Inspection on 02/04/08 for Elmlea

This inspection was carried out on 2nd April 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Elmlea 08/04/09

Elmlea 01/05/07

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 2nd April 2008 09:30 Elmlea DS0000067437.V358942.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.V358942.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.V358942.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 ****Post Vacant**** Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Elmlea DS0000067437.V358942.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered provider may provide the following category of service only: Care home providing personal care only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Learning disability (Code LD) The maximum number of service users who can be accommodated is 8. Date of last inspection 9th July 2007 Brief Description of the Service: Elmlea DS0000067437.V358942.R01.S.doc Version 5.2 Page 5 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. After parking to the rear of the property you enter the property through the front door. 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. The home has a Statement of Purpose and Service User Guide. Fees for the home start at £900.00 per week. Elmlea DS0000067437.V358942.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. The site visit to the home was completed on Wednesday 2nd April 2008. We then visited the organisation’s head office on Thursday 10th April to examine Criminal Records Bureau (CRB) Disclosures for the staff team. Whilst at the home we spoke to the manager and staff, observed the interactions between staff and people living in the home and completed a tour of the premises. The care of two people was looked at in depth that included looking at their financial, medication and personal records. Six staff were interviewed about the care they provide. Other records examined included staff files and health and safety information. What the service does well: What has improved since the last inspection? The kitchen has been replaced since the previous site visit was completed. People are being empowered to have more choices about lives. Elmlea DS0000067437.V358942.R01.S.doc Version 5.2 Page 7 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.V358942.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.V358942.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 5 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 living in the home and their advocates have access to information relating to the home through the service user’s guide. The organisation’s admissions procedure minimises the risk of people being admitted to the home whose needs cannot be met. There is a statement of terms and conditions for residency at the home. EVIDENCE: The previous inspection report made a requirement that all of the people living in the home should have a copy of the service user’s guide. The acting manager has done this and in addition there is a copy on the notice board in the dining room. There have been no new admissions to the home since the previous inspection was completed. Examination of the service’s admission procedure showed that it was comprehensive. People who are interested in moving into the home have access to a service user’s guide and the home’s statement of purpose. Elmlea DS0000067437.V358942.R01.S.doc Version 5.2 Page 10 Before anyone is offered a place in the home assessments are completed and the person has the opportunity to “test drive” the service by visiting. It is recommended that the policy be reviewed as it makes reference to the group and deputy group manager which no longer exist. A requirement of the previous inspection report was to ensure that all of the people living in the home agreed to the terms and conditions of their residence. The manager stated that terms and conditions had been agreed with all but 1 person, the advocate for this person feels that the contract could be made easier and it is recommended that the home address this. Elmlea DS0000067437.V358942.R01.S.doc Version 5.2 Page 11 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, 9 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. On the whole care plans provide staff with sufficient detail to meet people’s current needs. People are being empowered to make choices about their lives. People are being put at unnecessary risks due to the limited number of current risk assessments in place. EVIDENCE: A requirement of the previous inspection report was for the registered manager to ensure that the care plans were implemented. Since the previous inspection was completed the registered manager has left and the acting manager has been in charge since January this year. Since their arrival they have implemented a new care planning strategy. We examined care plans for 2 of the 5 people currently living in the home. This showed that each person had care plans for the following areas: Elmlea DS0000067437.V358942.R01.S.doc Version 5.2 Page 12 • • • • • • • • • • • • • • • Communication Maintaining a safe environment Mobility Eating and drinking Emotional needs Daily living skills Social skills Cultural needs Health Medication Personal hygiene Accommodation requirements Finance Behaviour management Activities Each of the plans examined had been written in March 2008. The care plans have been written in a clear, simple format. The care plans documented, and the manager stated that it is intended that reviews will be completed 3 monthly. On the whole the sample of care plans seen provided