Inspection on 23/10/06 for Elmbank Residential Care Home

This inspection was carried out on 23rd October 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 20/04/06

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 Key Unannounced Inspection 23rd October 2006 09:45 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.V316986.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 Residential Care Home DS0000066669.V316986.R01.S.doc Version 5.2 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.V316986.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th April 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 has 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.V316986.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 4 hours and was the second 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. The Deputy Manager, Jean Izzard, represented the establishment. A partial tour of the premises took place, most residents were spoken with, and a number of documents and files were sampled as part of the inspection process. Standards assessed and rated as ‘good’ at the previous inspection in April 2006 were not fully reassessed at this visit. The inspector would like to thank the residents, staff and Deputy Manager for their time, assistance and hospitality during this inspection. What the service does well: What has improved since the last inspection? A number of Requirements made at the last inspection have been met and some have been partially met. Resident’s care plans are now being regularly reviewed and the storage arrangements for medication have improved. Three staff records checked showed that the staff had had CRB and pova checks. The last three radiator covers have been fitted and thermostats have been fitted to resident’s hand basins; one toilet and one shower room have been totally refurbished to a good Standard. A legionella safety check was carried out. Cleaning arrangements have been reviewed and dedicated hours set aside for cleaning in the home. A dieticians advice was sought. Elmbank Residential Care Home DS0000066669.V316986.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Elmbank Residential Care Home DS0000066669.V316986.R01.S.doc Version 5.2 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.V316986.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents moving into this home have their needs assessed but more work needs to be done to meet this Standard in full. EVIDENCE: At the April 2006 inspection 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 have made it Elmbank Residential Care Home DS0000066669.V316986.R01.S.doc Version 5.2 Page 9 difficult to ensure that resident’s needs were all properly identified and then incorporated into their care plan. On this return visit in October 2006 two new residents files were examined. One was a social services client and therefore a community care assessment had been completed. The other client was privately funded and the home’s own assessment record had been completed. Record keeping had improved since the last inspection and the home’s own basic admission record had been filled in except for the resident’s weight - the deputy manager said the resident had gone out on the day resident’s weights were measured. The home’s own admission forms are not completed prior to admission therefore it would be difficult to assure potential residents that their needs could be met as they are not assessed before being admitted. This resident had come for a day before being admitted, as part of the assessment process, but there was no record of any assessments made or information gathered on that day. There were no assessments from other professionals on file for this resident. The Registered manager must review the arrangements for admitting residents in line with Standard 3 and as set out at the previous inspection. Elmbank Residential Care Home DS0000066669.V316986.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s care plans were properly completed and regularly reviewed. Medicines are being administered with care and some improvements have been made as recommended at the last inspection. Residents were observed to be treated with dignity and respect. EVIDENCE: These Standards were not fully reassessed during this inspection as the home scored well on some of them at the previous full key inspection in April 2006. At that time it was noted that 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 and when three care plans were checked in this regard at the October 2006 inspection, all were found to have been reviewed in a timely fashion. Elmbank Residential Care Home DS0000066669.V316986.R01.S.doc Version 5.2 Page 11 In April 2006, it was found that health care needs were documented and all residents registered with local GPs. The GPs had just reviewed all residents at Elmbank with regard to general health needs, including nutrition. Residents at Elmbank regularly see 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. A return visit by the community pharmacist in July 2006 made only minor recommendations and was complimentary about the home’s stock control and the medication administration record (MAR) keeping. No residents are self-medicating and there are no controlled drugs at this home. Minor recommendations made at the last CSCI inspection in April 2006 had been completed but this time one resident’s photograph was not on the MAR file, and the home’s policy on this issue has not been updated. At this previous inspection it was documented that ‘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.’ A further Requirement will be made in this regard. 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.V316986.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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. EVIDENCE: This Standard was not fully re-assessed during this inspection as the outcome from the April 2006 inspection was good. In April it was noted that there is a programme of activities provided and care plans highlight resident’s 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 Elmbank Residential Care Home DS0000066669.V316986.R01.S.doc Version 5.2 Page 13 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. At the April 2006 inspection it was noted that 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. On the day of the inspection residents had sausages, boiled potatoes and mixed frozen vegetables with gravy. The frozen vegetables were steamed. The menu said ‘beef casserole’, not sausages, and the deputy manager explained that residents preferred sausages as they were easier to chew. To ensure residents receive a varied and nutritious diet, arrangements need to be made to ensure meat (such as beef) is tender enough for resident’s to eat. Residents said they had enjoyed their lunch and portion sizes were substantial for most residents, though a few had smaller meals on request. 