Inspection on 04/12/07 for Elmbank Residential Care Home

This inspection was carried out on 4th December 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 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 23/10/06

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 Unannounced Inspection 4th December 2007 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.V354758.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.V354758.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 0208 578 3890 elmb4nk@hotmail.co.uk 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.V354758.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd October 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. Fees for the home are currently £410 per person per week. Elmbank Residential Care Home DS0000066669.V354758.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took place over 8 hours. The inspection was carried out by Mrs. Helen Dickens, Link Inspector for the service. Mrs. Saggu, joint owner and registered manager, and the deputy manager, represented the establishment. Mr. Saggu, joint owner, also assisted with some aspects of this inspection. A partial tour of the premises took place and a number of files and documents, including resident’s assessments and care plans, staff recruitment files, quality assurance information, and the annual quality assurance assessment were examined as part of the inspection process. A number of questionnaires returned to CSCI from residents, relatives and healthcare professionals were also used in writing this report. Three residents were interviewed in their rooms, and several others conversed with throughout the day. The inspector would like to thank the residents and staff, and Mr. And Mrs. Saggu for their time, assistance and hospitality. What the service does well: What has improved since the last inspection? The majority of the Requirements made at the last inspection have been met including more work on assessments and care plans, and improvements in the administration of medication. Staffing levels have been reviewed and there are now dedicated hours of domestic help every day. There are also dedicated hours each day for one member of staff to lead activities with residents. More work has been done on ensuring the prevention of legionella within the home and monitoring of water temperatures etc are now carried out and documented. The home is now displaying the current insurance certificate. Elmbank Residential Care Home DS0000066669.V354758.R01.S.doc Version 5.2 Page 6 Some refurbishment has been undertaken since the last inspection including replacing the carpet in the conservatory and ordering new chairs; replacing the chairs in the dining room, and replacing the bedspreads on all residents beds. Some resident’s beds have also been replaced, others have had their rooms decorated, and some had their net curtains replaced. The home has purchased a new large flat screen TV for the lounge, and a gazebo for the garden. There is a new sit-down weighing scale ensuring all residents can now be weighed. 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.V354758.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.V354758.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 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s needs are assessed prior to them moving into this home but more work needs to be done to meet this Standard in full. EVIDENCE: Two resident’s files were sampled and both had an assessment carried out by the home prior to admission. Other assessments had been sought from the social services department, as well as from health colleagues. For one resident, staff had quickly observed a risk of falling in relation to going to the toilet and a falls risk assessment had been carried out. Some residents had separate information recorded about activities, and a member of staff had started to compile social profiles of each resident. Five residents completed questionnaires for CSCI prior to the inspection, though some needed help from staff to complete these. All five said they received the care and support they needed. Elmbank Residential Care Home DS0000066669.V354758.R01.S.doc Version 5.2 Page 9 However, the homes own assessment form is very brief and the two sampled were not completed in full, for example regarding the social aspects of new resident’s needs – the manager said this information is documented elsewhere but this was not easy to access. A recommendation will be made that information on social activities and interests is recorded on (or attached to), the initial assessment so that it can be properly incorporated into the care plan. The home now has mostly social services sponsored residents but if they were taking new referrals from privately funded clients, they would need a much more detailed assessment form of their own, and it would need to be completed in full. A Requirement will be made for the home to review their assessment procedures. Elmbank Residential Care Home DS0000066669.V354758.