Inspection on 01/05/07 for Elmlea

This inspection was carried out on 1st May 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Elmlea 08/04/09

Elmlea 02/04/08

Elmlea 10/10/06

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

CARE HOME ADULTS 18-65 Elmlea 99 London Road Gloucester Glos GL1 3HH Lead Inspector Mr Paul Chapman Unannounced Inspection 1st May 2007 09:00 Elmlea DS0000067437.V338836.R01.S.doc Version 5.2 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 Elmlea DS0000067437.V338836.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 Adults 18-65. 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. Elmlea DS0000067437.V338836.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elmlea Address 99 London Road Gloucester Glos GL1 3HH 01452 550438 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) www.holmleigh-care.co.uk Holmleigh Care Homes Ltd To be appointed Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Elmlea DS0000067437.V338836.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th October 2006 Brief Description of the Service: Elmlea is a detached two storey, Victorian brick built property situated in Gloucester. There is off-road parking and a good-sized garden to the rear of the house. The home provides living accommodation on the ground and first floors. On the ground floor there is a lounge, kitchen, dining room, bathroom and one bedroom. On the first floor there are seven single bedrooms and a bathroom. Elmlea provides accommodation for up to eight people with learning disabilities that may also display behaviour that is challenging. The home is staffed 24 hours a day, seven days a week. The property is one of a group of seven registered care homes in Gloucestershire that are owned by Holmleigh Care. The fees for the home range from £780.00 to £1000.00 per week. After parking to the rear of the property you enter the property through the secure garden into the home’s kitchen. The garden has a couple of tables and chairs. The kitchen is a good size and people living at the home have access to it at all times. On leaving the kitchen and entering the rest of the property the door to the staff office is in front of you. Turning left into the rest of the property there is a bedroom on the left of the corridor with doors to the dining room and the lounge further down the corridor. Both the lounge and dining room provide people with substantial shared accommodation. Both rooms have large windows and high ceilings. The first floor is accessed from the stairs at the bottom of this corridor. It is a large, wide staircase that turns to the right as it ascends. At the top of the staircase (to the right) is a long corridor with a high ceiling that all of people’s bedrooms and a bathroom are accessed from. Elmlea DS0000067437.V338836.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was completed over a period of 8 hours on a day in May. The manager was present throughout the day. The first thing that strikes you on entering the home is the massive improvement to the environment. Since the previous inspection the home has been renovated throughout. The home is now warm and homely. Time was spent observing the care of people and their interactions with staff. Two of the people living at the home spoke to the inspector, and some of the bedrooms were seen. At the previous inspection 25 requirements were made for the registered person to address, and although 13 requirements have been made in this inspection report the CSCI feel this is a significant improvement. The care of three people was looked at in depth. This included looking at their financial, medication and personal records. Four staff were interviewed about the care they provide. Other records examined included staff files, health and safety information and quality assurance records. What the service does well: What has improved since the last inspection? People are now provided with a comfortable homely environment that meets their current needs. All of the people living in the home have had their needs assessed and care plans have been written to meet those assessed needs. This will help to provide a consistent approach by staff and allow for continuous monitoring of peoples’ needs. Potential risks to people living in the home are assessed by the manager and plans to minimise those risks are present. Staff receive regular training and records are available to support what they have achieved. Elmlea DS0000067437.V338836.R01.S.doc Version 5.2 Page 6 The manager supervises all staff. Health and safety audits are completed regularly. Medication administration is managed effectively and this minimises potential risks to people living in the home. 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. Elmlea DS0000067437.V338836.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Elmlea DS0000067437.V338836.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has a Service User’s Guide and a Statement of Purpose that enables people to make an informed decision about the home before they move in. Reviewing these documents with the people already living in the home enables people to have a better understanding of what they can expect from the service. Peoples needs are assessed before they enter the home to minimise the risk of the home not being able to meet a persons needs once they have moved in. People being able to spend time in the home before they are admitted supports this process. Individual residency agreements identify the responsibilities of each party. EVIDENCE: The home has a Service User’s Guide and a Statement of Purpose. The manager explained that since the previous inspection they have met each person living at the home individually and explained the documents to them. Elmlea DS0000067437.V338836.R01.S.doc Version 5.2 Page 9 The manager stated that people do not have individual copies of the documents at present but a file with all of this information in is being developed for each individual to keep in their bedroom. It becomes a requirement of this inspection report that this is completed. Since the previous inspection two people have been admitted to the home. The inspector met both people throughout the site visit, observations showed them to appear happy and