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 kitchen was clean and tidy and the staff member preparing the food was noted to be taking the time to cut the crusts off the bread for the resident’s teatime sandwiches. During the visit to the home in March 2006 inspectors asked the proprietor to get the opinion of a dietician regarding the current menus. This was made into a recommendation at the April 2006 inspection. However, the dietician’s advice gained by the home since then has consisted of written information about what constitutes a good diet for older people – there was nothing specific in the written report about the suitability of the current menu at this home. The deputy manager cited some suggestions made by the dietician, for example having oily fish on the menu once per week, and this had now been included in the form of sardines on toast as an option for supper. A further recommendation will be made in this regard. Elmbank Residential Care Home DS0000066669.V316986.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Concerns and complaints are likely to be taken seriously at this home, though the complaints book could not be found on the day of the inspection. Staff are aware of the policy for protecting vulnerable adults but recruitment practices need further work in order to fully protect residents. EVIDENCE: The home has a complaints procedure and keeps a central log of complaints – at the April 2006 inspection it was noted that the last formal complaint received was in 2003. However, on the day of this inspection, the complaints book could not be found and the complaints procedure was a ‘bought in’ policy which hadn’t been tailored to the requirements at the home e.g. if did not have a timescale within which the home would respond to complaints. The registered person must ensure that a log of complaints are kept and made available at inspections, and the policy is tailored to the requirements of this home. Residents can also raise concerns directly with the proprietor who is in day-to-day charge of the home, or in resident’s meetings. The home has a copy of the Surrey multi-agency procedures for the protection of vulnerable adults. Staff interviewed in January knew what their Elmbank Residential Care Home DS0000066669.V316986.R01.S.doc Version 5.2 Page 15 responsibilities were with regard to reporting vulnerable adult issues. However, on the day of this inspection it was noted that not all new staff had a properly documented full employment history and this could potentially place residents at risk. The registered person must ensure that they comply fully with the Care Homes Regulations 2001 (as amended), and with Schedule 2, when recruiting new staff. Elmbank Residential Care Home DS0000066669.V316986.R01.S.doc Version 5.2 Page 16 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, 25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is generally well maintained and a number of decorative improvements have been made since the last inspection. There have been some improvements in the standard of hygiene at this home though more work needs to be done. EVIDENCE: These Standards have not been fully reassessed as they were partially met at the April 2006 inspection. At that time it was noted that the home is continually renewing and updating the furnishings and fittings as well as carrying out repairs. Since the last inspection all of the new radiator covers Elmbank Residential Care Home DS0000066669.V316986.R01.S.doc Version 5.2 Page 17 have been fitted and a toilet and shower room have been totally refurbished to a good standard. The Requirement at the last inspection to get a legionella safety test was met though the home does not yet have a written policy on the measures they are taking to keep the premises legionella free. The deputy manager said the home has now finished fitting individual thermostats on basins accessible to residents. The final Standard in this section covers general hygiene and the control of infection. The kitchen has been steam cleaned since the monitoring visit in March and on the day of this inspection in October it was found to be clean and tidy; the cleaning rota was examined and was satisfactory. The communal sitting areas used by residents were generally well kept and the refurbished toilet and bathroom downstairs have been fitted with soap and towel dispensers. However, there were still some shortfalls in cleanliness and hygiene in the toilets and bathrooms. The refurbished toilet downstairs had no light shade and there were cobwebs on the ceiling; the floor also needed to be cleaned. The downstairs shower room had a bar of soap for communal use on the basin; the deputy manager said this belonged to a resident who did not like the soap from the dispenser. It was suggested that this resident may like to keep their own soap in a soap box for their private use and to prevent cross infection. The registered person has reviewed cleaning arrangements since the last inspection and instituted two hours per day of dedicated cleaning but this matter needs to be kept under review to ensure a good standard of cleanliness can be maintained. Elmbank Residential Care Home DS0000066669.V316986.R01.S.doc Version 5.2 Page 18 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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff numbers should be reviewed to ensure resident’s needs can be met at all times and recruitment practices need further work to meet this Standard in full. There is a positive attitude to training at Elmbank and the ratio of trained to non-trained staff exceeds what is required in this Standard. EVIDENCE: The home had 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 were deemed adequate during the mornings. However, on the morning of this inspection the manager was away on holiday. The deputy manager was in charge and only one other member of the care staff was working as a care worker. Another member of the care staff is employed from 8-10am as a cleaner. The start of the inspection needed to be delayed slightly as the deputy manager was already involved in providing personal care for a resident. Three residents were ill with influenza and needed assistance with food and drinks in their rooms at lunchtime, and another gentleman took ill in the dining room as he sat down to lunch and had to be assisted out of the room. There were barely sufficient staff to meet resident’s physical needs and at lunchtime the cook had to be one of the three staff assisting residents to eat. One resident who was confused needed more support and supervision than was available and wandered into the kitchen. The Elmbank Residential Care Home DS0000066669.V316986.R01.S.doc Version 5.2 Page 19 registered person must review the arrangements for staffing including ensuring that contingency plans are made for emergency situations and temporary changes in needs for example when several residents are ill at the same time. 