but three of the radiator covers have been fitted – the remainder have arrived but need further work in order to fit them properly. The home provides nice touches for the benefit of residents such as an aquarium in the lounge and a small library in the hallway. However, the paintwork on the skirting board to the first floor is quite marked and needs cleaning or repainting; the ‘pink’ toilet downstairs needs Elmbank Residential Care Home DS0000066669.V288701.R01.S.doc Version 5.1 Page 16 redecorating, especially around the basin and pipe work, and there were cobwebs hanging from the ceiling. The downstairs shower room still has mouldy tiles and grouting and this is an outstanding requirement from the last monitoring visit in March. The proprietor said this will be totally replaced, as will the shower mat and curtain which are also very worn. Three radiator covers are still waiting to be fitted. Standard 25 covers safe comfortable surroundings with particular regard to heating, lighting and water. The previous inspection resulted in a requirement that all water outlets accessible to residents needed to have localised thermostatic controls to ensure residents using hand basins were not scalded. When checking whether this requirement had been met it was not clear whether the water had been controlled by reducing the thermostat on the main hot water tank. As this can increase the risk of legionella, an Immediate Requirement was made that the proprietor get professional advice regarding their water system and the correct temperature for storing hot water. In addition, a test for legionella safety must be carried out immediately and the result sent to CSCI. The inspector also asked the local environmental health department to give the proprietor some advice on this matter. The final Standard in this section covers general hygiene and the control of infection. The kitchen has been cleaned since the monitoring visit in March and the communal sitting areas used by residents were generally well kept. However, the toilets and bathrooms could be further improved. One toilet/shower had urine on the floor and other toilets had cotton towels rather than paper ones, and one had no soap. This issue was also raised at the March visit to the home. An Immediate Requirement was made in this regard. Elmbank Residential Care Home DS0000066669.V288701.R01.S.doc Version 5.1 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): 27,28,29 and 30. Resident’s commented positively on the staff in this home but a number of improvements and reviews will need to be carried out in order to properly protect residents. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has recently carried out the Residential Forum calculation to ascertain how many care staff are needed according to the assessed needs of current residents. Two care staff plus the manager are deemed adequate during the mornings but on the morning of the inspection the manager had had to pop out, the deputy was on duty with one other staff member who was doing the laundry – this staff member turned out not to have had a POVAfirst check and should not have been in the home. The other staff member is employed as the cook from 9am to 1pm, and for cleaning, including the toilet areas from 8am-9am and therefore not available for care duties. On her return the proprietor sent for another member of the care staff to come on duty and remained in the home until she arrived. It also became apparent that care staff carry out virtually all the cleaning and domestic work including the laundry and cleaning of residents bedrooms and communal areas, as well as toilets and shower rooms. The proprietor was asked to review these arrangements to ensure sufficient care staff are available to help residents. Elmbank Residential Care Home DS0000066669.V288701.R01.S.doc Version 5.1 Page 18 There is a positive attitude to training in this home and the walls in hallways contain framed certificates of the many training courses completed by staff. The manager and deputy have both got the Registered Managers Award, and the member of staff who cooks in the morning and is a care worker in the afternoons is also qualified to NVQ Level 4. The home’s recruitment practices were outlined in the January 2006 report and some aspects generally found to be satisfactory. However, a member of staff working in the home on the day of this inspection had not had a POVAfirst check carried out. This had also happened at the January inspection with a different member of staff. An Immediate Requirement was made in this regard. The three staff files checked showed that staff had received induction training and the home provides paid training for staff which exceed the three paid training days per year as set out in this standard. Elmbank Residential Care Home DS0000066669.V288701.R01.S.doc Version 5.1 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): 31,33,35 and 38 The registered manager is experienced in running a care home and resident’s financial interests are safeguarded by the home’s practices. However, more work needs to be done with regard to quality assurance to ensure the home is run in the best interests of residents and to ensure their health, safety and welfare at all times. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. EVIDENCE: One of the proprietors acts as the registered manager and has many years experience working with older people; she has managed this home for 6 years. She updates her own training and over the last year has had training in food handling and hygiene, the care and control of medication, and fire protection. Elmbank Residential Care Home DS0000066669.V288701.R01.S.doc Version 5.1 Page 20 The home has a number of measures in place to gain views of residents and their relatives, including regular resident’s meetings which now clearly demonstrate what choices residents have been given and any contributions they have made. The proprietor said she also keeps in touch with relatives and, if she does not see them at the weekend when they visit, then she telephones them. However, the home needs to meet all aspects of Standard 33 on quality assurance and this is an outstanding Requirement from the previous inspection. Resident’s finances are managed by themselves and their own family, or by a solicitor or social services – the home does not manage any resident finances. However, they do pay the hairdressing, chiropody and newspaper bills for some residents and keep records and receipts which are then presented to relatives who settle the bills. A number of documents were sampled with regard to health and safety and these included the annual fire alarm testing certificate (16/12/05), the visit from environmental health (08/08/05), the annual gas safety certificate (13/12/05), and the lift-servicing certificate (22/02/06). However, a number of matters subject to Requirements at the January inspection have still not been fully addressed including fitting radiator covers (there are still three left to do) and the fitting of local thermostats or other measures to ensure residents are not scalded whilst using the hand basins in their rooms and communal toilet areas. These issues and those regarding the dangers of adjusting the thermostat on the main water tank have been outlined earlier in the report. Elmbank Residential Care Home DS0000066669.V288701.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 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 1 2 X X X X X 1 1 STAFFING Standard No Score 27 1 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 1 Elmbank Residential Care Home DS0000066669.V288701.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 OP3 Regulation 14(1)(a) (b)(c) Requirement All residents must have an adequate assessment of their health and social care needs (as set out in Standard OP3), prior to, and in the early days of, being admitted to the home. Resident’s care plans must be regularly reviewed as set out in Standard OP7.4. The responsible individual must review the current arrangements for the storage of medication, as some staff are unable to safely reach the highest shelf. The responsible individual must review the home’s policy and practice regarding identifying residents during the administration of medication. Whichever system is chosen (e.g. photographs on MAR charts, or some other method) should be clearly set out in the home’s policy and happen in practice. For the protection of residents, the responsible individual must not allow new staff to work in the care home until a DS0000066669.V288701.R01.S.doc Timescale for action 20/05/06 2. 3. OP7 OP9 15(2)(b) 23(2)(a) (l) 20/06/06 27/04/06 4. OP9 13(2) 20/05/06 5. OP18 13(6) 20/04/06 Elmbank Residential Care Home Version 5.1 Page 23 6. OP19 23(2) (b)(d) 7. OP25 13(4)(a) (b)(c) satisfactory POVAfirst check has been carried out. This was an Immediate Requirement and outstanding from 09/01/06 when the same Immediate Requirement was made in relation to other staff. The responsible individual must 20/05/06 arrange for the fitting of the final three radiator covers; remove or redecorate the blackened area on the skirting board going up to the first floor; and arrange for the redecoration and cleaning of the ‘pink’ toilet on the ground floor as outlined in the report. The cleaning/replacement of the mouldy shower tiles in the downstairs shower room is outstanding from the previous inspection in March and must be attended to as soon as possible. 20/04/06 The responsible individual must ensure that water systems within the home are safe: • Professional advice must be taken on the safe storage temperatures for water in the main hot water tank. • A legionella safety check must be carried out and the safety certificate sent to CSCI as soon as possible. • An action plan setting out timescales for the fitting of localised thermostatic controls must be sent to CSCI, with risk assessments in place until all outlets accessible to residents are within safe limits. • The result of the Environmental Health Officers inspection on water safety must be sent DS0000066669.V288701.R01.S.doc Version 5.1 Page 24 Elmbank Residential Care Home to CSCI. 8. OP26 13(a)(b) (c) Toilets and bathrooms must be 20/04/06 kept clean at all times and cotton towels must not be used in communal hand washing facilities. Individually dispensed soap must be made available in all communal hand washing areas. An Immediate Requirement was made in this regard. This is outstanding from January 06 when the same requirement was made. The responsible individual must 21/04/06 review staffing levels at the home as discussed during the inspection and set out in this report. Staff should be present as per the staff rota. The home should review how domestic work is currently allocated to ensure that care staff are not unduly diverted away from the care of residents. If care staff are expected to carry out domestic work then additional care staff hours will need to be allocated POVAfirst and Criminal Records 20/04/06 bureau checks must be carried out on all staff as set out in the Care Standards Act as amended. (Staff awaiting full CRB clearance must be supervised according to the same regulations.) Immediate and outstanding from January 06. The responsible individual must 20/06/06 send an action plan to CSCI setting out how the home will meet each aspect of Standard 33 regarding quality assurance. 9. OP27 18(1)(a) 10. OP29 19 11. OP33 24(1)(2) (3) Elmbank Residential Care Home DS0000066669.V288701.R01.S.doc Version 5.1 Page 25 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 OP9 Good Practice Recommendations The storage in the medicines cupboards should be reviewed to reduce the small risk of error due to overcrowding, excess medicine supplies, and non-related items being stored in these cupboards. The dietician’s advice regarding the current menus at Elmbank should be sent to CSCI. 2. OP15 Elmbank Residential Care Home DS0000066669.V288701.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Elmbank Residential Care Home DS0000066669.V288701.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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