Inspection on 23/02/05 for Elvy Court Nursing Home

Care Home For Older PeopleElvy Court Nursing Home204 London Road Sittingbourne Kent ME10 1QAUnannounced Inspection23rd February 2005 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Elvy Court Nursing Home Address 204 London Road, Sittingbourne, Kent, ME10 1QA Email address Name of registered provider(s)/company (if applicable) Southern Cross Healthcare Services Limited Name of registered manager (if applicable) Type of registration Care Home No. of places registered (if applicable) 57 Tel No: 01795 437449 Fax No: 01795 437450Category(ies) of registration, with (number of places) Dementia - over 65 years of age (32), Old age, not falling within any other category (25), Physical disability (8), Terminally ill (5) Registration number H060000153 Date first registered Date of latest registration certificate 19th July 2002 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspection 19th July 2002 YES NO 21/06/05 If Yes refer to Part CElvy Court Nursing HomePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 323rd February 2005 08:00 am Robert PettifordID Code105756Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionMr Keith Bartlett (Manager)Elvy Court Nursing HomePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementElvy Court Nursing HomePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Elvy Court Nursing Home. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Elvy Court Nursing HomePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Elvy Court Nursing Home is a purpose built nursing home set over two floors. The home is situated on the main A2 road with Sittingbourne town centre being approximately ¾ mile distance. A bus stop is located nearby with the nearest railway station being in the town centre. Parking is available to the front of the home. Service users are accommodated on two separate units within the home. Each unit has separate lounge and dining rooms. Specialist bathing facilities and additional specialist equipment, for example hoists, are provided. There is a garden for use by service users. The home has a full time activities coordinator. A hairdresser visits the home on a regular basis.Elvy Court Nursing HomePage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This Unannounced Inspection of Elvy Court Nursing Home place on 23rd February 2005 9:15AM ­ 3:00PM. The Inspector agreed and explained the inspection process with the manager. Documentation and records were read. A tour of premises was undertaken. The inspector spent time talking with staff and service users. The focus of the inspection was to assess Elvy Court Nursing Home House in accordance to the National Minimum Standards for Older Persons. In some instances the judgement of compliance was based solely on verbal responses given by those spoken with. As this report was made following an unannounced visit and may not cover the standards in sufficient depth for the reader to make a judgment about the home, it is recommended that a copy of the last announced inspection report be also obtained dated 21st June 2004. Positive feedback was received from service users spoken with about standards of care within the home. Choice of Home (Standards 1-6) 0 of the 6 standards assessed were met 6 not inspected Not inspected. Inspected at the Announced Inspection 21st June 2005. Health and Personal Care (Standards 7-11) 3 of the 5 standards assessed were met 2 not inspected The service users plans are generated from the assessment. The service user plans seen detailed the actions required in order to meet the service users needs. Care plan information, in the examples seen, included statements on service users disabilities and assessed needs, goals of care allocated to each need and progress or otherwise on how care needs are being met. The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. The inspector viewed the storage arrangements and some records including Medication Administration Record (MAR) sheets. The inspection of the medication brought to light several areas to be reviewed. Daily Life and Social Activities (Standards 12-15) Elvy Court Nursing Home Page 6 0 of the 4 standards assessed were met 4 not inspected Not inspected. Inspected at the Announced Inspection 21st June 2005. Complaints and Protection (Standards 16-18) 2 of the 3 standards assessed were met 1 not inspected The home ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. The home ensures that service users are safeguarded from abuse. Environment (Standards 19-26) 0 of the 8 standards assessed were met 8 not inspected Not inspected. Inspected at the Announced Inspection 21st June 2005. Staffing (Standards 27-30) of the 4 standards assessed were met Not inspected. Inspected at the Announced Inspection 21st June 2005. Management and Administration (Standards 31-38) 3 of the 8 standards assessed were met 5 not inspected The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. The Manager is actively involved in the day-to-day management of the Home and works with staff and service users. Effective quality assurance and quality monitoring systems are in place.Elvy Court Nursing HomePage 7 Requirements from last Inspection visit fully actioned? If No please list belowNASTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for actionAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Met (Yes / No)Elvy Court Nursing HomePage 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action 13.--(2) The registered person shall make arrangements for the recording, handling, safe keeping, safe administration and disposal of medicines received into the care home. Regulation 17(1)(a) Schedule 3 (k) a record of all medicines kept in the care home for the service user, and the date on which they were administered to the service user; 1 13(2) OP9 Standard 9 The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 23/04/05RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. Elvy Court Nursing Home Page 9 No.Refer to Standard *Good Practice Recommendations* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.Elvy Court Nursing HomePage 10 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES NO NO YES YES NO NO NO YES NO YES NO YES YES NO NO NO YES NO YES 4 0 0 NO NO YES YES 26 10 23/02/05 9:15AM 5.5Elvy Court Nursing HomePage 11 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Elvy Court Nursing HomePage 12 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide. Range of fees charged From (£) X To (£) XAny charges for extrasYES 0If yes, please state what the extras are: Key findings/Evidence Standard met? Not inspected. Inspected at the Announced Inspection 21st June 2005.Elvy Court Nursing HomePage 13 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 0 Key findings/Evidence Standard met? st Not inspected. Inspected at the Announced Inspection 21 June 2005.Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 0 Key findings/Evidence Standard met? st Not inspected. Inspected at the Announced Inspection 21 June 2005.Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 0 Key findings/Evidence Standard met? st Not inspected. Inspected at the Announced Inspection 21 June 2005.Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 0 Key findings/Evidence Standard met? st Not inspected. Inspected at the Announced Inspection 21 June 2005.Elvy Court Nursing HomePage 14 Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable service users to return home. 0 Key findings/Evidence Standard met? Not inspected. Inspected at the Announced Inspection 21st June 2005.Elvy Court Nursing HomePage 15 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 3 Key findings/Evidence Standard met? The service users plans are generated from the assessment. The service user plans seen detailed the actions required in order to meet the service users needs. Care plan information, in the examples seen, included statements on service users disabilities and assessed needs, goals of care allocated to each need and progress or otherwise on how care needs are being met. Evidence of risk assessments was seen. Evidence of regular reviews was also noted. On care plans reviewed evidence was seen that service users who had been identified as being nutritionally vulnerable were weighed regularly. The Nurse uses an assessment tool for which evidence was seen. Staff spoken with demonstrated a sound working knowledge of the care plans. The inspector directly observed correct moving and handling techniques used by care staff.Elvy Court Nursing HomePage 16 Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) X 63 Key findings/Evidence Standard met? The manager described how service users who still have or have just recovered from pressure sores are progressing. Service users are turned every 2 hours, creams used, dressings applied and appropriate food is given to help the service user counter infection and recover. A tissue viability nurse from the Primary Care Trust also visits to provide direct input and for the purpose of staff guidance and training. Equipment that helps with the care of people with pressure sores is available. Records seen show that service users weight is taken and these are monitored. Many service users require incontinence equipment. The manager stated that staff are trained and competent in the application of this equipment. Also it was stated that the home has close contact with a continence advisor. Care plan records indicated that service users have access to dental, specialist medical, chiropody and therapeutic services. The home has a hairdressing salon. This is used on a regular basis by many of the service users.Elvy Court Nursing HomePage 17 Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 2 Key findings/Evidence Standard Met? In the medication room on the ground floor there was a locked mobile drugs cabinet (anchored to the wall when not I use), a small fridge, and three locked purpose built cupboards for medication. A locked steel cupboard for storage of schedule 1 drugs was located within one of the locked cupboards. Controlled drugs have a separate record of numbers dispensed/remaining. Service users are not treated in the medication room the individuals bedroom is used. The home works closely with the prescribing Doctor and dispensing pharmacist to ensure that medication is dealt with appropriately. Regular internal audits take place. Evidence of which was viewed by the inspector. The Home uses a Monitored Dosage System. The inspector viewed the storage arrangements and some records including Medication Administration Record (MAR) sheets. The inspection of the medication brought to light several areas to be reviewed. The home was requested to review appropriate storage for temperature sensitive medication as the ambient temperature in the medication room at time of inspection was 23 degrees C and the correct storage of the medication viewed was a max of 25 degrees C. The drugs fridge was seen to be in need of defrosting. Four large sharps bins were noted within the room. The manager is requested that these are disposed of as soon as possible and regular collections arranged in the future. Large quantities of bandages were stored within the medication room. Upon inspection the inspector requested that the expiry dates are check and that such checking forms part of the audit process. The First Aid kit in the medication room was found to be inadequate for dealing with any emergency within the home. It is requested that all First Aid kits are checked within the home, and are checked on a regular basis thereafter. The medication room did have a copy of The Royal Pharmaceutical Society of Great Britain (RPS) guidelines dated June 2003, but the homes policy on medication also found in the room was dated February 2001. Therefore it would not contain the amendments of the RPS June 2003. The manager agreed to address the issues identified as part of the homes action plan.Elvy Court Nursing HomePage 18 Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 0 Key findings/Evidence Standard met? st Not inspected. Inspected at the Announced Inspection 21 June 2005.Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 0 Key findings/Evidence Standard met? st Not inspected. Inspected at the Announced Inspection 21 June 2005.Elvy Court Nursing HomePage 19 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 0 Key findings/Evidence Standard met? st Not inspected. Inspected at the Announced Inspection 21 June 2005.Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences. 0 Key findings/Evidence Standard met? Not inspected. Inspected at the Announced Inspection 21st June 2005.Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 0 Key findings/Evidence Standard met? st Not inspected. Inspected at the Announced Inspection 21 June 2005.Elvy Court Nursing HomePage 20 Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 0 Key findings/Evidence Standard met? Not inspected. Inspected at the Announced Inspection 21st June 2005.Elvy Court Nursing HomePage 21 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days X X X X X X X 3 Key findings/Evidence Standard met? The inspector viewed a copy of the Homes complaints procedure and complaints record. The procedure included details of how to complain, timescales for response and information for referring a complaint to the Commission for Social Care Inspection. A copy of the complaints procedure has been provided and explained to service users/relatives/advocates. There was evidence that the Home had investigated and responded to the complaints and taken action to address identified issues within the timescales of the Homes procedures.Elvy Court Nursing HomePage 22 Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 0 Key findings/Evidence Standard met? st Not inspected. Inspected at the Announced Inspection 21 June 2005.Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists YES 03 Key findings/Evidence Standard met? The inspector viewed and discussed copies of the Homes Policy for the Protection of Service Users and staff Whistle blowing procedure. These include procedures for the reporting of suspicion or evidence of abuse with a format for the recording of any allegations and action to be taken. Full training is provided to all staff. The Registered Manager is aware of her obligations with regard to ensuring the safety of Service users and protecting them from abuse. The homes involvement with service users finances is limited to safekeeping small amounts of cash and providing support with minor personal expenditures such as a pub lunch or hairdressers appointment. Records were being maintained and checked.Elvy Court Nursing HomePage 23 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 0 Key findings/Evidence Standard met? st Not inspected. Inspected at the Announced Inspection 21 June 2005.Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 0 Key findings/Evidence Standard met? st Not inspected. Inspected at the Announced Inspection 21 June 2005.Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 0 Key findings/Evidence Standard met? Not inspected. Inspected at the Announced Inspection 21st June 2005.Elvy Court Nursing HomePage 24 Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 0 Key findings/Evidence Standard met? st Not inspected. Inspected at the Announced Inspection 21 June 2005.Elvy Court Nursing HomePage 25 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite NO NO NO X X X X 0 X XX X X XKey findings/Evidence Standard met? st Not inspected. Inspected at the Announced Inspection 21 June 2005.Elvy Court Nursing HomePage 26 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 0 Key findings/Evidence Standard met? Not inspected. Inspected at the Announced Inspection 21st June 2005.Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 0 Key findings/Evidence Standard met? Not inspected. Inspected at the Announced Inspection 21st June 2005.Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 0 Key findings/Evidence Standard met? st Not inspected. Inspected at the Announced Inspection 21 June 2005.Elvy Court Nursing HomePage 27 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours X X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff X X X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X XX X X 0Key findings/Evidence Standard met? Not inspected. Inspected at the Announced Inspection 21st June 2005.Elvy Court Nursing HomePage 28 Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 X X 0Key findings/Evidence Standard met? st Not inspected. Inspected at the Announced Inspection 21 June 2005.Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 0 Key findings/Evidence Standard met? st Not inspected. Inspected at the Announced Inspection 21 June 2005.Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? Not inspected. Inspected at the Announced Inspection 21st June 2005.Elvy Court Nursing HomePage 29 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 3 Key findings/Evidence Standard met? The manager has recently moved to Elvy Court from a sister home in Rochester. The manager is a qualified RMN Nurse and has been working in the care industry for 25 years. He benefits from 14 years of management experience and is currently studying for an NVQ Level IV in Management. Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? The Manager is actively involved in the day-to-day management of the Home and works with staff and service users. From observation and staff feedback the owner/manager offers a clear sense of direction and leadership, which staff and service users understand. Service users, their relatives and staff are encouraged to comment on the services the Home offers and to voice any concerns they may have.Elvy Court Nursing HomePage 30 Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 3 Key findings/Evidence Standard met? Quality Assurance methods used at the Home include: individual service user feedback, feedback from staff and residents at meetings. Other methods include supporting a good working relationship with relatives and social care professionals, key-worker reports, service user questionnaires, Regulation 26 (reports submitted by the Registered Provider Company to CSCI) visits and Inspections by external agencies Kent County Council and CSCI. Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 0 Key findings/Evidence Standard met? Not inspected. Inspected at the Announced Inspection 21st June 2005.Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders Key findings/Evidence Standard met? st Not inspected. Inspected at the Announced Inspection 21 June 2005. 0 X X XElvy Court Nursing HomePage 31 Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 0 Key findings/Evidence Standard met? Not inspected. Inspected at the Announced Inspection 21st June 2005.Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 0 Key findings/Evidence Standard met? st Not inspected. Inspected at the Announced Inspection 21 June 2005.Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 0 Key findings/Evidence Standard met? Not inspected. Inspected at the Announced Inspection 21st June 2005.Elvy Court Nursing HomePage 32 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead InspectorRobert PettifordSignatureSecond Inspector Regulation Manager Date 9/3/05Signature SignatureElvy Court Nursing HomePage 33 Public reports It should be noted that all CSCI inspection reports are public documents.Elvy Court Nursing HomePage 34 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 23rd February 2005 and any factual inaccuracies: Please limit your comments to one side of A4 if possible Providers comments available from west kent area office 01622 724950Elvy Court Nursing HomePage 35 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESNOYESNote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 6th April 2005, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESNONOOther: enter details here NOElvy Court Nursing HomePage 36 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I Mr Philip Scott of Elvy Court Nursing Home confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I Mr Philip Scott of Elvy Court Nursing Home am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Elvy Court Nursing HomePage 37 Elvy Court Nursing Home / 23rd February 2005Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000026162.V210052.R01© This report may only be used in its entirety. 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