Inspection on 26/03/07 for Elmwood

This inspection was carried out on 26th March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 but made no statutory requirements on the home.

Other inspections for this house

Elmwood 02/08/07

Elmwood 13/06/06

Elmwood 20/03/06

Elmwood 19/01/06

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Elmwood 42-46 Southborough Road Bickley Kent BR1 2EW Lead Inspector Miss Rosemary Blenkinsopp Unannounced Inspection 26th March 2007 10:15 X10015.doc Version 1.40 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 Elmwood DS0000066220.V332301.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 Older People. 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. Elmwood DS0000066220.V332301.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elmwood Address 42-46 Southborough Road Bickley Kent BR1 2EW 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) 020 8249 1904 020 8249 4117 Mission Care ** Post Vacant *** Care Home 67 Category(ies) of Old age, not falling within any other category registration, with number (66), Physical disability (1) of places Elmwood DS0000066220.V332301.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 place registered for service user category PD for named service user only. 13th June 2006 Date of last inspection Brief Description of the Service: Elmwood is a purpose-built facility providing accommodation for up to sixtyseven residents in the category of older persons. It is located over three floors with a large reception area on the ground floor. The Manager’s office is also located in this area. There are additional facilities by way of a cinema and coffee lounge on the first and second floor. Each floor has a dedicated dining/sitting area. The middle floor is dedicated to intermediate care where the beds are funded through the Primary Care Trust. The maximum stay in this unit is six weeks. A multi disciplinary team of staff work intensively with residents to facilitate a move back to their own homes. The two other floors are for those residents in the category of older persons. These two floors provide long-term care and occasionally respite. Staff are allocated to specific floors to promote team working and provide a consistency of care. Each floor has a senior qualified nurse leading the team with support and ancillary staff. There is a qualified nurse managing the home, this is an interim measure whilst a permanent Manager is recruited. Elmwood DS0000066220.V332301.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted unannounced by two people the lead inspector and the Regulation Manager from Croydon office. The inspection covered a period of approximately seven and a half hours. This was the second key inspection of the year. Random inspections have been conducted in addition to the key inspections. The inspection was facilitated by the acting person in charge, Betty Burnett. She was also the second qualified on the intermediate care unit .At the time of the inspection there were 22 residents on the second floor, 21 on the first floor and 18 on the ground floor. The two inspectors focused on those requirements identified at previous inspections as well as issues, which had been referred to the CSCI office. Not all of the standards were addressed at this inspection as these had been inspected previously. What the service does well: What has improved since the last inspection? The evidence of the inspectors was that there had been improvement in many of the areas, which had previously caused concern. Staff training and induction had improved. Recruitment was on going and although some agency staff were use this had significantly reduced Care plan information and assessment documentation had improved although more work is required to ensure a comprehensive system of care planning and risk assessments. Elmwood DS0000066220.V332301.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Elmwood DS0000066220.V332301.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Elmwood DS0000066220.V332301.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There was evidence of assessment information provided both through the multi disciplinary team and obtained through the home’s own assessment procedures, therefore residents are assessed prior to admission to ensure their care needs can be met. EVIDENCE: The inspectors sampled assessment information for residents, which they selected as part of the inspection process. Within the intermediate care unit there is a specific multi disciplinary single assessment form. The assessment information is comprehensive and detailed to ensure that immediately on admission the rehabilitation process can begin. Other information included hospital discharge letters and information from community services. Mission Care conducts their own assessment using their own documentation. Trial visits do not take place for those residents admitted onto the intermediate care Elmwood DS0000066220.V332301.R01.S.doc Version 5.2 Page 9 unit. In the other two floors these are only undertaken when this is possible. Relatives are invited to visit the home prior to any admission taking place. Within one of those newly admitted resident’s files requested, who was on the intermediate care unit, there was information, which clearly identified that the resident was outside of the category of registration namely that they suffered Dementia. In the event that Dementia is the primary diagnosis, the home must not admit such residents. The home is not registered for Dementia and must only seek to admit residents in their registration category. This diagnosis was on a number of records and staff should have been alerted to this. This resident’s documentation is further referred to under the next section. Please see requirement 1. Elmwood DS0000066220.V332301.