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 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s needs are set out in their care plans, but more detailed information is needed, and care plans must be reviewed every month. Resident’s healthcare needs are not fully met, as a review of arrangements for continence management needs to be carried out. Staff respect the privacy and dignity of residents in their daily duties, but more work is needed regarding malodours in the home, which has a negative effect on resident’s dignity. EVIDENCE: Residents have a care plan in place and two of these were sampled. Basic information is recorded for example in relation to resident’s personal and healthcare needs, falls, mobility, medication, diet and nutritional needs, and religious and cultural needs. Though the written information was very basic, the staff spoken with were knowledgeable on resident’s needs and how these had changed over time. One visitor was interviewed with their relative who Elmbank Residential Care Home DS0000066669.V354758.R01.S.doc Version 5.2 Page 11 had lived at Elmbank for two years. They said there were enough people around to help when needed, and when asked how they liked it at Elmbank, the resident said ‘Excellent’. However, care plans are very basic and more information could be included, particularly on how residents want their support to be delivered. The two sampled had not had monthly reviews for every month as set down in Standard 7, and a Requirement will be made in this regard. Residents have a basic health care plan and appointments and visits by the doctor are recorded. A separate book is kept to note when residents are unwell and the doctor needs to be called, together with any changes made, for example with medication. Residents have home visits from the GP, district nurses, chiropodist and optician. Some positive comments were received from these professionals on questionnaires to CSCI. One wrote that ‘Staff are always very caring and endeavour to act on any of our recommendations.’ Another noted, in answer to the question ‘What do you feel the care service does well?’ they stated that Elmbank ‘Respects individual needs.’ A dietician’s advice has been sought on the menus at Elmbank and the manager said the few recommendations made have been taken on board. The home has purchased a new sit-down weighing machine to ensure all residents can be weighed. From sampling resident’s files it is clear that resident’s weights are noted on admission and thereafter, though not recorded on a monthly basis as the manager stated. More work must be done on continence management at Elmbank as, on the day of the inspection, there were some areas of the home, including three bedrooms, where there were unpleasant odours. Two visitors to the home, one some months ago, and another in the week following the inspection, have both reported to CSCI that there are unpleasant odours in the home. This will also be discussed under Standard 19 on ‘Premises.’ Arrangements for administering medication have continued to improve since the last inspection. All residents now have a photograph on their medication administration records (MARs), and two MARs checked had no unexplained gaps. The medication cabinet has been re-sited to ensure all staff can reach the top shelves safely. There are no controlled medicines at this home. On their questionnaire returned to CSCI, one of the GPs attending this home ticked ‘always’ in response to the question on whether the home managed medication correctly. A recent community pharmacist’s report was complimentary about the arrangements for managing medication noting ‘Excellent control of medication.’ The pharmacist had also noted that the home had made enquiries about further training for staff on administering medication. Elmbank Residential Care Home DS0000066669.V354758.R01.S.doc Version 5.2 Page 12 Staff on duty on the day of the inspection were seen to be respectful towards residents. The deputy manager should be commended for the patience shown towards one resident who was becoming forgetful and needed extra support. Residents can have visitors in private in their own rooms, or use the conservatory if it is free - one visitor said she usually took her relative to the conservatory and that staff always brought them a tray of tea. Both health professionals returning questionnaires to CSCI noted, for the diversity question, that Elmbank always responds to the differing needs of individuals. However, as already mentioned, there were some unpleasant odours in this home on the day of the inspection. This does not promote the dignity of residents and Requirements will be made under healthcare (regarding the management of continence), and under premises (regarding hygiene and the control on infection). Elmbank Residential Care Home DS0000066669.V354758.R01.S.doc Version 5.2 Page 13 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 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. There are some social activities arranged by this home and family links are encouraged. Residents are given some opportunities to exercise choice and control in their daily lives and arrangements for meals are satisfactory. EVIDENCE: Resident’s care plans have basic information of past interests and hobbies, though, as mentioned earlier, these had not been completed in full. There is a daily activities plan and an activities book recording what activities had happened and who took part. Two residents spoken to confirmed there were activities provided. The home has purchased a large flat screen TV for residents, and there is a music player in the lounge. Residents were having a sing a long before lunch, and there was a craft activity in the dining room in the afternoon. Not all residents join in, and two relatives commented on their questionnaires that they felt more should be provided in the way of activities, one said the person she visited was bored. These comments were discussed with the manager during the inspection. Elmbank Residential Care Home DS0000066669.V354758.R01.S.doc Version 5.2 Page 14 Family and friendship links are encouraged and the manager outlined the policy for welcoming them to the home. One visitor who has been going to the home for two years confirmed that she has always been made welcome and a tray of tea arranged for her and her relative when she arrives. However, one complaint