Inspection on 16/11/05 for Elmstone, The

This inspection was carried out on 16th November 2005.

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 19 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Elmstone, The 10/09/07

Elmstone, The 04/04/06

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 16th November 2005 08:30 Elmstone, The DS0000022763.V266050.R01.S.doc Version 5.0 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.V266050.R01.S.doc Version 5.0 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.V266050.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Elmstone, The Address 17 Norwood High Street West Norwood London SE27 9JU 020 8670 9294 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) L`Arche (Registered Office) Ms Louise Heatley Care Home 5 Category(ies) of Learning disability (0) registration, with number of places Elmstone, The DS0000022763.V266050.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th July 2005 Brief Description of the Service: The Elmstone is a home for five adults who have a learning disability. It is one of six residential care homes in the area that are part of the Lambeth LArche community. The home is a large Victorian house. Each service user has their own bedroom and access to a communal living room, dining room and kitchen. The Elmstone is in a one-way street, which is not residential, and there are therefore no immediate neighbours. The home is adjacent to the LArche Lambeth head office and workshops, with which it shares a large patio area. The LArche community aims to provide a strong sense of belonging and value for community members and their assistants. There is on street parking available nearby. West Norwood Station is near as is the High Street with bus links, shops, community and leisure facilities. Elmstone, The DS0000022763.V266050.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted in seven hours and involved talking with the three service users living in the home, two members of staff, the recruitment co-ordinator and the care co-ordinator. Records relating to care, the environment and staff recruitment were examined and there was also a tour of the premises. What the service does well: What has improved since the last inspection? The home manager has registered with the CSCI. Two new staff members have been recruited and staffing levels have increased. LArche has recently appointed an additional member of staff to support service users with community activities, education and leisure pursuits. Stakeholder surveys have been developed and sent out, including a format accessible to service users about the future of the LArche community. Decisions made by service users in weekly house meetings are now recorded. LArche has taken steps to improve staff retention and working conditions. Elmstone, The DS0000022763.V266050.R01.S.doc Version 5.0 Page 6 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. Elmstone, The DS0000022763.V266050.R01.S.doc Version 5.0 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.V266050.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 & 5. Prospective service users have adequate information to make an informed decision to move into the Elmstone. There is an extensive opportunity to ‘test drive’ the home. Individual needs and aspirations are assessed and met and each service user has a written contract stating the terms and conditions of occupancy. EVIDENCE: There is an informative ‘Statement of Purpose’ and a ‘Service Users’ Guide’ to the home. Emphasis has been placed on making the guide accessible to service users with a learning disability and it contains many colour photographs, symbols and clear language. L’Arche offers long-term placements only and has a lengthy placement process, which is tailored to meet the needs of the individual and usually involves at least two brief visits to the home and three longer visits, including overnight stays. This allows the referred person the opportunity to experience life in the home before making a positive choice to move in for a trial period. L’Arche places emphasis on providing staff with communication support skills including Sign-along training and specialist training for communicating with adults with a learning disability. A database of photographs of all community members (service users and staff), significant locations and other useful objects is being developed to assist with this. Elmstone, The DS0000022763.V266050.R01.S.doc Version 5.0 Page 9 Each service user has a contract of service and occupancy that has been explained to them if they are unable to understand the document themselves. Copies are available in individual care files. There are three service users living in the Elmstone at the time of this inspection. One service user has recently moved to a flat. Her placement is being maintained in the Elmstone for six months in case she changes her mind and wants to move back. There is no resettlement work underway with any prospective service users. Elmstone, The DS0000022763.V266050.R01.S.doc Version 5.0 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, 8, 9 & 10 Although there is a good care plan review process in place, assessed and changing needs are not reflected in individual plans, as the plans have not been reviewed recently. Service users can make decisions about their daily lives. Risk taking procedures are in place. However, individual risks identified had not been reviewed with the required frequency. This has health and safety implications and may also impede further development of independent living skills. EVIDENCE: Each service user has a file that contains personal information, assessment information, written care