Inspection on 10/10/06 for Elmlea

This inspection was carried out on 10th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 no outstanding requirements from the previous inspection report, but made 25 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 01/05/07

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 Key Unannounced Inspection 10th October 2006 09:00 Elmlea DS0000067437.V308027.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.V308027.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.V308027.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elmlea Address 99 London Road Gloucester Glos GL1 3HH 01452 550452 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 Acting Manager – Robin Cornock Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Elmlea DS0000067437.V308027.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 23/11/05 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 staff 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 £787.65 to £1336.43 per week. This site visit has shown that each person does not have a personal copy of the Service User Guide. The manager must address this. 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 from. As identified in the body of this report the home is being extensively renovated at the moment. Elmlea DS0000067437.V308027.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Holmleigh Care Ltd became the owner of this property on April 1st 2006. The organisation’s management team recognised that a number of areas of the home were not maintained to a satisfactory standard, in line with their policies and procedures. Since April the organisation have had regular dialogue with the CSCI regarding these issues. The CSCI recognise the organisation’s commitment to address these issues. The report accurately reflects the findings at the time of the inspection but significant improvements have continued to be implemented within the home since the inspection. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes intro account the view and experiences of those using the service. This site visit was completed over a period of 8 hours. The acting manager was present throughout the site visit. The principle method used to gather evidence was case tracking. This involves examining the care notes and other related documents for a select number of people living at the home. This is followed up by talking to them or their relatives/representatives, or observing them. This provides a useful, in depth insight as to how people’s needs are being met from more than one source of evidence. At this inspection three of the people living at the home were case tracked. As no relatives or representatives were at the home the CSCI have sent surveys for the home to distribute to people. The findings of these surveys may form the basis of future inspections. What the service does well: What has improved since the last inspection? What they could do better: All of the people need to have a copy of the Service User’s Guide. Elmlea DS0000067437.V308027.R01.S.doc Version 5.2 Page 6 All of the people must have an individual contract or statement of terms and conditions. All of the people must have their needs assessed by appropriately qualified staff. All of the people must have care plans in place that meet their assessed needs. Staff must ensure that all people have choices in their everyday lives, for example in activities and meals. Risk assessments must be developed to minimise potential risk to people in their everyday lives. All of the people must be informed of the complaints process and how they are able to use it. The financial accounts for each of the people who are unable to manage their finances must provide a clear audit trail of their income and expenditure. Care plans must also identify how this process is managed for each person. Staff must complete training in the protection of vulnerable adults to ensure potential risk are minimised. People’s personal care needs must be identified and met by the staff team. No health assessments have been completed and this should be addressed to minimise potential risks to people. The manager must ensure that there is an ongoing program of maintenance for all parts of the home. The manager must ensure that staff complete training in protection of vulnerable adults. The manager must ensure that all staff files and training records are kept in the home. The manager must complete training in the supervision and appraisal of staff and ensure that all staff receive regular supervision sessions. Quality Assurance systems must be put in place. These systems should involve people living in the home. The manager must ensure that the appropriate COSHH data sheets are available for all of the chemicals stored in the home. The manager must ensure that the risks of cross infection are minimised through the correct storage of mops used for cleaning different areas of the home. Elmlea DS0000067437.V308027.R01.S.doc Version 5.2 Page 7 The manager must ensure that the appropriate fire safety checks are completed regularly. 