received some months ago from another relative concerned relatives not being made welcome; this has since been dealt with by the manager. A questionnaire returned from a relative prior to the inspection had also noted that they felt communication with relatives could be better – a recommendation will be made in this regard. Residents are able to exercise some choice and control over their daily lives; they were heard to be given choices for example, in relation to where they wanted to spend the morning (in the lounge or in their rooms), and regarding food and drink. Those interviewed in their rooms showed the inspector that they had brought in a number of personal possessions with them. Most residents at this home have assistance from families to manage their finances but the manager said some residents do have small amounts of money with them; otherwise any significant bills (e.g. hairdressing and chiropody) are given to relatives to settle. With only three care staff including the manager on the morning shift, the inspector felt resident’s choices could be limited as staff were likely to be busy; this is discussed below under staffing. Resident’s care plans note their nutritional needs and a previous recommendation to have menus reviewed by a dietician has now been done and the inspector saw the written report. Some recommendations were made and the manager said these have now been incorporated into the menus. Residents had home made cottage pie, followed by bananas and cream. The main course was not seen by the inspector as lunch was served early, but comments from residents suggested the food at the home is satisfactory. Residents can now be weighed regularly as the home has purchased sit-down scales. One relative noted on a questionnaire that residents are ‘Well fed, and made comfortable.’ The kitchen was clean and tidy and a recent environmental health officer’s visit resulted in a satisfactory report. Elmbank Residential Care Home DS0000066669.V354758.R01.S.doc Version 5.2 Page 15 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 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Complaints are listened to at Elmbank, but residents will not be fully protected from abuse until proper recruitment arrangements are in place. EVIDENCE: A complaints procedure is in place and the home has recorded one complaint, made by a relative, since the last inspection. This complaint was sent to CSCI in the first instance and has since been dealt with by the home. A number of issues were raised including relatives not being admitted to the home according to the home’s own policy on visiting, and malodours within the property. Since the inspection, but before the report was completed, a further complaint was received from another visitor about malodours at Elmbank. Requirements are made at the end of this report regarding this matter. The manager said day-to-day concerns from residents are dealt with on the spot, and there are a number of ways for residents to highlight issues. They can speak either to the manager or her deputy, raise issues at the resident’s meetings, or use the complaints procedure. The home has a copy of the Surrey local procedures for safeguarding adults and new staff cover this subject during their induction. The manager said most staff have done a separate training course on this subject but this was difficult to demonstrate without going through every staff file to look at their certificates. The manager has started work on a centralised training record but Elmbank Residential Care Home DS0000066669.V354758.R01.S.doc Version 5.2 Page 16 this is not yet complete. She said she would complete the training matrix as soon as possible and book a further course for any staff who needed refresher training on this subject. A Requirement will be made under staffing, later in this report. The home has purchased new policies and procedures since the last inspection and the policy on safeguarding adults does not fit with the Surrey procedures – the manager was asked to review the in-house procedure, especially in relation to who investigates any potential incidents. The current recruitment arrangements are not satisfactory and could potentially place residents at risk – a Requirement under staffing is being repeated from the last inspection. Elmbank Residential Care Home DS0000066669.V354758.R01.S.doc Version 5.2 Page 17 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 and 26 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents benefit from continued improvements at this home, but more work needs to be done. The home has better arrangements for cleaning, but there are still malodours within the premises. EVIDENCE: The owners continue to make improvements to the home including purchasing new items such as chairs for the dining room, a gazebo for the garden, and a new carpet for the conservatory. There are many homely touches in the property, including an aquarium in the living room, and plants and pictures throughout the home. Three residents who were visited in their rooms said they were happy with them, and showed the inspector personal items they had brought when they moved in. The home is accessible for frailer residents with a lift to the first floor. The gardens are well maintained. The main issue with the home on the day of the inspection were the unpleasant odours and some Elmbank Residential Care Home DS0000066669.V354758.R01.S.doc Version 5.2 Page 18 cleaning shortfalls, which detracted from the otherwise homely environment. These are dealt with under the next Standard on hygiene. Arrangements for domestic help at the home have improved as this used to be done by care staff in addition to their caring duties. There is now