staff with enough detail to enable them to meet people’s needs consistently. Some plans required more detail to accurately reflect a person’s needs and the input required by staff. It becomes a requirement of this inspection report that the acting manager ensures that this is addressed. This month the manager has implemented Key worker meeting forms. People’s key workers will complete them each month to confirm that care plans have been updated, the amount of family contact, a summary of what they have eaten, activities they have completed and what behaviours have been displayed. In addition to the care plans being developed at present staff are also completing Person Centred Plans (Commonly known as a PCP, this approach empowers people to make changes in their lives, achieve their goals and ensure that resources are in place to meet their future needs). The PCP’s sampled showed good progress towards completion, but as yet they have not been implemented. A recommendation of this inspection report is that the PCP’s are completed and implemented. A requirement of the previous inspection was to ensure that people living in the home are empowered to make decisions about their lives and that records were kept to evidence it. The acting manager has started this by holding resident meetings each Sunday afternoon. At the meeting people are asked to choose what food they would like for the following week. The choices are made from a photo album created by the manager and her staff. This is recognised as good practice as it enables the people living in the home who have communication difficulties. Elmlea DS0000067437.V358942.R01.S.doc Version 5.2 Page 13 At the beginning of this month the manager also implemented a similar system for choosing activities. Speaking with staff the consensus of opinion was that since the acting manager has been at the home “people have more choice”. A small number of risk assessments were in place for both of the people whose records we sampled. This was discussed with the manager, they stated it was their intention to review risk assessments for all of the people in the home. From the sample examined current risk assessments are putting people at unnecessary risks as they do not cover a broad spectrum of risks and have not been reviewed regularly. It becomes a requirement of this inspection report that the acting manager addresses this. Elmlea DS0000067437.V358942.R01.S.doc Version 5.2 Page 14 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): 12, 13, 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 empowered to make choices about the activities they are involved in. Staff support people to maintain family relationships where it is required. People are able to choose what food they would like to eat. EVIDENCE: As identified earlier in this report all of the people living in the home are given the opportunity to choose what activities they would like to do. The manager stated that people will be given the opportunity to go out at least once a day. People are asked to suggest what activities they would like to do in the weekly resident meeting. This is a new approach only started at the beginning of March. We looked at what people had asked to do, and what had actually happened and this showed that people’s requests were being met. Elmlea DS0000067437.V358942.R01.S.doc Version 5.2 Page 15 Discussions with staff also confirmed this. Whilst we were completing the site visit 3 people went horse riding in Cheltenham, staff went for a walk in a local park with 1 person, and later staff supported another person to go into Gloucester for a coffee and to get some shopping. All of the staff spoken with during the site visit were in agreement that since the new manager has been in post people have had more choice about activities. This was also supported in a letter received from 1 person’s parents. Some of the activities that take place regularly include: • • • • • • • • • Going into Gloucester shopping, for meals and coffee. Visiting family. Cinema. Walking. Attending a day centre. An aromatherapist visits regularly. Social club. People have days when they are 1 to 1 with staff. Bowling. Staff also stated that in the week following this site visit 1 person was going to try golf. We sent surveys to parents to gather their opinion of the home. One parent said, “They always keep us informed of what my son is doing or has done. They pick me up and bring me home, as well as bring my son to visit me. They are always at the end of the phone if I need to contact them”. Whilst we were completing the site visit arrangements were being made for one of the parents to come to lunch on Sunday. The acting manager has completed a cultural needs care plan for each person living in the home. Speaking to the manager they stated that from their assessment no one has indicated that they would like to attend a church. As mentioned previously the manager has introduced a picture menu book to enable people to choose meals more easily. All of the people in the home have varying degrees of communication difficulties and using pictures is good practice and makes it easier for people to make choices. The manager explained that they are currently trying to employ a housekeeper who will cook meals, they will then be asked to take photos of the meals to add to the picture menu book. This is also good practice and will make it easier for people to choose. We examined a sample of the previous menus which showed that the choices made by people in their resident meetings were being included as part of the menus. In addition to choosing what meals are eaten people are also given the opportunity to be involved in cooking. The day before this site visit was completed 1 person had made some chocolate cornflake cakes with staff. Elmlea DS0000067437.V358942.