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area adequate. This judgement has been made using available evidence including a visit to this service. There was evidence that care plans were in place for residents, however these did not fully reflect the totality of their identified needs. Supporting documentation was also incomplete hence staff would be unable to provide the care residents needed. EVIDENCE: The inspector requested one care plan of a resident whose behaviour had been conveyed to the CSCI because it was said to be inappropriate and causing concern .The resident has been relocated to more appropriate accommodation. This resident, had whilst in Elmwood, been in the intermediate care unit. The information for this resident was inspected. It included a behaviour assessment, which indicated aggressive and restless behaviour as well as the fact that they were a danger to themself and others. This was indicated on the documentation, that this was under the category “severe”. This was not dated Elmwood DS0000066220.V332301.R01.S.doc Version 5.2 Page 11 although signed by staff. It was clear from information within the file that the resident had a diagnosis of Dementia this was documented on the discharge letter from Lewisham hospital and included on the other information records. The home is not registered for Dementia and therefore referrals under this category must not be accepted, unless a variation for the individual resident has been obtained. It was also clear that Betty Burnett had facilitated the move of this resident to another facility. It was clear an incident had occurred between staff and the resident however the CSCI had not received a notification under Regulation 37 relating to this. A summary of the incident needs to be forwarded to the CSCI. This resident’s care plan was inspected. Within the care plan there was a psychiatric referral dated January 2007 .The “FACE” overview assessment was completed. The admission summary stated that the residents had a history of Dementia. The daily events referred to confusion, restlessness aggression and that they were refusing care. The residents care plan had only two issues that the inspector could locate even though their medical and presenting problems were multi faceted and included Dementia, poor hearing, chronic leg ulcers amongst others. The two issues, which were identified, were in relation to an ulcer and their confusional state, these were not fully reflective of their presenting problems. A second care plan was inspected it contained assessment information including an intermediate care referral form, a hospital discharge letter, and completion of Mission Care assessment documentation .The resident was on the intermediate care unit hence trial visits do not take place prior to admission. There was good information contained with in these documents. This resident had a high waterlow score of 19, which is indicative that there is a risk of tissue breakdown. Their nutrition risk assessment also indicated that they had a poor appetite. The resident was said to require supplements such as “Ensure”. The residents weight was 39 kilos. These assessments had been completed 5/1/07, and because of the identified risks, more frequent reviews should be undertaken with detailed actions on reducing/eliminating the risks. The resident’s care plan included personal hygiene; risk of falls, and reduced mobility. They also had pressure sores to their sacrum and left heel. The hospital discharge letter referred to the presence of MRSA, although the inspector was unable to ascertain if this was still the case. The care plan reflected mainly physical health problems with an additional care plan provided from Bromley PCT. There was a separate wound care plan for the sores. This resident was on a fluid balance chart. The fluid charts were in operation as there were concerns regarding their nutrition and hydration status. These charts were incomplete with no entries after 18.00- 18.30 – nil recorded Elmwood DS0000066220.V332301.R01.S.doc Version 5.2 Page 12 overnight. The daily input was less than the recommended daily intake, with totals of 800 mls recorded. The running total on one chart was incorrect. The turn charts were also not completed, headed up with the resident’s first name only, and on the sheet dated 10/1/07, there were no entries recorded. Another resident’s turn chart was inspected. They too were on such a chart as there were concerns regarding their skin integrity. On these charts some basic information was incomplete for example the resident’s full name, date etc. On several charts there were no entries after 18.00- 18.30 – nil recorded overnight. The lack of entries particularly by night staff was apparent on several charts including fluid intake. The Manager is reminded that all residents admitted to the home, including those to the intermediate care unit, must have been assessed to confirm that their needs can be addressed within Elmwood. The Manager has the responsibility to refuse admission to any one whom the home cannot fully meet the assessed needs. Part of the medication administration for the lunch time medications was observed .The practice was correct, checking the medication against the prescription chart, then administering the medications and therafter signing the chart .On the medication charts the resident’s photograph was in place. Medications were checked in and signed. Those medications, which were hand transcribed, need two signatures to confirm the accuracy of the recording. Those medications which are to be administered “as required “need to have full instructions recorded to include, the maximum dose, frequency and reason for the administration of the medication. As noted on previous inspections, the medication rooms are small, and on the day of the inspection the room was particularly congested as the new monthly supply of medication had arrived as well as several boxes of drink supplements. The sharps bin needs to be dated on opening. In bedroom 21 there was a bottle of Lactulose easily accessible although there was a lockable cabinet within the bedroom. All medications must be stored securely. A tablet counter had been obtained for the handling of the controlled drugs during checking procedures. Please see requirements 2 and 3. Please see recommendation 1. Elmwood DS0000066220.V332301.