plans, goals and minutes of care review meetings. The internal care plans for one service user were examined. Although the review had been detailed and involved all aspects of the service users life, the care plan had not been reviewed since November 2004. Recent recommendations made as a result of psychological assessment are not reflected in the care plan. There had not been an annual statutory social work care review either. An internal review is scheduled for December 2005. This does not provide service Elmstone, The DS0000022763.V266050.R01.S.doc Version 5.0 Page 11 users with an adequate frequency of a review of care needs and arrangements to meet them. (See requirements 1 & 2). Each service user has a range of risk assessments on file. These risks have not been reviewed for over a year. Risks and actions taken to minimise them must be reviewed frequently, or as needs change, to ensure that service users independent skills development is not impeded and also to ensure that new risks are assessed. (See requirement 3). L’Arche aims to provide each service user with a ‘reference person’ in the home to act as a key worker. Service users have a key member of staff to work with who has special responsibility for assisting with decision making, planning and day-to-day arrangements. L’Arche uses a semi-independent advocacy system with people who know the service user 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. Service users are encouraged to participate in the day-to-day running of the home and in community planning. They take part in weekly house meetings, ‘talking group’ meetings with the director nine times a year and community council elections. Service users are also involved in the assessment of new staff during their probationary period. Written information about service users is stored securely and shared with others on a need to know basis only. Elmstone, The DS0000022763.V266050.R01.S.doc Version 5.0 Page 12 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): EVIDENCE: This group of standards was examined and assessed as being fully met in the July 2005 inspection. Since that inspection a new member of staff has been appointed with responsibility to provide increased community access to activities for all LArche service users. One service said that he was looking forward to going out dancing and listening to music in nightclubs and discos. Elmstone, The DS0000022763.V266050.R01.S.doc Version 5.0 Page 13 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. Service users receive personal support in the way they prefer and require. Although there is evidence of links with health specialists and ongoing healthcare, records and planning are inadequate. Arrangements to ensure that new staff have an understanding of the particular healthcare needs of one service user are inadequate and this presents a major risk to her health. The home’s medication practices do not provide service users with appropriate levels of protection. EVIDENCE: Times for getting up and going to bed are flexible and reflect planned activities. Service users are able to undertake personal care tasks without support from staff. Risks to a service user who has epileptic seizures are minimised by use of a shower rather than a bath and not having a plug (to prevent drowning). Service users are able to choose their own clothes and hairstyles, with minimal assistance from staff. Assistance provided is advice such as, the need to put on a clean shirt and wear appropriate clothing. Service users are well dressed in clothes that reflect their personal taste and their planned activity. For example, sensible work clothing for a gardening job. A service user said that she enjoys shopping for clothes with a member of staff. Elmstone, The DS0000022763.V266050.R01.S.doc Version 5.0 Page 14 LArche is able to provide a degree of consistent staffing despite regular staff turnover, as the Elmstone has four full time staff and staffing shortfalls as a result of leave or sickness are covered by other members of community staff who are known to the service users. Each care file has a detailed health information form to be given to medical staff in the event that a service user has to be taken to hospital in an emergency. This is good practice. Staff support service users to make and attend appointments. Records do not show whether service users have seen appropriate health care specialists, the outcomes of the appointments or when follow up visits are due. There are capacity to understand and consent issues around routine health screening for cancer. The home manager must seek advice from health professionals and multidisciplinary teams involved. (See requirement 4) One service user has a medical condition for which a written protocol is in place to ensure that if certain symptoms are observed, urgent action is taken, including calling an ambulance. Staff on duty were not aware of this, which potentially places the service user at serious risk. All staff that work with this service user must be made aware of her specific needs and the symptoms that require emergency medical attention. (See requirement 5) A format for person-centred health action plans is available, although not in full use. (See recommendation 1) Two of the three service users are supported to take responsibility for their own medication. Staff fill a week’s supply of medication into dossette boxes, which are kept in individual locked tins in a locked drawer. There are individualised weekly recording sheets that service users sign to indicate they have taken their medication. Staff also use the sheets to record the balance of stock remaining in the bulk-dispensed container. One service