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 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. Care plans for people’s personal care do not provide sufficient information to enable staff to meet people’s needs consistently. Each person has an ok healthcare plan but it is difficult to confirm that these accurately reflect people’s current needs. Medication administration ensures that people are not put at unnecessary risks. EVIDENCE: People have a section in their care planning named personal hygiene. The files sampled showed that the personal hygiene sections had been completed. Reading the plans with the manager it was clear that greater detail was required to enable the staff to meet people’s needs consistently. It becomes a recommendation of this inspection report that this is completed. People have OK Health checks (1). These had been completed in April 2007 and it was difficult to confirm that they accurately reflected people’s current needs. The manager stated that they intend to review the health checks annually in Elmlea DS0000067437.V358942.R01.S.doc Version 5.2 Page 17 the future. This becomes a recommendation of this inspection report. The manager stated that they are in the process of arranging for all of the people living in the home to have general health appointments with their GPs, dentists and opticians. A survey completed by a parent of a person that used to live in the home states, “The manager and the staff of Elmlea gave my son great care and attention in his last illness”, they also state, “they gave us great support. We are very grateful to them”. Medication administration was examined. On the whole this was seen to be managed effectively with medication being stored correctly and staff signing to confirm that people had received their medication as prescribed. 2 shortfalls were identified, 1 was a tube of cream with no opening date on it that appeared to have been open for longer than 28 days. The 2nd was a procedure for administering a person’s emergency medication. Talking to the manager about this only 3 staff are trained to administer this medication. The policy makes no mention of what staff should do if there are no trained staff on duty. The manager agreed with this and gave their had been an oversight and gave their assurance that this would be addressed immediately. It becomes a requirement of this inspection report that the procedure states that an ambulance must be called if no trained staff are on duty. 1. A document especially designed to help recognise the health care problems of people with learning disabilities. It is a comprehensive checklist that enables carers to participate in assessing people’s health care needs. The information gathered from the checklist can then be interpreted by health care professionals enabling them to construct care plans to meet peoples needs. Elmlea DS0000067437.V358942.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. 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. There is an easy read format complaints procedure available to enable people to follow the procedure when they are unhappy. Staff training ensures that potential safeguarding risks are minimised. Both staff and people at the home are being put at risk due to staff not being trained to meet people’s behavioural needs. Financial administration is confusing and needs to be reviewed. EVIDENCE: The home has a complaints procedure in an easy read format. A copy of this was on the notice board in the dining room. The acting manager stated that they had not received any complaints while they had been at the home. The CSCI have not received any complaints. Records of training for staff in safeguarding adults showed that the acting manager needs to complete some update training. New staff complete training in this area as part of their induction. A number of the staff spoken with during the site visit were asked what they would do if they witnessed someone being abused. All of the staff were clear that they would report the incident without hesitation. Elmlea DS0000067437.V358942.R01.S.doc Version 5.2 Page 19 Some of the people living in the home display behaviours that can challenge. The organisation use Positive Behaviour Management (PBM) to support people who present behaviours that challenge. 2 incidents were witnessed while we completed our site visit. The Care plans seen included a behaviour management section containing guidelines for staff to follow and we examined records of incidents written by staff. The manager stated that they were in the process of reviewing all of the present guidelines. This becomes a requirement of this inspection report. We examined records of staff training in PBM and found that only 3 of the team including the manager had completed this training. The manager was open about this and said that she had booked 4 staff on training later this year. This was discussed with the manager and we explained that training should be completed sooner as at present both staff and people living in the home were being put at unnecessary risks. It becomes a requirement of this report that all staff who may be expected to support a person whose behaviour challenges complete the appropriate training. We examined the financial administration for 2 people in the home. Records show the income and expenditure