interacting positively with the other people living in the home and the staff supporting them. Before either person moved in they were able to visit the home. An example of this is that one person visited with their staff, they worked with staff at the home providing them with information about best practice when working with the person. The home’s diary provided evidence that the person had visited the home at different times including mornings, afternoons, evenings and weekends. This is a good practice. The manager gathered information for both of the people from their previous carers/placements. One person did not have a community care assessment but the previous carer provided detailed information about the person. The manager stated that they are going to complete a further assessment of both of these people and this, along with the current information will form the basis of their care plans. A requirement of the previous inspection was to ensure that each person had an individual residency agreement. A number of the people living at the home do not have the capacity to read and understand the agreement. The manager stated that he has invited a number of people’s parents and relatives in to discuss the document, while others have taken the agreement away to sign. The manager stated that they are going to try and access advocates for people without parents and relatives. Examples of the signed agreements were available for inspection. At the next site visit the residency agreements will be examined again to ensure that all documents have been signed. The requirement of the previous inspection report is carried over in this inspection report. Elmlea DS0000067437.V338836.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Completed needs assessments have enabled the development of care plans to meet people’s needs. Care plans have not been implemented and until they are it is impossible to confirm that peoples current needs are being met appropriately. Staff enable people to make informed choices about their lives and do not restrict them if they ignore this advice. People are consulted on the day-to-day running of the home which promotes the service being led by the needs of the people living there. Risk assessments minimise the potential risks to people while they go about their daily activities. Elmlea DS0000067437.V338836.R01.S.doc Version 5.2 Page 11 EVIDENCE: As part of this inspection three people’s files were studied in detail. Of those three people one person has lived at the home for a considerable time whereas the other two are new to the home. A requirement of the previous inspection report was the manager had to complete needs assessments for each of the people living at the home. One file was examined in detail and all of the other people’s files were seen. This showed that the manager had completed needs assessments for each person. The assessments seen were detailed and looked at peoples needs across their lives. The only people who assessments had not been completed for were the two people recently admitted to the home. The manager plans to complete these assessments. Three people have completed PCPs (Person Centred Plans) with staff. The manager stated that the plan is for key workers to complete PCPs with all other people. The PCPs seen provided information about peoples hopes, dreams and wishes. The manager has completed care plans (based on the needs assessments) for all of the people living in the home. Examination of one person’s care plans showed that they were detailed highlighting the aim and steps taken to achieve that aim. In addition to examining one person’s care plans in detail a number of others were sampled. A minor shortfall noticed by the inspector was that some of the topics e.g. personal care could have been broken down into smaller aims. An example of this may be instead of the aim being that “the person maintains their personal care independently”, that they start with “the person is able to give themselves a wash”. The manager agreed with this and as a result agreed to look at the other plans to ensure all of the aims are achievable. A recommendation of this report would be that with agreement of the people living at the home a small number of care plans are identified as important to each person. These care plans should then be focused on for improving/developing peoples skills e.g. the development of skills that will make a significant difference to the person’s quality of life, or what they would like to achieve. Although all of the care plans have been written they have not yet been implemented, this needs to be addressed. The manager explained that this has been difficult due to staff shortages recently but it is his intention that key workers will take responsibility for all of the care plans. They will be responsible for the monitoring and future development of all care plans with people at the home. A requirement of this inspection report is that all of the care plans are now implemented. Elmlea DS0000067437.V338836.R01.S.doc Version 5.2 Page 12 A requirement of the previous inspection report was to ensure that all people were empowered to make decisions about their lives and that the staff recorded this. Since the previous inspection staff have been working closely with one person especially who accesses the community independently. The manager explained that there have been occasions where staff have advised the person of the possible negative results of their actions so that they are able to make an informed choice. It is a requirement of this inspection report that on occasions where this happens staff make detailed notes of the conversation or their actions. A requirement of the previous inspection report was for the manager to ensure that all people are given the opportunity to participate in the day-to-day running of the home. A good example seen on this occasion was the way in which people choose what they would like to eat. In addition to this staff were able to give good examples of people being empowered to make decisions about the activities they are involved in. Observations throughout the site visit showed staff asking people to make decisions about what they would like to do. The manager explained that they have been supporting people to try different activities that they may not have tried previously and that they plan to develop a picture activity book for people to choose from. The manager has completed comprehensive risk assessments for the majority of the people living at the home. The only shortfall noted was that there were no risk assessments for the people who had moved in recently. Although they were relatively new to the home the inspector would have expected that some risk assessments were in the process of development. The manager must be aware of this with any future admissions to the home. All records are now stored securely in the home’s office. Elmlea DS0000067437.V338836.