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this. It was evident that there were choices in the resident’s day as far as possible, however more attention to residents needs must be addressed to ensure that they receive the best care service. EVIDENCE: The inspector met with one resident on the ground floor. They had been in the home for four weeks. They said they were quite comfortable and generally staff were good although some could be ” stern”. The resident was sitting in a wheelchair although they did not complain nor was he uncomfortable about this. The resident was waiting for staff to give him a shave the inspector noticed that his fingernails also needed attention. Residents were seen to spend time either in their own bedrooms or the communal areas. In bedroom 6 the resident was watching TV and knitting which they said they enjoyed doing. Elmwood DS0000066220.V332301.R01.S.doc Version 5.2 Page 14 On the three floors in the home, the menus displayed, indicated different weeks of the four-week cycle. This could be confusing to the residents. Variable comments were received in respect of the food in the home some positive some not so good. The dining room on the second floor was set up for lunch. There was a bowl of fruit on the unit. Dining tables were laid with cloths, serviettes, salt pepper and cutlery. The inspector observed lunch on this unit. There was choice of chicken pie or sausage toad, mashed /boiled potatoes and mixed vegetables were served with it. Chicken gravy was served as an accompaniment. Seven residents sat at the dining tables, one was assisted to feed whilst in her recliner chair. Two staff were serving lunch, the qualified nurse was doing the medications. There were five residents who appeared to need assistance, supervision or prompting with their meal. Juice was served with the meal. The inspector noted that there was no adapted cutlery or plate guards in use, both of which would have assisted residents to eat. Those residents requiring pureed meals, had their food items individually liquidised, this is good practice. The meal itself although of a good quality, appeared unappetizing as the food had an anaemic appearance. The inspector noted one lady whose meal was in front of her yet not eaten. At 13.15 the lunch remained uneaten and was taken away. Staff did not seem to offer an alternative meal or supplement drink. In bedroom two the inspector observed staff feeding this resident, demonstrating patience and good practice throughout the task. On the top floor there was a resident in their day clothing in bed, apart from their dress they appeared to have little other clothing on. This resident had a jug of water in the bedroom although their call bell was out of reach; there was no music or other stimulation. In the lounge, after lunch, there were fourteen residents of which nine had their eyes closed and looked drowsy. On the long term units the inspectors noted that clothing was marked with bedroom umbers. More personal means of identification should be used with resident names in their clothes. During the inspection there was a fashion show for residents. The activity organiser was observed to spend time with residents interacting and trying to engage them. Several visitors were seen to come and go through out the day. Please see recommendations 2,3 and 4. Elmwood DS0000066220.V332301.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Complaints procedures are in place although responses and action are not always addressed within the stated time frames. Residents can be generally satisfied that their complaints will be actioned. Residents may not always feel fully protected as staff had a limited working knowledge of abuse. EVIDENCE: Mission Care have a complaints procedure which is available within the home and in their Statement of Purpose. The CSCI had been asked to intervene as complaints referred to Elmwood had not been responded to. These complaints were made several months ago and include care and medication issues. These complaints had been reported in writing to senior staff although at the point at which the CSCI became involved, no response to the complainant had been received. This has since been addressed with the complainant. Another complaint, which arose out of comment card received by the CSCI, during the last key inspection, had been found to be partially substantiated by the homes own investigation. Staff with whom the inspector met, had some knowledge of adult protection and were aware that they should report it, although had limited knowledge in relation to external sources of reporting and or the interagency guidance. Training in this topic is provided during induction although on going training to reiterate procedures should be undertaken. Staff need to be familiar with adult Elmwood DS0000066220.V332301.R01.S.doc Version 5.2 Page 16 protection procedures and whistle blowing procedures in order that they can take the appropriate action. Please see requirement 4 and 9. Elmwood DS0000066220.V332301.