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 manager have both passed the Registered Managers Award, and in total, 8 of the 13 care staff are trained to at least NVQ Level 2 (including 5 with NVQ Level 3) – this exceeds the NMS target of having 50 of all care staff at the home trained to this level. Recruitment practices have improved since the last inspection and the three new staff taken on since April 2006 had all had CRB and pova checks. However, not all had a documented full employment history and some of the referees had not stated in what capacity they knew the applicant. The registered person must ensure that all staff taken on have had the necessary recruitment checks as set out in Schedule 2 of the Care Home Regulations 2001 (as amended). They should also get advice from the CRB website concerning the correct storage and disposal of CRBs. The final Standard was not reassessed during this visit as the home scored well on induction and training at the April 2006 inspection. Then, of the three staff files checked, all showed that staff had received induction training and the home provides paid training for staff which exceeds the three paid training days per year as set out in this standard. Elmbank Residential Care Home DS0000066669.V316986.R01.S.doc Version 5.2 Page 20 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): 31,33,34,35,37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 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. EVIDENCE: These Standards were not fully reassessed where the home was rated as good at the last inspection. At the previous inspection it was noted that 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.V316986.R01.S.doc Version 5.2 Page 21 The home has a number of measures in place to gain views of residents and their relatives, including regular resident’s meetings and the notes 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. More work has been done on this Standard since April 2006 including some evidence of work on self monitoring and planning but no overall plan was available. However, the home needs to meet all aspects of Standard 33 on quality assurance and this is an outstanding Requirement from the previous inspection. At the April 2006 inspection it was noted that 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 at the previous inspection 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). A number of matters subject to Requirements at the January inspection have now been fully addressed including fitting radiator covers (the last three have now been fitted) and the fitting of local thermostats to ensure residents are not scalded whilst using the hand basins in their rooms and communal toilet areas. However, on the day of the inspection there was no evidence that the home had a documented policy on the practices they should be following to keep the home free from legionella, any monitoring of water temperatures, or on the advice given by the environmental health department. The Employers Liability Insurance certificate had run out 2 days earlier and the deputy manager said she was sure the owner had the new certificate and it just needed to be put up when she got back from holiday. No fax facility was available as the owner had locked the room where the fax and photocopier were kept. Other policies and procedures checked in the policy manual seemed to have been ‘bought in’ and had not been tailored to the particular situation at the home – for example the complaints policy did not state how many days the home would take to respond to a complaint – the space was left blank; and the medication policy did not identify which method the home would use to identify residents and this was a Requirement from the last inspection. Elmbank Residential Care Home DS0000066669.V316986.R01.S.doc Version 5.2 Page 22 Elmbank Residential Care Home DS0000066669.V316986.R01.S.doc Version 5.2 Page 23 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 3 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 2 17 X 18 2 3 X X X X X 2 2 STAFFING Standard No Score 27 2 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 2 3 X 2 2 Elmbank Residential Care Home DS0000066669.V316986.R01.S.doc Version 5.2 Page 24 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. Outstanding from 20/05/06 The registered person 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. Outstanding from 20/05/06 Timescale for action 23/11/06 2. OP9 13(2) 23/11/06 3. OP25 13(4)(a) (b)(c) The registered person must 23/11/06 ensure that water systems within the home are safe and a policy on the prevention of legionella, and arrangements for monitoring this, must be clearly documented and relevant staff informed. Elmbank Residential Care Home DS0000066669.V316986.R01.S.doc Version 5.2 Page 25 4. OP26 13(a)(b) (c) Toilets and bathrooms must be kept clean at all times and the staff hours dedicated to keeping the home clean must be kept under review for the safety and comfort of residents. The registered person must review staffing levels at the home as discussed during the inspection and set out in this report. 30/10/06 5. OP27 18(1)(a) 23/11/06 6. OP29 19 Schedule 2 The registered person must 23/11/06 ensure that all new staff have had the necessary recruitment checks as set out in Regulation 19 and Schedule 2 of the Care Home Regulations 2001 (as amended). All staff recruited since July 2004 must have these checks carried out and in particular, a full and documented employment history. They should also get advice from the CRB website concerning the correct procedure for the storage and disposal of CRBs. The registered person must send 07/11/06 an action plan to CSCI setting out how the home will meet each aspect of Standard 33 regarding quality assurance. Outstanding since 20/06/06 The registered person must produce an improvement plan setting out the methods by which, and the timetable to which, the registered person intends to improve the services provided in the care home. The home must obtain and display a current insurance certificate in respect of liability which may be incurred in relation to the care home. DS0000066669.V316986.R01.S.doc 7. OP33 24(1)(2) (3) 8. OP33 24A(1)(2) 23/11/06 9. OP34 25(2)(e) 30/10/06 Elmbank Residential Care Home Version 5.2 Page 26 10. OP37 13(b)(c) The home must review its ‘bought in’ policies and procedures and ensure each one is tailored to the procedures at Elmbank and relevant policies made known to staff. 23/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 2. Refer to Standard OP15 Good Practice Recommendations The dietician’s advice should be sought regarding the current menus at Elmbank. Elmbank Residential Care Home DS0000066669.V316986.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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