for each person and some transactions had receipts. At the time of the site visit the amounts in people’s wallets tallied with records. When examining people’s records we did note a couple of areas that could be improved. A number of the receipts were not numbered with the transaction making it difficult to tell to which transaction they related. The 2nd area that the manager should review is what people at the home pay for when they are out. Whilst examining transactions for 1 person it showed that they had paid for parking. When this was brought to the attention of the manager they agreed that the home paid for this. Since the previous key inspection was completed we have completed 2 random inspections. Both of these inspections focused on the medication procedures in the home. A specialist pharmacist inspector completed the last random inspection making a number of requirements. These requirements were seen to be met on this occasion. Elmlea DS0000067437.V358942.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28, 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 home provides people with ample shared spaces to meet people’s current needs. People live in a comfortable and homely environment. EVIDENCE: Over the previous 2 years the home has been through a major refurbishment which has improved the quality of the environment making it more homely for the people living there. This has recently been completed with a new kitchen and laundry room being fitted. A tour of the premises was completed with the acting manager. In the kitchen the fire door was being held open with a fire extinguisher and the manager was asked to remove this. The manager said that they had spoken to the organisation’s maintenance manager about the need to fit door closers on a number of doors around the home and was waiting for them to be fitted. Elmlea DS0000067437.V358942.R01.S.doc Version 5.2 Page 21 Another door requiring a closing system was the dining room. The manager explained that they are waiting for all of the carpets downstairs (main hallway and lounge) to be replaced, as they are worn and dirty. All of the communal areas in the home were seen to be decorated to a good standard, and personalised with people’s possessions. Two people’s bedrooms were seen with their permission. The manager explained that one person has just chosen new colours for their bedroom to be decorated. They hope this will be done in the near future. The person who owns this room dislikes items like lampshades, curtains and pictures on their walls. In people’s care plans there is a section named accommodation requirements and all of the above issues should be noted in there. The other bedroom seen was tidy and decorated to a good standard. The window was missing the blind and the manager said that the person had pulled this down. This had been reported to maintenance. There is a bathroom on the first floor which was re-fitted as part of the refurbishments. This is in good condition but missing a blind, this must be replaced. On the ground floor there is a shower room with a toilet. The door had no lock and it is a requirement of this inspection report that this is addressed. To the rear of the property is a secure garden where a raised garden has been developed. The manager stated that they have recently asked for the patio to be replaced, as it is uneven. Seeing the patio it is clear that due to its current condition this may pose a health and safety hazard to people living in the home. It becomes a requirement of this inspection report that it is replaced as part of the home’s ongoing maintenance programme. The new laundry is fitted with industrial style machines, and a sink. The COSHH (Control of Substances Hazardous to Health) cupboard has been moved to this room along with the associated data sheets. At the time of this site visit the home was clean and hygienic. Elmlea DS0000067437.V358942.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 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. Potential risks to people living in the home are minimised through the organisation’s thorough recruitment procedures. The induction and training of staff enables the majority of peoples needs to be met consistently. People living in the home and staff are being put at risk due to there being insufficient staff trained in behaviour management. EVIDENCE: We looked at the recruitment records for 4 staff. On the whole these had been completed thoroughly. One shortfall was highlighted where a member of staff did not have a full employment history, this was brought to the attention of the manager. We visited the organisation’s registered office to inspect the Criminal Records Bureau (CRB) disclosures for the home. All of the CRB were seen and can now be disposed of. We spoke to 6 staff when we visited the home. All of the staff confirmed that they had completed an induction course before starting work at the home. Staff explained that the induction training covered areas including COSHH Elmlea DS0000067437.V358942.R01.S.doc Version 5.2 Page 23 (control of substances hazardous to health), first aid, fire safety, food hygiene, health and safety, equality and diversity, safeguarding adults and manual handling. Each of them were asked about the training that was available to them after induction. Examples of courses completed included training in Positive Behaviour Management (PBM), infection control, diabetes, epilepsy, autism and medication administration. In addition to these courses staff are also completing National Vocational Qualifications (NVQ) at a minimum of level 2. All of the staff spoken with were positive about the amount of training that is available to them. As highlighted earlier in this report we identified that they were insufficient staff trained in PBM to manage risks safely. As a result a requirement was made for staff to complete PBM training. In the week after completing this inspection we phoned the manager who told us that they had 2 staff currently completing PBM training, and that other staff were booked on an upcoming course. Elmlea DS0000067437.V358942.