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People are supported by the staff team to take part in appropriate activities that they have chosen to do. The manager’s idea about creating a picture book of activities to allow people with communication difficulties to make choices will further empower people living at the home. The food available at the home is chosen by the people living there and menus showed that the choices were varied and provide people with a healthy diet. EVIDENCE: Due to the recent staff shortages over the previous two weeks before this site visit the manager explained that some activities were not able to be completed (this has been addressed with new staff employed). Records seen, and Elmlea DS0000067437.V338836.R01.S.doc Version 5.2 Page 14 comments from staff during discussions with the inspector provided evidence of the following activities being completed regularly. Activities include swimming, horse riding, shopping, walking, eating out, bowling, attending evening social clubs and other activities. On the day of this site visit some people were going out for a picnic as the weather was really good. In house activities include staff reading newspapers to people, doing jigsaw puzzles, playing football, card making and some people do some cooking. During the daytime people also attend day services. The owner of the home has recently started a day service called the 66 Centre and people at the home are starting to attend different activities being provided there. Records showed that people have good contact with members of their family. Members of people’s family visit them at the home and staff help them to maintain contact. Previous menus were examined and the manager and staff all confirmed that each Sunday staff meet with all the people to choose the menu for the next week. The staff have developed a picture book for people to use making it easier for them to choose what they would like to eat. The manager explained that the book had been developed over a period of time with new pictures added regularly. Due to peoples limited communication skills the book helps everyone to have a choice about what they would like to eat. This is a good practice that the home are commended for. Two people are able to help with preparing meals while other people’s input might be limited and put them at unnecessary risk. People were observed having a choice about what they would like to eat for breakfast. Elmlea DS0000067437.V338836.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s personal care needs are assessed which identify people’s needs, but care plans must be implemented to ensure staff follow a consistent approach. Where the home identify they are unable to meet people’s needs they make good use of healthcare professionals to ensure people’s needs are met. Medication administration is managed correctly and this minimises the potential risks to the people. EVIDENCE: The previous inspection report made a requirement that people’s personal care needs should be assessed and care plans developed to meet peoples needs. Examination of people’s files showed that assessments had been completed and care plans were now in place. Again these care plans must now be implemented. Elmlea DS0000067437.V338836.R01.S.doc Version 5.2 Page 16 All of the files seen contained detailed records of input by other health care professionals. Ok health checks are being completed at present. These forms identify important facts about each person that in the case of a hospital admission would enable other healthcare professionals to meet people’s needs. The manager said that he had asked the local GP for support in completing these forms but they refused, but the practice nurse is completing health checks with each person. One person in the home has epilepsy and with the input of a community nurse in November 2006 they wrote a profile and intervention plan. This was written at the person’s previous placement. Reading through this document the inspector identified that part of the profile is no longer appropriate. This was brought to the attention of the manager. They stated that the Community Nurse was due to visit in the following week and that they would get the plan updated. Medication administration was examined and no shortfalls were identified. The manager stated that he has sent questionnaires to parents/relatives asking for guidance about what actions may need to be taken in the case of increased mental and physical frailty/serious illness. One of the files examined contained information relating to this and the manager stated that others are still being addressed. Elmlea DS0000067437.V338836.