Inspection on 10/09/07 for Elmstone, The

This inspection was carried out on 10th September 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Elmstone, The 04/04/06

Elmstone, The 16/11/05

Elmstone, The 01/03/05

Elmstone, The 21/06/04

Elmstone, The 27/03/04

Elmstone, The 13/01/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Elmstone, The 17 Norwood High Street West Norwood London SE27 9JU Lead Inspector Sonia McKay Unannounced Inspection 10th September 2007 12:00 Elmstone, The DS0000022763.V345061.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 Elmstone, The DS0000022763.V345061.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. Elmstone, The DS0000022763.V345061.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elmstone, The Address 17 Norwood High Street West Norwood London SE27 9JU 0208 655 9631 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) elmstone.lambeth@larche.org.uk www.larche.org.uk L`Arche Lambeth Care Home 5 Category(ies) of Learning disability (0) registration, with number of places Elmstone, The DS0000022763.V345061.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th March 2007 Brief Description of the Service: The Elmstone is a home for five adults who have a learning disability. It is one of five residential care homes in the area that are part of the Lambeth LArche community. The home is a large Victorian house. Residents have their own bedroom and access to a communal living room, dining room, kitchen and courtyard garden. The home is adjacent to the LArche Lambeth head office and workshops. The LArche community aims to provide a strong sense of belonging and value for residents and their assistants. There is on street parking available nearby. There is good access to West Norwood train station, bus links and shops. Elmstone, The DS0000022763.V345061.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection visit began at 12.00 a.m. and was completed in three hours. The purpose of the inspection was to examine progress in meeting the requirements made in the previous inspection report and to look at performance in key areas of the national minimum standards. The inspection consisted of discussion with the assistants on duty. There was a partial tour of the home premises and examination of records relating to care and staffing. The Commission required that the manager complete a written assessment of the service provided in the home (an Annual Quality Assurance Audit or AQAA). Information supplied in this self-assessment is used to inform this report. Assistants provided residents with support to complete satisfaction surveys sent by the Commission. The outcomes of a brief random inspection visit carried out on 19th March 2007 are also included in this report. The Commission would like to thank all those who kindly contributed their time, views and experiences to this inspection. What the service does well: There is accessible information about the services provided. This is useful to prospective residents who may find text only documents difficult to understand. There is ample opportunity for residents to experience life in the home before making a decision to move in for a trial period. Residents know that their assessed and changing needs are reflected in the written plans for how they wish to be cared for. They are assisted to make decisions about their lives and are consulted on all aspects of life in the home and the wider L’Arche community. There is a homely atmosphere and pleasant surroundings. Elmstone, The DS0000022763.V345061.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Elmstone, The DS0000022763.V345061.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 Elmstone, The DS0000022763.V345061.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 & 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is accessible information about the services provided. This is useful to prospective residents who may find text only documents difficult to understand. There is also ample opportunity for residents to experience life in the home before making a decision to move in for a trial period. Written information about the service must be updated to include more information about fees in accordance with changes in legislation in 2006. EVIDENCE: There is an informative guide about the service provided in the home. Emphasis is placed on making the guide accessible to residents with a learning disability and it contains many colour photographs, symbols and clear language. The ‘Resident’s guide and associated individual contracts must provide greater detail relating to the standard package of services provided. The terms and conditions (including fee levels) that apply to key services (both personal care and food) and the payment arrangements (resident contribution/local authority contribution) must be stipulated. Elmstone, The DS0000022763.V345061.R01.S.doc Version 5.2 Page 9 The guide must also state whether the terms and conditions (including fees) would be different in circumstances where a person’s care is funded, in whole or in part, by someone other than the resident. (See requirement 1) L’Arche offers long-term placements and there is a lengthy placement process. This is tailored to meet the needs of the individual and involves at least two brief visits to the home and three longer visits, including overnight stays. This provides an opportunity to experience life in the home before making a positive choice to move in for a trial period. The random inspection carried out in March 2007 noted that a new resident had moved into the home. This resident is a long-standing member of the L’Arche community who moved to the Elmstone when the Mustard Seed residential home closed in late 2006. The resettlement is reported to be going well and the resident, who has severe visual impairment, is settling in to life in the Elmstone. Elmstone, The DS0000022763.V345061.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. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents know that their assessed and changing needs are reflected in the written plans for how they wish to be cared for. They are assisted to make decisions about their lives and are consulted on all aspects of life in the home and the wider L’Arche community. People are supported to take risks as part of maintaining and developing greater independence and staff have improved in the way that these risks are assessed and monitored. The cultural needs of residents are not adequately assessed and there are no specific plans for how these needs are to be addressed. EVIDENCE: Each resident has three files of written information for staff reference. One file contains detailed information about current care needs and risks and personal life history information, another file contains medical and health records and a third is used to safely store older information. This indicates that a Elmstone, The DS0000022763.V345061.R01.S.doc Version 5.2 Page 11 recommendation to make ‘current’ information more accessible to staff has been implemented. There is a written plan for each resident describing the type of support that each person needs in areas if daily living. There are also goals for each resident to achieve. These goals are decided during annual review meetings with the resident and key people in their lives. Progress in achieving these goals is monitored well. The outcomes of placing authority review meetings are also held on file. Although residents have not signed the plans, there is evidence in the minutes of the review meetings that residents are consulted about how they want to be cared for and what things are important to them. The AQAA (the audit of the service undertaken by the home manager before the inspection) states that there are plans to improve the accessibility of the written plans this year. L’Arche aims to provide each resident with a ‘reference person’ in the home to act as a key worker. Residents have a key member of staff to work with who has special responsibility for assisting with decision-making, planning and dayto-day arrangements. L’Arche uses a semi-independent advocacy system with people who know the resident well. This ensures that someone from outside the home is involved. When major decisions need to be made L’Arche aims to provide the services of fully independent advocates. Involving people with learning disabilities in decision making is a LArche priority for 2006/07. Residents are encouraged to participate in the day-today running of the home and in community planning. They take part in weekly house meetings, ‘talking group’ meetings with the Community leader and they are able to vote in community council elections. Residents are involved in the assessment of new staff during their probationary period and increased involvement in staff appraisal is being developed. There was resident involvement in setting the priorities for the Community as a whole and in the review of the day services that are also provided. Residents make day-to-day decisions about what to wear, how to spend their leisure time, who to invite to dinner and what to cook. All need assistance from staff to manage their own finances. During the key and random inspection visits it was noted that written risk assessment documents were out of date. Staff have addressed this and there is now clear written information about risks that residents may be exposed to whilst going about their daily lives and activities and how any potential dangers can be/are minimised. These written risk assessments are now reviewed Elmstone, The DS0000022763.V345061.R01.S.doc Version 5.2 Page 12 regularly to ensure that information is still accurate. This is done to ensure that residents can be as independent as possible. One area of improvement is also required. One resident is African-Caribbean, none of the staff or other residents are. The resident is in contact with family who live in the area. Although some cultural needs relating to food are mentioned in care plans, there are no specific plans for meeting wider cultural needs. The local community is culturally diverse. An assessment of the cultural needs of all of residents would be of benefit to them as staff, who are not of the same cultural background as the residents may not have sufficient knowledge to adequately support residents to address and meet their cultural needs. (See requirement 1) Elmstone, The DS0000022763.V345061.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. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users have opportunities for personal development and are encouraged to be responsible in their daily lives. They take part in a wide range of leisure activities and therapeutic employment and they are offered a healthy diet. Appropriate relationships with family and friends are encouraged and supported. EVIDENCE: L’Arche is a faith-based community and offers active support to each resident to develop their faith and spiritual lives. Residents who choose not to attend religious activities of any particular denomination are offered opportunities to engage in art, music and nature instead. Two of the four residents are away at a L’Arche meeting and community gathering in Scotland at the time of this inspection. The remaining resident was out engaging in his daytime activities. Elmstone, The DS0000022763.V345061.R01.S.doc Version 5.2 Page 14 Each of the residents has a place in the L’Arche supported employment workshops (weaving, stone work, gardening and candle-making). Two residents also attend college. The close proximity of the other L’Arche homes provides an opportunity for residents visit each other and goes out for dinner. L’Arche Lambeth has been operating for more than 30 years and has developed good relationships with local individuals and organisations. All residents are offered a minimum two weeks of holiday away from the home in each year, either alone (with staff support) or as part of a