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. Elmlea DS0000067437.V308027.R01.S.doc Version 5.2 Page 8 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.V308027.R01.S.doc Version 5.2 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 5 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Due to no recent admissions to the home it is impossible to judge the assessment process completed for prospective new admissions. EVIDENCE: No new people have been admitted to the home since the previous inspection. The organisation has produced a Service User’s Guide and a Statement of Purpose. The manager must ensure that all people have a copy of the Service User’s Guide and that the Statement of Purpose is available in the home. The manager must ensure that all people have a written contract or statement of terms and conditions with the home. The group manager stated that this is being addressed at present. Elmlea DS0000067437.V308027.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9, 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The personal files for people living at the home are poorly organised making it difficult for staff to identify people’s needs and the support they should provide. People are put at unnecessary risk when completing activities as assessments are not completed. Completed needs assessments have either not been reviewed in the previous twelve months or are not dated. It is impossible to confirm that the assessments seen were still relevant. Care plans do not provide staff with accurate information that is regularly reviewed to ensure that it still meets people’s needs. Elmlea DS0000067437.V308027.R01.S.doc Version 5.2 Page 11 EVIDENCE: Files for two of the people living at the home were examined (there are currently seven people living at the home). Both of the files examined contained needs assessments that covered a number of the titles listed in standard 2 of these standards. Unfortunately a number of major shortfalls were evident in both examples: 1. The first assessment was not dated; there was no record of who had written it and no evidence of it ever being reviewed. This made it impossible to ascertain whether it was current and whether it had been completed by someone trained to complete a needs assessment. 2. The second assessment had been completed in a different format by the previous registered manager. It was an assessment/care plan. Again it did not provide clear goals for the person but did provide staff with instructions on how they should support the person. It had been completed in July 2005 and reviewed in August 2005. There were no records for any reviews since this date. One file examined provided a review completed by the person’s funding authority in November 2005. The funding authority had complied a general care plan providing targets for example, of “maintaining their residence at the home”. This care plan had been used as the main care plan for the person. It was very general not providing measurable goals. As highlighted above the other file provided a form of care plan, again this provided some goals. One of the sections of this document was titled “Behaviour”, in the sub section titled “staff intervention” the instructions to staff were “he is told in a firm manner that if he continues that his stereo will be removed for the rest of the day and night”. The manager confirmed that this approach is not being used. Due to the poor administration system currently being used it is difficult to find evidence of where people are supported appropriately to make decisions about their lives. The manager must ensure that where staff support people to make decisions that it is recorded. One person had a considerable number of risk assessments. Again it was difficult to ascertain when they had been completed and some were not dated and there were no records of review. Some assessments that were dated were up to four years old, and again no records of review were present. Examination of the other person’s file did not provide any evidence of any risk assessments. The manager confirmed that he had not been able to find any risk assessments. Elmlea DS0000067437.V308027.R01.S.doc Version 5.2 Page 12 At the time of the inspection people’s information was being stored on shelves in the home’s office. The manager explained he had thought about storing people’s information in filing cabinets in the basement. The manager must ensure that people’s information is stored securely. A requirement of the previous inspection report was for the then manager to complete assessments of peoples needs. This requirement has not been met. Although only two peoples files were seen the manager was asked whether this files were representative of the other people’s files. They confirmed that they were. The current manager has been in post for two months. The requirement to complete assessments of people needs from the previous inspection report must be met. The manager must ensure that the person being assessed is involved throughout the process. It is recommended that the home use the subtitles of standard 2 (assessment) to assess each person living at the home. As part of the assessment other professionals and family members should also be involved. From the completed assessments future goals should be identified and care plans developed that are specific, measured, achievable, realistic and time-constrained. Care plans must provide staff with guidelines to ensure that people receive a consistent approach by staff. The manager should also consider the use of pictures, symbols and photos to support people who also have communication difficulties. Elmlea DS0000067437.V308027.