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area adequate. This judgement has been made using available evidence including a visit to this service. This purpose built facility provides residents’ a good standard of individual bedroom accommodation although storage space is limited. Staff need to pay more attention to detail in the units to ensure they are well maintained and safe. The lack of storage space impacts on the rest of the home as other areas are used as such, and this then distracts from a homely environment. EVIDENCE: Elmwood is a purpose-built facility providing accommodation for up to sixtyseven residents in the category of older persons. It is located over three floors with a large reception area on the ground floor. The Manager’s office is also located in this area. There are additional facilities by way of a cinema and coffee lounge on the first and second floor. Each floor has a dedicated dining/sitting area. Elmwood DS0000066220.V332301.R01.S.doc Version 5.2 Page 18 The inspectors undertook a tour of all areas in the home. There was evidence of personalisation of bedrooms on those floors, which accommodate long stay residents. There was evidence of call bells at hand in the majority of bedrooms, fluids although available, were not always accessible. The stairwell on the ground floor was congested and looked as though it were being used as an office. This could be a potential fire hazard. The first floor bathroom was particularly congested with items of equipment namely a bed table, linen skips, a large box of clothes and a wheelchair. The lack of storage space was evident throughout the home, this Colin Bloom advised, was due to be reviewed as was the clinical rooms. The inspectors noted that throughout the building several radiator guards were loose and detached. On questioning this it was stated that this was the design to allow easy access to the radiator itself. They could be easily reattached; the handy man was addressing this. Portable fans were available in communal and bedroom areas. These should have supporting risk assessment documentation in place to ensure they are safe for use in resident areas. On the intermediate care floor the radio and the TV were both playing, this made communication difficult even for those who were fully hearing. Newspapers and magazines were available. Please see requirement 8. Elmwood DS0000066220.V332301.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are provided in sufficient numbers to address residents needs. Training has improved and supervision has been introduced to provide better support and guidance for staff to ensure that resident’s needs are met. EVIDENCE: It was evident to the inspector that since the last inspection that recruitment, induction and on going training had improved. On each of the floors there were two qualified nursing staff and care assistants. The inspector had received information relating to a shortage of staff on the night shift. Betty Burnett explained that there had been one night when there had been a shortage, however this was not a long term problem and this was now resolved. It had been a one off episode. In addition to the nursing and care staff on duty there was a number of ancillary staff including the gardener and the handy man. On the intermediate care floor, there were 21 residents on site. There were two qualified staff including Betty Burnett, they were supported by four care staff, Betty Burnett was also the person in charge of the home and is the acting Manager. Elmwood DS0000066220.V332301.R01.S.doc Version 5.2 Page 20 The inspectors met with staff throughout the course of the inspection. Two of the newest recruited staff met with the inspector and thereafter their personnel files were inspected. The staff member had been working for an agency prior to starting with Mission Care. They confirmed that they had received a threeweek induction, which had covered resident’s needs, orientation to the building and some of the policies and procedures. The first staff member stated that they had received fire training manual handling and infection control. They had a basic knowledge of infection control referring to appropriate use of protective clothing and hand washing. The staff member had some knowledge in respect of adult protection procedures and was aware of the need to report it. A second employee was interviewed. They too confirmed induction, which included fire procedures, manual handling and infection control. The staff member had a limited knowledge of adult protection procedures and this needs to be supplemented with further training /guidance. The staff member was unable to confirm that they had received supervision and did not seem to understand the term. These two employees personnel files, along with two qualified nurses were selected for inspection. The personnel files contained confirmation of CRB clearance, identity checks, occupational health clearance, references and interview notes. Training certificates were located within these files. Evidence of training in customer care, COSHH, an introduction to Dementia, equality and diversity were some of the certificates seen. In one file, the references were not obtained from the employees’ last post in care. Regardless of how long it has been since the last employment in care a reference must be sought from this employment. All references must be on headed paper or have the company stamp as confirmation of their authenticity. The file of the qualified staff member was inspected; they had been in post for some time. In this file, confirmation of their NMC pin number was included as well as CRB confirmation identity checks, National insurance documentation passport and the birth certificate. This file contained a number of training certificates covering both statutory training and those pertaining to residents needs. Supervision was being developed. Standard supervision forms are used with a copy of the actual supervision notes issued to the employee. Elmwood DS0000066220.V332301.