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The staff team have completed training in the protection of vulnerable adults which has obviously raised their awareness of issues relating to protection. Although the majority of the people living at the home may find it difficult to use the complaints procedure, staff knowledge of other physical clues ensures that if people were unhappy staff would notice this. The manager manages people’s finances and records enable easy audits of spending minimising the risk of potential abuse. EVIDENCE: Whilst speaking with staff they were asked what they would do if a person made a complaint about the service they were receiving. The answers given showed that the staff had a good knowledge of the procedure and would ensure that the person was protected. A significant number of the people living at the home have communication difficulties, staff were asked what other signs they would look for that may show a person is unhappy and what they would do to address this. Responses showed that staff had a good understanding of the other indicators that may be displayed. The home has a complaints procedure and since the previous inspection the manager and staff have gone through the policy with each person. As Elmlea DS0000067437.V338836.R01.S.doc Version 5.2 Page 18 mentioned earlier in this report the manager is creating an information file to be kept in each person’s bedroom. This file will also contain a copy of the complaints procedure. Since the previous inspection all of the staff have completed training in the protection of vulnerable adults. Training records in staff files confirmed this. The home is responsible for managing everyone’s finances. Each person has had an assessment and care plans that support the need for the manager to manage their finances. The financial records examined were correct at the time of the site visit. It was noted that some transactions are only signed by one staff member and it is recommended that the manager ensures that two staff sign all transactions. Elmlea DS0000067437.V338836.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The environment of the home has been significantly improved and now provides people with a homely, comfortable environment that meets their current needs. EVIDENCE: At the previous site visit the environment throughout the house was seen to be very poor. Since that site visit the home has been renovated throughout to a high standard. The renovation of the property has included decorating, new carpets, furniture, curtains, pictures and other fittings. All of the communal areas now look comfortable, tidy and homely. Bathrooms throughout the home have also been replaced. Fittings and fixtures are of a good standard. Both of the bathrooms need to have blinds fitted to protect people’s privacy. Elmlea DS0000067437.V338836.R01.S.doc Version 5.2 Page 20 Some people have had their bedrooms decorated. Those completed have been decorated to a good standard. The ceiling of one of the bedrooms on the ground floor has been damaged from a water leak above, and must be repaired. As part of the original refurbishment plan the kitchen was going to be replaced. This has not been done as yet, but the manager explained that it is planned for the near future. This becomes a requirement of this report. The home has a dedicated cleaner who came on duty at the start of the day. Whilst completing the tour of the premises the inspector was concerned by the cleanliness of some areas. In one bedroom there was a strong smell of faeces. The manager proceeded to ask staff to address this and clean other areas. The front of the property is onto a busy main road with a bus stop. An issue discussed with the manager was that on a daily basis items like clothing and magazines are seen on two of the first floor windowsills. This makes the property stand out from other properties on the road. The manager explained how difficult it was to stop this happening. It was agreed that staff should be more vigilant and ensure that any items were removed daily. Elmlea DS0000067437.V338836.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The organisation provides the staff with training to meet the needs and minimise potential risks to of the people living in the home. Staff recruitment records meet the criteria of these regulations and confirm that people living at the home are not being put at unnecessary risk. Staff receive regular supervision from the manager enabling them to discuss concerns and plans for the future. EVIDENCE: At the previous site visit there were no training records for any of the staff. At this inspection staff files for 5 staff were examined in detail. Each file provided certificates confirming the training completed since the previous site visit. The training completed varied depending on the needs of the staff member with new staff completing a comprehensive induction, while other more experienced staff completed other more specialised topics. All of the staff spoken with Elmlea DS0000067437.V338836.R01.S.doc Version 5.2 Page 22 agreed that the training provided by the organisation was good. Records showed that future training is planned and an example of this was safe handling of medication. Recruitment and selection records were examined and showed that except for staff CRB (Criminal Records Bureau) disclosures all of the records required by the regulations were present. Each file contained a memo from the organisation’s head office confirming staff had a CRB disclosure. It has been agreed that CRB’s will we held securely in the organisation’s head office. All of the staff spoken with confirmed that they had completed an interview as part of the recruitment process. Staff files showed that the manager was supervising staff regularly. Staff also confirmed this was happening and everyone spoken with felt that regular supervision sessions with the manager were helpful. Elmlea DS0000067437.V338836.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The manager has shown a commitment to meeting the National Minimum Standards for Younger Adults and this has led to the lives of people in the home improving. The people living in the home must be involved in the quality assurance process for the home, but this can be supported with other systems to ensure the service provided at the home is of a high quality and meeting people’s needs. Health and safety monitoring has improved and has helped to minimise some risks to people but people are still put at unnecessary risks. Elmlea DS0000067437.V338836.R01.S.doc Version 5.2 Page 24 EVIDENCE: The new manager started in this post two months before the previous site visit in August 2006. Before becoming the manager of Elmlea he worked for the organisation in other roles in their other establishments. The previous inspection report made 25 requirements that had to be met by the manager. This site visit has shown that the majority of these requirements have now been addressed, some requirements still need to be fully met, an example of this are peoples care plans. The manager has worked hard completing assessments and writing care