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The number of activities has increased over recent months with people now leading more active and varied lifestyles. The manager has taken steps to develop better working relationships with people’s relatives to enable them to voice any issues or concerns about the home. Menus showed that people are now offered a healthy, varied diet but choice is limited due to communication and the methodology employed to decide the menus. EVIDENCE: Five people’s daily notes from the previous eighteen months were sampled. These showed that some people were involved in regular activities (two people attended day services), other activities were completed like going shopping in Elmlea DS0000067437.V308027.R01.S.doc Version 5.2 Page 14 town, going to the pub and going for a picnic. People’s daily notes made a considerable reference to them “wandering about” or “stayed in their bedroom”. In the past three weeks the manager has implemented a new timetable of activities. This showed that people now have regular activities including attending day services, college, different social clubs and spending time one – to – one with staff. The activities identified on this timetable were checked against entries in people’s daily notes, this confirmed that these activities were taking place. One person spoke about the activities they were involved in, they said “I am able to do a lot more now a days” and “these staff are really nice”. Going through their timetable with them they confirmed that they have completed all the activities identified. The needs assessment to be completed by the manager and his team should identify what goals and needs people have socially and educationally. At the time of this site visit two people were being supported by the staff team to have a holiday at a popular holiday park. The manager explained that at the weekend before this inspection he had invited all of the parents to visit the home. The aim of the visit was to show relatives the decoration improvements currently being completed and introduce himself to them. It was suggested that to further develop this relationship with relatives the manager could develop a newsletter to be sent to people on regular occasions during the year. People living in the home could produce the newsletter. When speaking with one person they explained how they go to the local pub regularly and that in the previous evening they had attended bingo. Whilst completing this site visit one person went shopping locally. During the day a person spoke about there no longer being rules and restrictions about their smoking. Until earlier this year they were not allowed to control the amount of cigarettes they had each day. Another example of people’s rights being respected is the person who is now allowed to keep their stereo in their bedroom. They explained that they thought this was “much better”. Since this practice has been introduced the person is longer destroying them regularly. The manager explained that they have recently employed a housekeeper who is responsible for preparing food and meals. The menus for the previous couple of weeks were examined and showed that people are provided with a healthy and varied diet. The manager explained that they planned to develop a rolling rota for menus. It was suggested that as a number of the people have communication difficulties that they could develop the use of pictures, symbols using various photos in albums or scrapbooks. Also, this could be done weekly as part of a regular house meeting. The organisation’s group manager was Elmlea DS0000067437.V308027.R01.S.doc Version 5.2 Page 15 present during the inspection and explained that when they first took over the home that all of the meals were ready prepared frozen meals that were heated up for each meal. Later when speaking with one person they said that the food had improved and confirmed that previously meals had been frozen ready meals. Elmlea DS0000067437.V308027.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Peoples personal support needs are not sufficiently assessed and do not provide staff with clear guidelines detailing peoples needs and wishes. Some records for people’s appointments with other professionals were present but detail was poor and the manager has started to address this. This should minimise unnecessary risks to people. People’s healthcare needs have not been assessed and recorded and therefore it is impossible to identify whether peoples needs are being met. EVIDENCE: Neither of the files examined provided sufficient evidence that staff would be able to meet peoples personal support needs. This again must be addressed by the assessment to be completed by the manager and guidelines/care plans developed. Elmlea DS0000067437.V308027.R01.S.doc Version 5.2 Page 17 Records were present providing details of appointments with other professionals. The manager has recently introduced a new form where all of this information will be recorded in the future. It is recommended that the home use the health assessment/care plan available from the local PCT. It minimises the risks of peoples health needs not being addressed. None of the people living at the home administer their own medication. The administration sheets were examined and showed a number of omissions where staff should have signed to confirm the medication had been administered. Speaking to the manager