user is using the form incorrectly indicating that he does not understand the form or that the form is unsuitable. A stock check showed that the medication is being administered incorrectly. The medication in use is to prevent epileptic seizure; it is therefore essential that the correct dosage be taken. (See requirement 6) The re-dispensing of medication into dossette boxes by staff can introduce errors so it is not good practise. If the home wishes to continue to do this to facilitate self-administration, it must be a carefully controlled process, carried Elmstone, The DS0000022763.V266050.R01.S.doc Version 5.0 Page 15 out in a closed area with an identity and quantity check for each medication verified by a second member of staff. (See requirement 7). The medication administration record used to record staff administration of medicines for one service user also records the use of homeopathic medication. This is good practise. Receipts and returns of medication are recorded in a separate log. Although the date of receipt is recorded, the start-date must also be recorded so that a justified stock audit trail is available (stock received minus stock used equals stock returned). (See requirement 8) Homely remedies (over the counter medication for minor ailments) are used, but without a stock record book of what is being kept, a running total or authorisation from each individual service users GP to say that the homely remedy is suitable for use (in case of interaction with prescribed medication). A record must also be kept of their administration. (See requirement 9). Staff undergo a two-day training course by a pharmacist. There is an authorised signature list of staff that administer medication. This list includes the names of staff from other L’Arche homes that occasionally work at The Elmstone. Elmstone, The DS0000022763.V266050.R01.S.doc Version 5.0 Page 16 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 Service users views are listened to and acted upon. Service users are protected from abuse by well-trained staff and adult protection policy and procedures. However, safeguards from financial and material abuse are inadequate, as home staff do not document all of the cash and valuables held in safekeeping. EVIDENCE: The home has a good complaints policy. There is text version and a more accessible version for service users who may not be able to understand a text only document. A complaints poster is displayed on the notice board in a communal area and this has colour photographs of people who can assist with a complaint, including the CSCI. Regular house meetings provide service users with an opportunity to raise concerns. The record of complaints shows that there have been no complaints made in the last twelve months. A service user identified a member of LArche staff that he would talk to if he had a complaint to make. A record of visitors is available. Abuse awareness training is part of the L’Arche induction and formation training undertaken by all new staff. A staff member on duty had a thorough knowledge of signs of abuse, forms of abuse and action to take if he witnessed or suspected abuse. All service users require assistance with financial issues. Receipts are retained for all transactions and stored with the individual accounts. Elmstone, The DS0000022763.V266050.R01.S.doc Version 5.0 Page 17 A spot check of service user finances held in safe keeping by staff showed that cash balances and bank balances are accurately recorded. However, foreign currency available for one service user is not accounted for at all in the records, nether are valuable documents such as passports. Transactions are checked and signed by only one member of staff. This does not adequately protect service users from financial abuse. (See requirement 10) Elmstone, The DS0000022763.V266050.R01.S.doc Version 5.0 Page 18 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, 25, 26, 27, 28 & 30. Service users live in a clean, comfortable and homely environment. Their bedrooms suit their individual needs and lifestyles. Shared spaces complement and supplement individual living space. Some environmental safety features are in place, but more must be done to monitor and ensure the safety of the environment. EVIDENCE: The premises are safe, comfortable, bright, airy, clean and free from offensive odours. 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. The home has a men’s bathroom and a women’s bathroom situated close to the bedrooms. Both bathrooms rooms have a shower facility in the bath. Bathroom door locks are of a type that can be opened in an emergency using a pin, which is stored above the doorframe. This necessitates a verbal handover of information to each member of staff, and also requires regular checks to ensure that the pin is in place. A recommendation was made in the previous Elmstone, The DS0000022763.V266050.R01.S.doc Version 5.0 Page 19 inspection report to replace these locks with a type that is operated without use of a pin. Staff on duty were unaware of how to open these doors in an emergency and were not aware of the location of the pin. Suitable locks are now required to ensure the safety of service users. (See requirement 11) Lighting is insufficient in the bathroom used by women and the electric light bulb is exposed. (See requirement 12) Hot water outlets are fitted with thermostatic valves to prevent scalding. However, the hot water temperatures are not routinely checked. (See requirement 13) A separate toilet is available on the ground floor close to the dining area. A radiator cover had been fitted to the radiator in the bathroom used by men to prevent contact burns, as one of the service users