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area adequate. This judgement has been made using available evidence including a visit to this service. The home is under temporary management arrangements at present .The management and administration structures in the home are improving but they need to demonstrate a sustained improvement over a period of time. The lack of a Registered Manager does not ensure that residents can feel that the home is managed competently or in their best interests. EVIDENCE: The home has been without a permanent Manager for some time. Since the departure of the permanent Manager there have been two occasions where temporary staff have filled the position. Elmwood DS0000066220.V332301.R01.S.doc Version 5.2 Page 22 Only a limited health and safety inspection was undertaken which focused mainly on the visual observations made by the inspectors. Service certificates were not inspected, as these had been inspected at the last key inspection June 2006, and this home was a new build. At that inspection there was a fixed wiring and emergency lighting certificate for the electrical installation for a period of five years. The lift was serviced the 15 May 2006. Initial fire risk assessments were done in April 2006, however an emergency response plan was required. The fire doors were requiring adjustments. Weekly fire alarm checks were in place. The CSCI require confirmation that the monthly hot water temperatures are checked and recorded, in addition the gas certificate and the emergency fire response plan needs to be forwarded Pat stickers were on the plugs to indicate annual testing. Hoists had stickers attached to indicate servicing under the LOLER. Regulations. All windows inspected were restricted. It has been documented in previous sections that health and safety measures were compromised by the lack of storage and the use of the stairwell as office space. Quality assurance measures were discussed. Colin Bloom indicated that a recent residents survey had been undertaken. The results of this need to be collated and an action plan to address any identified shortfalls provided .In addition the inspectors were advised from a resident, that they had seeked fellow residents views on the service. The home enables them to canvass these opinions. Visiting is open and Betty Burnett stated that she provides an open door system to enable anyone to share their views on the service .The inspectors have under a separate letter, dealt with the reports from the Regulation 26 visits which are received infrequently by the CSCI. The financial records of residents were not inspected. Please see requirement 5,6 and 7. Elmwood DS0000066220.V332301.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 2 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X X X 2 Elmwood DS0000066220.V332301.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 OP3 2. OP7 15 Standard Regulation 14 Requirement Timescale for action 30/04/07 The Manager must ensure that only residents in the category of registration are admitted into the home The Manager must ensure that 30/06/07 care plans are reflective of needs, kept under review and have supporting risk assessments in place. All supporting records must be fully completed. Previous timeframe for action 28/02/06. This is now outstanding. The Manager must ensure that medication records are completed with full instructions including those for PRN medications. Storage of all medications must be secure. The Manager must ensure that complaints are responded to within given timeframes and that evidence of the complaint, the investigation and the outcome are retained. 30/06/07 3. OP9 13 4. OP16 22 30/06/07 Elmwood DS0000066220.V332301.R01.S.doc Version 5.2 Page 25 5 OP38 23 6 OP31 7 OP33 8 OP19 8 26 13(4)(a) 9 OP18 13(6) The Manager must ensure that all aspects of health and safety are addressed in the home and those items requested are forwarded to the CSCI The Responsible Individual must continue to seek to recruit a permanent Manager for this facility The Responsible Individual must submit Regulation 26 reports to the CSCI arising out of the monthly unannounced visits. The Responsible Individual must identify and provide additional storage to allow residents to be able to use the bathroom safely. The Responsible Individual must ensure that all staff are fully conversant with Adult Protection policies and procedures. 30/06/07 30/09/07 30/06/07 30/06/07 30/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. OP9 2 OP12 3 4 OP15 OP15 Refer to Standard Good Practice Recommendations The Manager should ensure that all hand transcriptions have two signatures in place to confirm the accuracy of the record. The Manager should ensure that residents are treated in a dignified manner in all aspects of their care. The Manager should ensure that the correct menu is displayed and is available to all residents. The Responsible Individual should ensure that the presentation of food looks appetising both in colour and presentation. Elmwood DS0000066220.V332301.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup 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 Elmwood DS0000066220.V332301.R01.S.doc Version 5.2 Page 27 - 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!