these occasions were brought to their attention and they were asked for reasons. One occasion had been due to there being no trained staff on duty and the manager arranging for a trained staff member to come in to administer medication. Unfortunately the manager had not recorded the name of that person so it was impossible to follow up this shortfall. The manager was advised that they must record this information. A staff member spoken with during the day confirmed that they had not completed their medication training and were therefore unable to administer medication. Another shortfall relates to the staff not using the key on the medication sheet, i.e R for refused. One person was prescribed two items that according to their records should be administered daily. Records showed these items were administered inconsistently at best. The person in question had stated to staff that they “didn’t think it worked anyway”. The infrequency of the items being administered would call into question the need for the medication. It was discussed whether a medication review was required. Whilst inspecting the cabinet where the medication is kept the following issues came to light. 1. Staff must not keep wage slips and money in the cabinet. 2. Creams and ointments must have the date they are opened recorded on them. 3. When medication is returned to the pharmacist staff must ensure that the pharmacist signs to confirm they have received the medication. Medication training has been arranged for staff. Files and notes examined did not contain any information to meet the criteria of standard 21. People’s wishes must be identified and recorded. Elmlea DS0000067437.V308027.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a complaints procedure but it has not been explained to people. This may cause confusion with some people and make them feel as if they cannot complain. Staff have not completed training in the protection of vulnerable adults which may be putting people at unnecessary risk. Records of people’s finances are poor and do not provide a clear audit trail of income and expenditure making it impossible to confirm that people are receiving all of their monies. EVIDENCE: Holmleigh have a complaints procedure that they have developed in a picture format. The manager stated that this has not been used as yet. A requirement of this inspection report is for each person to be given a copy of the procedure and it is recommended that a copy is placed on the home’s notice board. In addition to this the manager could use a house meeting to go through the procedure with people as a group. One person confirmed that if they were unhappy that they would be able to speak to staff. When asked whether they believed that staff would act on what they said appropriately they said they felt they would. When talking to the manager they confirmed that they had attended a course in the protection of vulnerable adults. The manager stated that to his Elmlea DS0000067437.V308027.R01.S.doc Version 5.2 Page 19 knowledge the staff team had not. This will be checked with the group manager in a meeting to be arranged in the near future. People’s financial records maintained by the staff team were examined. These records were found to be poor, as they did not provide a clear audit trail. This was discussed with the manager and how the system should be developed to meet these standards. It is a requirement of this inspection report that this is addressed. On July 11th 2006 a random unannounced inspection was completed: The reason for this visit was the CSCI receiving an anonymous phone call stating that the people living at the home were not being supported appropriately due to staffing shortages. The staffing rotas for the four weeks prior to the site visit and the current staffing rotas were examined. The rotas seen confirmed that the staffing ratio had indeed been below what was agreed as a minimum previously. The inspector spoke to the manager about this, they explained that the shortages had been due to staff leaving and they had been interviewing for new staff earlier that day with the group manager. The manager stated that they hoped that they would have new staff in post in the near future. Elmlea DS0000067437.V308027.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 28, 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The quality of the fixtures and fittings are poor and this adds to the home looking un-homely and stark. EVIDENCE: The standard of the accommodation is poor and the provider that bought the property in April 2006 is in the process of addressing this. The CSCI acknowledges that the provider is making every effort to improve the environment. No specific requirements are being made as a result of this. The provider must however submit a improvement plan with timescales for when all of this work will be completed. At this inspection a team of builders were at the home and a significant amount of work had been completed: 1. The walls of the downstairs hallway had been re-plastered and a new ceiling fitted. 2. A new bathroom was being fitted on the first floor. 