has occasional seizures. A radiator cover is also fitted in his bedroom. One other service user is at risk of contact burns from his radiator as he has moved his bed next to the radiator. Steps must be taken to reduce the risk of contact burns for this service user also. (See requirement 14) All bedrooms are single occupancy, well furnished and personalised. The home has a communal lounge adjoining the kitchen. There is a separate dining room and large rear courtyard area with a fountain and relaxing seating area. Smoking is permitted in the rear courtyard only. Staff who sleep-in at the home have an adequate bedroom and places to keep personal belongings. Elmstone, The DS0000022763.V266050.R01.S.doc Version 5.0 Page 20 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): 31, 32, 33, 34 & 35 Staff have clearly defined roles. Steps are being taken to ensure that staff are equipped with the specialist training required to meet the needs of the service users although, as yet, this does not include a national vocational qualification in Care. Recruitment procedures must be further developed to ensure that service users are adequately supported and protected. EVIDENCE: House assistants within the L’Arche community are provided with board and lodgings. Staff at the Elmstone do not live on premises but take turns to sleep in at the home to provide night cover in case of an emergency. L’Arche is a Christian community that requires staff to be part of all aspects of care and support and a committed community lifestyle. A L’Arche framework of policies and procedures provides staff with guidance. There is also ongoing staff support from the homes co-ordinator and other long-standing community staff. As assistants usually only stay for between one and three years they do not normally have an NVQ qualification. The director of L’Arche has conceded that it will be hard for the organisation to meet this standard by 2005. (See requirement 15) Elmstone, The DS0000022763.V266050.R01.S.doc Version 5.0 Page 21 Two new staff have been recruited to the Elmstone team since the last inspection, when staffing levels were dangerously low. There are now three assistants and a home manager. LArche has also taken steps to improve working time arrangements to improve staff retention. Staff duty records are adequately recorded and show that between one and two members of staff are on duty during the day and one member of staff is on sleeping-in duty at night. Recruitment records are held at the L’Arche head office. A recruitment coordinator has made progress in auditing staff recruitment records and is currently revising the LArche recruitment procedures. The records are still incomplete in some cases. References taken up by telephone have not all been authenticated in writing. Twelve members of staff do not have UK CRB checks in place or confirmation of a satisfactory POVA First check. Overseas police checks are in place for these staff and all have applied for an enhanced UK CRB check. (See requirement 16) Training records are held at the L’Arche head office. A training co-ordinator has made progress with compiling training and development needs assessment for each of the L’Arche homes and records of training undertaken by individual staff. 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. NVQ training is provided for staff that are able to commit to more than two years. Working visa constraints prevent some staff from staying for more than a year so few have achieved this. Elmstone, The DS0000022763.V266050.R01.S.doc Version 5.0 Page 22 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, 40 & 42. The home manager has recently registered with the CSCI and has undertaken to complete the necessary vocational qualifications. The views of service users underpin the development of the LArche community. Steps are taken to ensure health and safety but some areas must still be improved. EVIDENCE: The recently registered home manager has commenced the required NVQ 4 in Care and the Registered Managers Award. The L’Arche community has an annual development plan for quality assurance in place. A representative of the responsible individual visits the home on a monthly basis, in accordance with The Care Homes Regulations 2001. Regular house and community meetings are held to ensure that the views of the service users impact on the running of the community and planning home life. Elmstone, The DS0000022763.V266050.R01.S.doc Version 5.0 Page 23 Policies and procedures are reviewed regularly and a number have been reviewed or developed in 2004/5, including physical restraint, challengingbehaviour, risk assessment, internal incident reporting, internal financial controls, confidentiality, medication, visitors, transport and recruitment. L’Arche has demonstrated that policy and procedure are reviewed in light of changing circumstances. Recruitment policies and procedures do not yet provide service users with adequate protection. Staff conduct regular health and safety checks of the premises. The annual Landlords gas boiler safety certificate was issued in December 2004. Mains electricity circuitry had been safety checked in October 2004. Small electrical appliances had been subject to an annual electrical safety test in January 2005. Hot water temperatures are restricted to within safe limits to prevent scalding although temperatures are not tested regularly (See requirement 13). Window opening restrictors are fitted. Fire authorities inspected the premises in December 2004 and their report confirms that fire safety precautions are adequate. Food hygiene arrangements were inspected in January 2005 and their report confirms that no major issues were