a dedicated cleaner for five hours each weekday and she was working in the home on the day of the inspection. Toilets now have soap dispensers and paper towels and there were no cotton towels in communal areas. However, one toilet/shower had grime on the floor in between the grouting, and around the toilet and waste pipe, and there were brown smudges on the tubular stand around the toilet. The manager said the cleaner had not yet been into the toilets to do the cleaning. The owner dealt with this matter himself and cleaned the area thoroughly; he is also arranging to have the grouting sealed to aid cleaning from now on. Unpleasant odours were noted in three bedrooms and some communal areas and this needs to be dealt with. The manager said carpets were already being cleaned regularly and they may need to consider replacing some floor coverings. A Requirement will be made in this regard. Elmbank Residential Care Home DS0000066669.V354758.R01.S.doc Version 5.2 Page 19 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 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s care needs are met by the numbers and skill mix of staff but this needs to be kept under review. This home exceeds the recommended percentage of staff with NVQ qualifications. Recruitment arrangements do not fully protect residents, and more work must be done on staff training to ensure all staff are trained and competent to do the work they are asked to perform. EVIDENCE: Staffing levels have been reviewed as required at the last inspection – there are now three care staff (including the manager), plus a cook and a cleaner who works every weekday morning for 5 hours. There are two night staff on overnight but they take it in turns having 3 hours sleep each in the rest room, and both working together for the busy periods up to midnight, and again from 6am. However, the manager was not in the home, as per the rota, when the inspector arrived, and other issues for example malodours in the home, and a resident who wanders and went unnoticed into another’s room, suggest staff numbers still need to be kept under constant review. A Requirement will be made in this regard. The manager went through the staff rota and counted how many staff have got NVQ qualifications – of the 12 care staff, only two have not done NVQ Level 2. The deputy has NVQ Level 4; 5 care staff have NVQ Level 3; and the remaining Elmbank Residential Care Home DS0000066669.V354758.R01.S.doc Version 5.2 Page 20 four have NVQ Level 2. This exceeds the National Minimum Standard on qualifications. The certificates were not checked by the inspector but many are framed and on display in the hallway of the home. Staff recruitment arrangements have shown some improvements since the last inspection and files were in better order. However three files were checked and a number of shortfalls were found including gaps in employment history, someone who had returned from maternity leave without having a new CRB check (and having worked elsewhere in the interim) and a volunteer who had been at the home for two months prior to recruitment checks being sought at the beginning of the year. One person who was from overseas had no photographic identification or confirmation that they could work in this country on their file. The manager had the gaps in employment history completed filled in that day, and identification and confirmation of entitlement to work in the country was brought to the home for the other member of staff. The volunteer had now become a paid member of staff and there was a CRB and pova check on file. The only outstanding matter was to get a pova first and CRB for the member of staff who had returned from maternity leave. The manager must go through all staff files to determine if there are any further shortfalls. She was also reminded that references from friends are not acceptable and in those circumstances, an alternative reference will need to be sought. The manager is currently compiling a staff training matrix as currently the only way to be sure which staff have done which training, is to look at certificates on their file, or framed certificates on the wall. There are training courses booked (manual handling and first aid all day on 14th December) and files showed staff had recently done training in fire safety. The manager was asked to complete the training matrix and ensure that any outstanding training which needed to be provided is prioritised and arranged as soon as possible. A Requirement will be made in this regard. Elmbank Residential Care Home DS0000066669.V354758.R01.S.doc Version 5.2 Page 21 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 and 38 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The registered manager is experienced in running a care home. Resident’s financial interests are safeguarded by the home’s practices. Improvements have been made, but more work needs to be done with regard to quality assurance processes – this is to ensure that the home is run in the best interests of residents and that any shortfalls are picked up in a timely way, and not only by CSCI inspections. Arrangements for health and safety have also improved at this home. EVIDENCE: One of the proprietors acts as the registered manager and she has many years experience working with older people; she has managed this home for 7 years. She undertakes periodic training and is familiar with the conditions and Elmbank Residential Care Home DS0000066669.V354758.R01.S.doc Version 5.2 Page 22 diseases of old age. There are clear lines of accountability within the home and she is supported by a deputy who has also worked at this home for many years. There is now a quality assurance folder where records of activities in relation to monitoring and reviewing the service are kept. There is an audit of various quality indicators which has been reviewed twice in the last year. Questionnaires have been sent out to relatives, visiting professionals and other stakeholders. Some favourable comments were made on these questionnaires, for example one healthcare professional described Elmbank as ‘One of the better homes run in Woking.’ A relative wrote ‘ I am always pleased when I leave Elmbank knowing my relative is in good hands. Thank you.’ There is a plan for renewal of various furnishings and fittings for the year, though no written annual development plan referring to the service or service users; the manager was asked to consider this in order to meet Standard 33.2. One concern with the current quality assurance processes is that they are not picking up shortfalls, which are subsequently highlighted during CSCI inspections. It is recommended that the home review their current arrangements to ensure shortfalls are identified in a timely fashion. 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’s 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. The manager has put a number of policies and procedures in place to promote the health and safety of residents and staff. The deputy manager is now responsible for health and safety matters and there is an annual health and safety audit carried out, together with a note of any actions required. Most of the radiators in the home are either covered, or in some way made safe to prevent resident’s being burned – for example the radiator in the conservatory has a wooden cabinet in front of it. This had been moved by staff in a rearrangement of the conservatory furniture, but was replaced by the owner when it was pointed out by the inspector. A recent inspection of the kitchen at Elmbank resulted in a good report from the environmental health officer. The manager said systems are in place to prevent legionella at the home, and there is regular monitoring of water temperatures and a legionella test was carried out in April 2006. The manager was asked to ensure that their arrangements for legionella followed guidance from the Health and Safety Executive which can be obtained from their website. A current insurance certificate and the home’s CSCI registration certificate were displayed in the entrance to the home. Elmbank Residential Care Home DS0000066669.V354758.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 2 8 2 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Elmbank Residential Care Home DS0000066669.V354758.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 Timescale for action 04/01/08 2. OP7 15(1) (2)(b) 3. OP8 16(2)(k) 4. OP18 13(6) Arrangements for assessing prospective residents must be reviewed, especially in relation to privately funded residents who may not have had an assessment from social services; this is to ensure that these residents have a sufficiently detailed assessment of their needs. A review of care planning 04/01/08 arrangements must be carried out to ensure that all plans contain sufficient detail regarding resident’s needs and how they would like their support to be delivered. Care plans must be reviewed regularly. A review of arrangements for 04/01/08 continence management must be carried out to ensure that resident’s needs are met and to keep the home free from offensive odours. The new in-house policy on 04/01/08 safeguarding vulnerable adults should be reviewed to ensure it dovetails with the Surrey local procedures, particularly in DS0000066669.V354758.R01.S.doc Version 5.2 Elmbank Residential Care Home Page 25 5. OP26 13(a)(b) (c) 6. OP27 18(1)(a) 7. OP29 19 Schedule 2 8. OP30 18(1)(a) relation to investigation. 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. (Not met from 30/10/06) A review of procedures must take place to ensure all malodours are eliminated from the home. The registered person must keep staffing levels under constant review at the home to ensure resident’s needs are met. The registered person must 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. (Not met from 23/11/06) A central training record, or training matrix, must be completed and a plan drawn up to ensure all staff are given appropriate training, or refresher courses as required. 18/12/07 04/01/08 04/01/08 04/01/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Elmbank Residential Care Home DS0000066669.V354758.R01.S.doc Version 5.2 Page 26 No. 1. 2. Refer to Standard OP3 OP13 Good Practice Recommendations The home should ensure that social interests of residents are recorded on their assessments, in order that this information can be incorporated into their care plans. Communication arrangements with relatives should be reviewed and the home should have regard to Standard 13.5 regarding written information being given to all relatives. Current quality assurance arrangements should be reviewed to ensure that shortfalls are picked up and dealt with in a timely fashion, rather than being highlighted at CSCI inspections. A written annual development plan should be produced, as set down in Standard 33.2. The booklet on preventing legionella in care homes should be obtained from the Health and Safety Executive website, and the manager check that the policies and procedures at Elmbank meet the guidelines laid down in this publication. 3. OP33 4. OP38 Elmbank Residential Care Home DS0000066669.V354758.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU 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 Residential Care Home DS0000066669.V354758.R01.S.doc Version 5.2 Page 28 - 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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