3. One person’s bedroom was having an en-suite bathroom fitted. Elmlea DS0000067437.V308027.R01.S.doc Version 5.2 Page 21 By the time the refurbishments are completed all of the communal rooms will have been re-painted, have new carpets and furniture. The manager has taken advice from a consultant psychiatrist about replacing the carpet in the lounge and the current patterned carpet will be replaced with a plain carpet. This will help people in the home who find perception difficult. The kitchen will have been replaced. All hallways and landings will have been redecorated and carpeted. The staff area (sleep in room and bathroom) was seen. In the bathroom the hot tap did not work, this must be repaired. The sleep-in room was dirty, untidy, poorly decorated with a blind that fell down. This room must be redecorated and the manager must ensure that staff have a lockable facility to store their belongings. The laundry area must be tidied, it appears to be being used as a “dumping ground” for unwanted items e.g. there was a car’s parcel shelf, suitcases and a mattress. In addition to this the area must be cleaned. Although substantial building work was being completed at the time of this inspection it was judged that due to the size of the property and the fact that facilities like bathrooms, toilets and the kitchen were still operational that it was acceptable for people to remain living at the home. In addition to this at the time of the inspection 3 of the 7 people living at the home were away. It has been agreed that once the work has been completed the organisation’s group manager will contact the CSCI and arrange for them to visit again. With the property being in a poor state of decoration at present it is difficult to maintain a good level of hygiene and cleanliness. Elmlea DS0000067437.V308027.R01.S.doc Version 5.2 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 36 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. No records for staff recruitment were present making it impossible to confirm whether the appropriate procedures had been followed. Staff’s personal files and training records were not present in the home. It is therefore impossible to confirm what training has been completed. EVIDENCE: None of the staff’s personal files were present in the home. When giving feedback to the group manager they stated that they believed that all of the files should be in the home, and that they had addressed this personally when all of the staff’s documentation had been reviewed in July/August. The manager must ensure that firstly the original files are found and that all staff working in the home have files containing the information required by these standards. The manager stated that he has completed training in supervision and appraisal of staff. No staff had received any supervision by this visit but the manager stated that they were going to start it in the near future. The need to meet the criteria of the standards was discussed. This becomes a requirement of this report. Elmlea DS0000067437.V308027.R01.S.doc Version 5.2 Page 23 No training records were present and the manager must ensure that these are present at future inspections. The group manager has assured the CSCI that all training and recruitment records are in place and meet the criteria of these regulations. Elmlea DS0000067437.V308027.R01.S.doc Version 5.2 Page 24 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The manager showed good awareness of the issues that need to be addressed in the home and showed enthusiasm in wanting to achieve them. Once the issues highlighted in this report have been rectified the home should be able to provide a needs led quality service. People are being put at unnecessary risk due to the fire safety checks not being completed as prescribed by the regulations. People are being put at risk due COSHH sheets not being available. With no quality assurance procedures and limited assessment and care planning in place it difficult to evidence that people have a say in the running of the home. Elmlea DS0000067437.V308027.R01.S.doc Version 5.2 Page 25 EVIDENCE: The new manager has been in post for two months. Before becoming the manager of Elmlea he worked for the organisation in other roles, in their other establishments. Talking to them they showed a good knowledge of working with this client group. They stated that they have completed all of their mandatory training and they have four units left to complete of their Registered Manager’s Award. As well as all of the staff’s training records being kept in the home the manager must ensure that his records are present. At present there are no quality assurance procedures in place. A conversation took place about different methodologies that could be employed, e.g. the use of questionnaires, meetings, reviewing peoples needs. Due to the quality of the current paperwork it is impossible to identify any quality assurance methods that may have been used previously. Future quality assurance methodologies must ensure that people living at the home are involved. Examination of the fire safety records showed no records of any fire alarm tests before 15/09/06. The manager was asked if there were any other records, they replied “no”. Other shortfalls identified included no records of fire drills, emergency lighting tests or staff fire training. The manager must ensure that these areas are addressed. The manager stated that a fire risk assessment had been completed by the deputy manager (and that they had completed training enabling them to do it). Unfortunately this was at head office at the time of this inspection. This will be examined at a future inspection. The