identified. Regular checks are conducted on fire detection and emergency equipment both in-house and by professional service. Fire evacuation drills are held with the required frequency and the results recorded. A fire risk assessment was last reviewed in October 2004. This risk assessment should be reviewed in light of a recent minor fire setting incident and also as is it overdue. (See requirement 17) Accidents, incidents, injuries and illnesses have been dealt with and recorded appropriately. Elmstone, The DS0000022763.V266050.R01.S.doc Version 5.0 Page 24 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 2 3 2 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 2 3 X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score 3 2 3 2 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Elmstone, The Score 3 1 1 X Standard No 37 38 39 40 41 42 43 Score 2 X 3 2 X 2 X DS0000022763.V266050.R01.S.doc Version 5.0 Page 25 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(2)(b) Requirement The registered person must ensure that care plans are reviewed regularly (at least 6monthly, on request or when needs change significantly). Previous timescale of 30/09/05 not met The registered persons must request a statutory review of care for service users who have not had a social work review in over one year. The registered person must ensure that risks posed to individual service users are reviewed regularly and when needs change. Previous timescale of 30/09/05 not met The registered person must ensure that the healthcare needs of service users are assessed and documented and that procedures are in place to address them and record the outcomes of health appointments. The registered manager must also seek advice about routine health screening in the best interests of service DS0000022763.V266050.R01.S.doc Timescale for action 31/12/05 2 YA6 15(2)(b) 31/12/05 3. YA9 14(2(a) 13(4(b) 31/12/05 4 YA19 12 17(2) Sch 3.3(k) 31/12/05 Elmstone, The Version 5.0 Page 26 users. 5 YA19 12(1)(a) 13(1)(b) The registered person must ensure that procedures are in place to ensure that staff are aware of any symptoms and medical conditions that necessitate an urgent course of action (for example, signs that a shunt may be malfunctioning). Previous timescale of 04/07/05 not met The registered manager and staff must encourage and support service users to retain, administer and control their own medication, within a risk management framework. The suitability of the format of the self-medication administration record in use by one service user must be reviewed (the service user is completing the forms incorrectly). The registered person must ensure that if re-dispensing into dossette boxes is carried out by staff, it must be a carefully controlled process, carried out in a closed area with an identity and quantity check on each medication verified by a second member of staff. Previous timescale of 31/08/05 not met The registered person must ensure the safe administration of medications by regular and justified stock checks. These checks must be recorded and must involve a process of checking stock collected against stock administered/returned and balance remaining. Any discrepancies must be investigated and recorded. DS0000022763.V266050.R01.S.doc 16/12/05 6 YA20 13(2) 13(4)(b) 12(1) 31/12/05 7 YA20 13(2) 31/12/05 8 YA20 13(2) 31/01/06 Elmstone, The Version 5.0 Page 27 9 YA20 13(2) 10 YA23 17(2) Sch 4(9) 11 YA42YA27 13(4) 12(1) 12 YA27 13(4) 12(1) 23(2)(p) 13(4) 12(1) 12(1) 13(4) 18(1)(a) 13 YA42YA27 14 YA42YA26 15 YA32 The registered person must ensure that if needed, Homely Remedies are stored at the home, with a stock record book of what is being kept, a running total, authorisation from each individual residents GP to say that these Homely Remedies are suitable for use (i.e. no interaction with prescribed medication) and a record of when they are administered. Previous timescale of 31/08/05 not met The registered person must ensure that service users are safeguarded from financial or material abuse. All currency and valuables held in staff safe -keeping must be recorded. All records of transactions must be checked and countersigned. The registered person must replace bathroom and toilet privacy door locks with a type that can be over-ridden in an emergency (without the use of a pin). The registered person must ensure that the bathroom used by women has adequate lighting and a covered bulb light fitting. The registered person must regularly test and record the hot water temperatures in the bathrooms. The registered person must take steps to reduce the risk of contact burns caused by a bed being pushed against a radiator. The registered person must 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 DS0000022763.V266050.R01.S.doc 31/01/06 31/01/06 31/01/06 31/01/06 31/01/06 31/01/06 31/12/05 Elmstone, The Version 5.0 Page 28 standard. 16 YA34 19(1)(b)(i) Sch 2 The registered persons must ensure that evidence of all information and documentation required by Schedule 2 of the Care Homes Regulations 2001 (revised in July 2004) is obtained for staff before they commence work in the care home. Previous timescale of 31/08/05 not met 31/12/05 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 YA19 Good Practice Recommendations The registered persons should devise person-centred health action plans with each service user. Elmstone, The DS0000022763.V266050.R01.S.doc Version 5.0 Page 29 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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 Elmstone, The DS0000022763.V266050.R01.S.doc Version 5.0 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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