group with shared interest. Two resident went to America for a holiday this year and there have been other holidays that all residents have taken part in as well. Residents regularly attend a wide variety of activities including a disco, swimming, sailing, church services and a mens group. Contact with family is maintained by visits and telephone calls. Feedback in the questionnaires sent to residents before the inspection is good. One resident says that she can do what she wants to do at the weekend and enjoys playing games. Records of the meals eaten show that a variety of meals are prepared. Food stocks are stored appropriately and contain plenty of fresh fruit and vegetables. Each resident chooses and prepares one evening meal each week to the best of their ability and as part of their skills development or assists in other aspects of mealtime chores, such as clearing up afterwards. There is good information about special diets (for example, gluten free recipes and food produce). Elmstone, The DS0000022763.V345061.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. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents receive personal support in the way they prefer and with an emphasis on maintaining privacy. The physical and emotional care needs of residents are addressed and met. Residents are supported to take responsibility for taking their own medication where possible. Staff must improve their practice around medication administration and record keeping ensuring that residents are protected from potential overdoses. EVIDENCE: Times for getting up and going to bed are flexible and reflect planned activities. Residents are able to undertake their personal care without support from staff and they choose their own clothes and hairstyles, with assistance from staff as required. Any support required is written in a plan. Staff support residents to make and attend healthcare appointments. Each persons care file has a detailed health information form to be given to medical staff in the event that a resident has to be taken to hospital in an emergency. This is good practice. Elmstone, The DS0000022763.V345061.R01.S.doc Version 5.2 Page 16 The health care of two of the residents was looked at. Records of the outcome of any healthcare are well kept, and there is evidence that residents receive appropriate assistance to maintain their physical health. The Lambeth specialist team for adults with a learning disability provides input on referral from the home when necessary. Input includes psychology and speech and language therapy, occupational therapy and physiotherapy. One resident has epileptic seizures. A requirement was made to address areas of healthcare relating to these seizures. This requirement is met. There is now a way for staff to be alerted if the resident has a seizure during the night and use of a prescribed medication has been reviewed and clarified. Seizure activity records are in place and the resident attends regular appointments at the hospital neurology department. A recommendation to review the furnishings around his sleeping area, to reduce the likelihood of injuries occurring during seizures, has been implemented. Staff supported the resident to obtain a lower level ‘futon style’ bed, select a soft textured bedside rug, remove a small table with sharp edges from the bedside vicinity and add padding to the headboard area. The local pharmacy provides staff with training and supplies prescribed medication in pre-filled measured dose packs. Homely remedies and homeopathic remedies are also used. There is stock record book of what is being kept, and authorisation from each resident’s GP about what ‘over the counter’ remedies they can safely use. Two of the residents are able to take a degree of responsibility for taking their own medication. Staff support them to do this in different ways and, as required in the previous inspection report, risks relating to self-medication are now assessed and there are clear risk management plans in place. This makes it safer for residents. Medication is stored securely and staff administer medication to two of the residents. Medication administration records examined indicate that there are gaps in recording on two occasions in August 2007. It is not clear whether the medication was administered and not signed for or whether the medication was not given. There is no evidence that these omissions have been noted or investigated. This is dangerous for residents. (See requirement 2) Medication administration records do not include a photograph of the resident, details of what each medication is for and any potential side effects. This is dangerous for residents. (See requirement 3) Elmstone, The DS0000022763.V345061.R01.S.doc Version 5.2 Page 17 Receipts and returns of medication are recorded in a separate log. Staff undergo a two-day training course by a pharmacist. There is an authorised signature list of staff that are trained to administer medication. This list includes the names of staff from other L’Arche homes that occasionally work at the home. Elmstone, The DS0000022763.V345061.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. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. There are adequate systems in place to ensure that residents have opportunities to raise concerns and make complaints. Record keeping must be improved, as there is insufficient information about a complaint made by a family member or how it was addressed. Staff are trained to recognise abuse and what to do if they suspect any form of abuse is going on. EVIDENCE: There is a complaints policy with a text version and a more accessible version for residents who may not be able to understand a text only document. A complaints poster is displayed on the notice board in a communal area. Regular house meetings provide residents with an opportunity to raise concerns. The record of complaints shows that there have been no complaints made in the last twelve months by any resident. The record of complaint has a brief, undated note that a resident’s mother made a complaint that was dealt with by a senior community member. Staff on duty did not know what the complaint was about or how it was addressed or resolved. This is inadequate record keeping. (See requirement 4) Abuse awareness training is part of the L’Arche induction and formation training undertaken by all new staff. The ‘response to abuse’ guidelines have Elmstone, The DS0000022763.V345061.R01.S.doc Version 5.2 Page 19 been reviewed to ensure that they meet with protocols defined by the local authority safeguarding adults procedures. All residents require assistance with financial issues. Receipts are retained for all transactions and stored with the individual accounts that are in good order. A record of visitors is available and is being used appropriately. Elmstone, The DS0000022763.V345061.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, 26 & 30. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable and homely environment and each has their own bedroom. A sink is required in the kitchen so that people can wash their hands before handling food. EVIDENCE: The premises are safe, comfortable, bright, airy, clean and free from offensive odours with sufficient lighting and heating. The home is in keeping with other homes in the area and is indistinguishable as a care home. The home offers good access to local amenities, transport routes and relevant support services. Furnishings and fittings are of good quality and there is a homely atmosphere with many photographs of residents and their friends displayed on the walls. All bedrooms are single occupancy. Elmstone, The DS0000022763.V345061.R01.S.doc Version 5.2 Page 21 The home has a men’s bathroom and a woman’s bathroom situated close to the bedrooms. Both rooms have a WC and a shower facility in the bath. A radiator cover had been fitted to the radiator on the mens side of the house as one of the residents has occasional seizures. Bathroom door locks are of a type that can be opened from the outside in an emergency. A separate toilet is available on the ground floor close to the dining area. There is a ground floor laundry room. A procedure is in place to ensure that soiled laundry is not carried through the kitchen during food preparation to prevent the spread of infection. The home has a communal lounge adjoining the kitchen. There is a separate dining room and large rear courtyard area with a fountain and seating areas. Smoking is permitted in the rear courtyard. Staff who sleep-in at the home have an adequate bedroom and places to keep personal belongings. The bathroom used by the two females now living at the Elmstone, has been re-fitted and decorated to enable a resident with visual impairment to maintain as much independence as possible during personal care. The patch of damp in this bathroom has also been addressed, so the requirement made to this affect is therefore met. Environmental health have required that a hand washbasin be fitted in the kitchen area, to ensure good hygiene. This has not been done. Elmstone, The DS0000022763.V345061.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. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Training plans are in place to ensure that staff, who stay for one or two years are equipped with the specialist training required to meet the needs of the residents. As yet, this does not include a national vocational qualification in Care. Recruitment procedures are adequate. EVIDENCE: Residents who commented said that staff treat them well and listen to them. House assistants within the L’Arche community are provided with board and lodgings. Each has a clear job description and contract of employment. Staff do not live on premises but take turns to sleep at the home to provide night cover in case of an emergency. The AQAA (Annual Quality Assurance Audit) states that a shortage of accommodation for staff means that the service is vulnerable to staff shortage if any assistants are ill or leave at short notice. Currently, these shortages are filled by staff working longer hours or coming from other houses or workshops to provide cover. Elmstone, The DS0000022763.V345061.R01.S.doc Version 5.2 Page 23 L’Arche is a Christian community that requires staff to be part of all aspects of care and support and a committed community lifestyle. The community welcomes staff and residents from all faiths. Records are kept of all staff duty rosters. Between one and two members of staff are on duty in the home depending on the activities and needs of the residents. A framework of policies and procedures provides staff with guidance. There is also ongoing staff support from the homes co-ordinator and other longstanding community staff. As assistants usually only stay for between one and three years they do not normally have an NVQ (National Vocational Qualification). The previous director of L’Arche conceded that it will be hard for the organisation to achieve the national minimum standards in regards to developing a vocationally qualified staff team. One option being looked at to address this is the recruitment of more local people. This will help with staff retention and may also help the team to retain qualified staff and have fewer accommodation problems. The training and development plan for 2007 identifies that staff who start a second year of employment will undertake an NVQ 3. None of the current staff team have achieved the qualification. (See requirement 5) Individual staff training records are in place, but it is not clear what training has been identified as being required for staff working with the residents of the Elmstone (for example, NVQ, refresher courses in Mandatory training, epilepsy, sensory impairment, autism, communication). (See requirement 6) Recruitment records are held at the L’Arche head office. They were made available during the inspection. Four sets were examined and there is evidence that adequate checks are made prior to recruitment. L’Arche provides all new assistants with induction training in the first six weeks. ‘Foundation training’ is undertaken in the first year, this is a combination of ‘in-house training’ and training provided by the local specialist learning disability team. Mandatory training includes first aid, health and safety (including epilepsy), food hygiene, manual handling, Sign-along, medication administration, challenging behaviour as communication, Gentle Teaching and training around taking risks and making choices. Elmstone, The DS0000022763.V345061.