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 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 living in the home benefit from the manager’s approach as it has increased people’s opportunities to be empowered. A range of documents implemented by the manager should enable them to assess the quality of the service being provided. The health and safety checks completed by staff ensure that people are not being put at unnecessary risks. EVIDENCE: The home has not had a registered manager since November 2007. The acting manager has been in post since earlier this year. The acting manager has extensive experience in working with this client group and was a registered manager with in another of the organisation’s homes before starting at Elmlea. The acting manager has applied to the CSCI to become the registered Elmlea DS0000067437.V358942.R01.S.doc Version 5.2 Page 25 manager. Speaking to the acting manager they have a clear vision for what they wish to achieve in the home. The acting manager puts great importance on ensuring that people living in the home have choice and that outcomes are good. Staff spoken with during the site visit were positive about the changes implemented by the acting manager since they have been in post. Regulation 26 visits are completed monthly and provide detailed information about the service. A discussion took place about developing quality assurance systems within the home. The acting manager has implemented a number of systems that will provide information about the quality of the service being provided. These include the regular resident meetings, choices of food and meals, a record of the activities chosen by people. The next site visit should provide good evidence as to whether people’s choices are being delivered by the home. The use of surveys with other professionals and family and friends was discussed. Records showed that staff check the fridge and freezer temperatures twice daily. A food probe is used regularly to check that food prepared in the home is served at the correct temperature. Cleaning chemicals are stored securely and data sheets are available in case of emergency. Fire safety practices were examined and showed that the home has a fire risk assessment, equipment is tested regularly and corrective actions are taken as required. Elmlea DS0000067437.V358942.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 3 2 2 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 2 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 3 X 3 X X 3 X Elmlea DS0000067437.V358942.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No 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 YA6 Regulation 15 (1) Requirement All of the care plans must provide staff with sufficient detail that enables them to meet people’s needs consistently. Each person must have comprehensive risk assessments to minimise potential risks in their day-to-day lives. The medication procedure discussed with the manager as part of the site visit must be updated to ensure that staff know what to do in an emergency. A sufficient number of staff must be trained in Positive Behaviour management (PBM) to enable them to meet people’s needs safely. The system for recording people’s financial transactions must be reviewed to ensure that all future transactions are clearly recorded. Fire doors must not be propped DS0000067437.V358942.R01.S.doc Timescale for action 04/07/08 2. YA9 13 (4) b, c 30/05/08 3. YA20 13(2) 09/05/08 4. YA23 13 (6), (7), 18 (c)(i) 04/07/08 5. YA23 17(2) schedule 4, 9 16/05/08 6. Elmlea YA24 13(4) a 16/05/08 Page 28 Version 5.2 open. 7. YA27 12(4) a The downstairs bathroom door does not have a lock and one must be fitted to minimise the risk too people’s respect and dignity. The patio to the rear of the property must be re-laid as it is uneven and poses a health and safety risk to people living in the home. When completing any future recruitment of staff the organisation must obtain a full employment history. 16/05/08 8. YA28 13(4) a, 23(2) b 29/08/08 9. YA34 7, 9, 19 Schedule 2 16/05/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA2 Good Practice Recommendations The home’s admission procedure should be reviewed, as it does not accurately reflect the organisation’s current management structure. Person Centred Plans should be introduced for each of the people living in the home. People’s personal care plans require greater detail to ensure that people’s needs are met consistently by staff. OK health checks should be reviewed to ensure that they accurately people’s current needs. The manager should complete training in safeguarding adults as it has been a number of years since they last completed this training. 2. 3. 4. 5. YA6 YA18 YA19 YA23 Elmlea DS0000067437.V358942.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection 4th Floor 33 Colston Avenue Bristol BS1 4UA 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.V358942.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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