plans to meet peoples needs, but these must now be implemented without delay. The CSCI recognise that the manager has addressed the majority of the requirements and this has led to a significant improvement to the lives of the people living in the home. The manager has now completed their registered manager’s award and is due to complete the CSCI’s registration process in the near future. Whilst speaking with staff they commented that the manager was “really good and helps me out”. The home’s proprietor completes regular regulation 26 visits to the home and provides the CSCI with the completed report. Regulation 26 asks a service provider to visit the home each month where they will inspect the premises, look at records of events and any complaints. They will also talk to people living at the home, their representatives and staff. The previous inspection report made a requirement for the manager to develop a quality assurance system that involves people living in the home. The manager has started this process with implementing a system that audits areas including medication, health and safety, fire safety, infection control and security each month. Although these audits don’t involve people living at the home they highlight any shortfalls in recording and enable the manager to address them. The majority of the people living at the home have communication difficulties and this makes it hard to gather their views of the service. The manager must try to address this allowing people living at the home to give their opinions. In addition to this a discussion took place about other methods the manager could implement to judge the quality of the service. Suggestions included auditing the activities people are involved in to ensure that there is a good variation and it is “quality, not quantity”. Also the manager could audit other areas including the food and care. As identified in the previous paragraph the home are completing monthly health and safety audits and evidence was available showing that where shortfalls were identified corrective actions were taken. Examination of the fridge/freezer temperature recording forms showed that the staff did not record them regularly. This was brought to the attention of the manager. Elmlea DS0000067437.V338836.R01.S.doc Version 5.2 Page 25 A requirement of the previous inspection was that the manager must ensure that all of the fire safety checks required by the relevant regulations are completed. Examination of the records showed some gaps where staff had not carried out a check of equipment. Also it was noted that staff were not testing all of the alarm points. This was discussed with the manager who and actions were agreed to address this. A fire risk assessment has been completed but it must be reviewed. A requirement of the previous inspection was that the manager must ensure that data sheets are available for all of the cleaning chemicals used in the home. At this inspection data sheets were available. A requirement of the previous inspection was to ensure that the risk of crossinfection was minimised. The issue had been the use of mops for different areas of the home. At this site visit different colour mops had been purchased for use in different areas of the home. Elmlea DS0000067437.V338836.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 2 26 3 27 2 28 3 29 3 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 3 3 X 2 X X 2 X Elmlea DS0000067437.V338836.R01.S.doc Version 5.2 Page 27 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 YA1 Regulation 5 Requirement The registered person must ensure that all of the people living at the home have a Service User’s Guide. Timescale from previous inspection report not met. 01/12/06 The registered person must ensure that each person has a statement of terms and conditions signed by either the person, or their representative. Timescale from previous inspection report not met. 01/12/06 The registered person must ensure that the care plans for each person are implemented. The registered person must ensure that all people are empowered to make decisions about their lives and records are kept evidencing this. Timescale from previous inspection report not met. 01/12/06 The manager must ensure that the care plans detailing peoples personal care needs are implemented without delay. DS0000067437.V338836.R01.S.doc Timescale for action 08/06/07 2. YA5 5 (1) b 06/07/07 3. 4. YA6 YA7 15 15(2) c 15/06/07 08/06/07 5. YA18 12, 15 15/06/07 Elmlea Version 5.2 Page 28 6. YA19 12, 14 7. YA22 22 8. YA24 23(2) c, d 9. YA27 23(2) d 10 YA30 13(3) 11. YA39 24 12. YA42 23(4) The registered person must ensure that all people’s health needs are assessed. Timescale from previous inspection report not met. 22/12/06 The registered person must ensure that all people have a copy of the complaints procedure. Timescale from previous inspection report not met. 01/12/06 The registered person must ensure that the kitchen is replaced as identified as part of the initial refurbishment plans. The registered person must ensure that the water-damaged ceiling in one person’s bedroom is repaired. The registered person must ensure that cleanliness and hygiene in the home is maintained at all times. The registered person must develop quality assurance systems that involve the people living at the home. Timescale from previous inspection report not met. 02/03/07 The registered person must ensure that all fire safety checks are completed as prescribed by the regulations. Timescale from previous inspection report not met. 01/12/06 06/07/07 15/06/07 01/11/07 06/07/07 15/06/07 03/08/07 15/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Elmlea DS0000067437.V338836.R01.S.doc Version 5.2 Page 29 No. 1. Refer to Standard YA8 Good Practice Recommendations The registered person should ensure that systems continue to be developed that allow people are given the opportunity to participate in the day-to-day running of the home. The registered person should ensure that the front of the property is kept tidy. 2. YA24 Elmlea DS0000067437.V338836.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Elmlea DS0000067437.V338836.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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