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. Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. A new manager is in post but has not yet registered with the Commission. This must be done to ensure he is a suitable applicant to manage the service. Residents can be confident that their views underpin the running of the home and the community. Systems are in place to promote health and safety although more must be done to ensure fire safety. EVIDENCE: During the random inspection of March 2007 it was noted that the home was in a period of management change. The previous registered manager left the service in November 2006 and interim management arrangements were in place until the new manager commenced in April 2007. Elmstone, The DS0000022763.V345061.R01.S.doc Version 5.2 Page 25 The new manager is now in post, but has yet to registered with the Commission. The requirement made in this regard is therefore unmet. (See requirement 7) The L’Arche community has an annual development plan for quality assurance in place. Regular house and community meetings are held to ensure that the views of the residents impact on the running of the community and planning home life. During the random inspection of 19th March 2007, it was noted that: • Electrical appliances had been safety tested and the outcomes of the tests recorded. The requirement to ensure that the appliances are safety tested was therefore met. Environmental health and safety and fire risk assessments had been reviewed, as required in the previous inspection report. Fire evacuation drills frequency had increased. Reports of the monthly visits to the service on behalf of the registered provider in accordance with Regulation 26 are available in the service and have been supplied to the Commission. A previous requirement was therefore met. • • • The last fire evacuation drill was an unplanned evacuation carried out in April 2007. One resident did not evacuate the premises. The most recent planned evacuation was in January 2007. Fire evacuation drills must be carried out more often and there must be suitable systems in place to alert all residents of the need to evacuate (taking into account any sensory impairment). (See requirement 8) Elmstone, The DS0000022763.V345061.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 1 2 3 3 X 4 3 5 X 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 3 25 X 26 3 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X 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 3 3 2 X 2 X 3 X X 2 X Elmstone, The DS0000022763.V345061.R01.S.doc Version 5.2 Page 27 Yes 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 YA6 Regulation 15 Requirement The registered persons must ensure that the cultural needs of each resident are clearly identified in written plans for their care. The registered person must ensure that residents are administered medications as they are prescribed and that a record is kept of any administration or reason why a medication is not administered. Justified stock checks must take place on a regular basis and any gaps in recording must be identified and investigated. The registered person must ensure that there is photograph of each resident attached to the relevant medication administration record and information about why a medication is prescribed and what potential side effects there may be must be available. The registered person must ensure that a record is kept of any complaint, how it was investigated, the outcome and the timescales. Summary details DS0000022763.V345061.R01.S.doc Timescale for action 30/11/07 2. YA20 13(2) 17(1)(a) 12/10/07 3. YA20 13(2) 17(1)(a) 12/10/07 4. YA22 22 17(2) 12/10/07 Elmstone, The Version 5.2 Page 28 5. YA32 18(1)(a) of any complaint made in the last 12 months must be supplied to the Commission by The registered person must 31/12/07 ensure that plans are in place to ensure that care staff hold a care NVQ 2 or 3, or are working to obtain one by an agreed date; or can demonstrate that through past work experience and training staff meet that standard. Previous timescales of 31/08/06 and 29/07/07 are not met. Evidence that action has been taken to meet this previous requirement must be sent to the Commission by 6. YA35 18 7. YA37 8 9 23 8. YA42 The registered person must ensure that there is a training needs analysis that results in a training and development plan for staff working at the Elmstone. The registered person must appoint a suitably qualified and experienced manager who must register with the Commission. The registered persons must ensure that planned fire evacuation drills are carried out on a regular basis. Planned drills must be carried out during the day and during the night. There must be suitable systems in place to alert any resident with a sensory, or other, impairment of the need to evacuate the premises. 30/11/07 30/11/07 30/11/07 Elmstone, The DS0000022763.V345061.R01.S.doc Version 5.2 Page 29 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Elmstone, The DS0000022763.V345061.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection SE London Area Office River House 1 Maidstone Road Sidcup Kent DA14 5RH 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 Elmstone, The DS0000022763.V345061.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. 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!