home has recently changed the supplier of their cleaning chemicals. These are usually stored in a lockable cupboard on the ground floor. At the time of this site visit none of the C.O.S.H.H. sheets were available. The manager must ensure that this is addressed and that these documents are always available. Whilst completing a tour of the premises some cleaning chemicals were found to be left out. This must be addressed. In addition to this the two mops were stored together (one for the toilet, the other for the kitchen). It is essential that two mops are used but the manager must ensure that when they are stored they are not touching. If this practice continues it increases the risk of cross infection. Records were present confirming that fridge and freezer temperatures were recorded regularly. Elmlea DS0000067437.V308027.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 X 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 2 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 1 28 3 29 X 30 1 STAFFING Standard No Score 31 X 32 1 33 X 34 2 35 X 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 X 1 2 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 1 2 2 2 1 X 1 X X 1 X Elmlea DS0000067437.V308027.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? 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. The registered person must ensure that each person has a statement of terms and conditions signed by either the person, or their representative. The registered person must ensure that needs assessments are completed for each of the people living at the home. The registered person must ensure that people’s identified needs are addressed in their individual care plans. The registered person must ensure that all people are empowered to make decisions about their lives and records are kept evidencing this. The registered person must ensure that all people are given the opportunity to participate in the day-to-day running of the home. The registered person must ensure that risks to people are assessed, minimised and DS0000067437.V308027.R01.S.doc Timescale for action 01/12/06 2. YA5 5 (1) b 01/12/06 3. YA6 14 22/12/06 4. YA6 15 02/03/07 5. YA7 15(2) c 01/12/06 6. YA8 16(2) m 01/12/06 7. YA9 13 (4) b, c 22/12/06 Elmlea Version 5.2 Page 28 8. 9. 10. YA10 YA17 YA18 17(b) 16(2) i 12, 14 11. 12. YA19 YA20 12, 14 13 (2) managed appropriately to enable people to live fulfilling lifestyles. The registered person must ensure that people’s documents are stored securely. The registered person must ensure that all people are given choices about the food they eat. The registered person must ensure that people’s personal care needs are assessed and that care plans are developed to meet those needs. The registered person must ensure that all people’s health needs are assessed. The registered person must: Staff must not keep wage slips and money in the cabinet. • Creams and ointments must have the date they are opened recorded on them. • When medication is returned to the pharmacist staff must ensure that the pharmacist signs to confirm they have received the medication. The registered person must ensure that people’s wishes relating to ageing and illness are identified and met. The registered person must ensure that all people are aware of the home’s complaints procedure. Each person must be given a copy of the procedure. The registered person must ensure that comprehensive records are kept for the monies of each person whose finances are managed by the home. A care plan should also be developed that supports this. The registered person must ensure that all staff complete training in the protection of DS0000067437.V308027.R01.S.doc 01/12/06 22/12/06 22/12/06 22/12/06 01/12/06 • 13. YA21 14, 15 02/03/07 14. YA22 22 01/12/06 15. YA23 17(2) schedule 4 (9) 01/12/06 16. YA23 13(6) 02/03/07 Elmlea Version 5.2 Page 29 vulnerable adults. 17. YA24 23 The registered person must supply the CSCI with an improvement plan detailing when all of the improvements to the environment will be completed. The registered person must ensure that records confirming staff training are available for inspection. The registered person must ensure that all staff recruitment records are kept in the home. The registered person must ensure that all staff receive regular supervision and appraisals The registered person must ensure that the manager’s application to be registered with the CSCI is submitted. The registered person must develop quality assurance systems that involve the people living at the home. The registered person must ensure that all fire safety checks are completed as prescribed by the regulations. The registered person must ensure that data sheets are available for all of the cleaning chemicals being stored in the home. The registered person must ensure that the risk of cross infection around the home is minimised. 01/12/06 18. YA32 7, 9, 19 schedule 2 (4) 7, 9, 19 schedule 2 18(2) 01/12/06 19. 20. YA34 YA36 01/12/06 01/12/06 21. YA37 8 (2) 01/12/06 22. YA39 24 02/03/07 23. YA42 23(4) 01/12/06 24. YA42 13(4) 01/12/06 25. YA42 13(3) 01/12/06 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.V308027.R01.S.doc Version 5.2 Page 30 No. Refer to Standard Good Practice Recommendations Elmlea DS0000067437.V308027.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Elmlea DS0000067437.V308027.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!