Inspection on 08/06/07 for Elwis House, 1

This inspection was carried out on 8th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Elwis House, 1 21/08/08

Elwis House, 1 18/12/06

Elwis House, 1 18/01/06

Elwis House, 1 22/09/05

Elwis House, 1 01/11/04

Elwis House, 1 23/04/04

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 Elwis House, 1 2-8 Bell Green Lane Sydenham London SE26 5TB Lead Inspector Lorraine Pumford Unannounced Inspection 8th June 2007 10:00 Elwis House, 1 DS0000025617.V338078.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Elwis House, 1 DS0000025617.V338078.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Elwis House, 1 DS0000025617.V338078.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elwis House, 1 Address 2-8 Bell Green Lane Sydenham London SE26 5TB 0208 778 9485 0208 297 1207 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) Providence Project Paul Thomas Revely Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Elwis House, 1 DS0000025617.V338078.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for 4 people with learning disabilities of whom up to 3 may be over 65 years and up to 3 may also have a physical disability 18th December 2006 Date of last inspection Brief Description of the Service: Elwis House provides a residential service to a maximum of four people with learning disabilities and high support needs, including older people suffering from dementia. The home is run by a registered charity PLUS, which has recently been formed by the former provider ‘The Providence Project’, merging with another charity, LINC. Accommodation is provided in a purpose built ground floor home, designed to meet the needs of people using wheelchairs. All residents have their own bedroom. The area is served by public transport and has a selection of shops and a supermarket. . Elwis House, 1 DS0000025617.V338078.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector spent time in the home over a two day period. During that time the manager and staff on duty were spoken with. None of the residents the inspector met were able to communicate their views. The relatives of two residents were spoken with and their views have been incorporated into this report. Over the two visits a number of records were examined and a tour of the premises was undertaken. The provider declined to provide information in relation to the fees they are paid by the Local Authority that has placed people in Elwis House. What the service does well: What has improved since the last inspection? Elwis House, 1 DS0000025617.V338078.R01.S.doc Version 5.2 Page 6 The organisation responsible for managing the home on a day to day basis will be funding a holiday for two of the less frail people living in the house. Since the last inspection the manager has been registered with the CSCI to manage the home on a day to day basis. Since the last inspection staff ensure that cleaning materials are kept secure at all times. What they could do better: Care plans must be formulated for all residents to provide staff with guidance on how to meet residents needs. Staff must find appropriate and meaningful activities for residents to participate in and keep a record of these. Due to Residents health care needs they should be regularly weighed as part of monitoring nutritional needs and as part of the moving and handling assessments. Some issues arose in relation to the storage and recording of medication. Doors from the lounge and from one residents bedroom are ill fitting and require attention to prevent drafts. It is recommended that the provider liaise with the organisation responsible for maintaining equipment in the home to improve the response times for repairs. Staffing levels must be reviewed in the light of the increasing age and frailty of the residents accommodated. Documentation must be held in the home and available for inspection to provide evidence that sound recruitment practises are in place to safeguard residents. The provider needs to ensure that there is evidence available for inspection that safety checks are carried out on portable electrical appliances on a regular basis. Quality assurance mechanisms need to be developed to include the views of residents, relatives and other relevant stakeholders. Elwis House, 1 DS0000025617.V338078.R01.S.doc Version 5.2 Page 7 Although the provider undertakes monthly audits, copies of these reports must be forwarded to the CSCI. Correction fluid should not be used to amend legal documents. 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. Elwis House, 1 DS0000025617.V338078.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Elwis House, 1 DS0000025617.V338078.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are systems in place to assess prospective residents to the home. EVIDENCE: The four residents living at Elwis house have lived there together for a number of years. The manager stated that in the event of a new resident being admitted the provider would ensure a comprehensive assessment was undertaken. Elwis House, 1 DS0000025617.V338078.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans need to be developed to ensure staff are provided clear information on how to meet the needs of the people accommodated. The risk assessment seen identified risks and action to be taken to minimise risk to residents whilst promoting independence. EVIDENCE: Two requirements were made by the CSCI in relation to the need to develop care plans and residents reviews following the last three inspections. All records pertaining to two residents were tracked in detail and documents in relation to another residents were seen. At present information regarding residents is distributed between a number of files, however There was no evidence of care plans being formulated in relation to the health, personal care, nutrition, activities etc. discussion took place with the manager regarding Elwis House, 1 DS0000025617.V338078.R01.S.doc Version 5.2 Page 11 the format of care plans. For example a basic care plan should identify the problem/issue, set outcomes and provide staff with guidance on how to meet outcomes. Risk assessment regarding moving and handling were stored separately along with other more general risk assessments pertaining to the house. These should be part of the care plan staff work from on a daily basis. One resident had been receiving regular medical input from health care professionals regarding a pressure area that occurred during a period in hospital. Staff stated the resident had made good progress and was able to spend periods of time out of bed. Written information regarding the resident was out of date indicating he was still being cared for in bed. There was no written guidance or guidelines for staff to follow on action required by them to meet the residents needs. For example one member of staff stated when the resident was in bed she regularly turned the person and placed a pillow behind him to support his body, this was her own interpretation of what was required and discussion took place with the manager regarding the need to involve the District Nurse to formulate a care plan to provide written guidance on the appropriate course of action to be taken by all staff. There was a comprehensive written review on one file. the manager sated this has been completed by a residents social worker, however this was not dated. Discussion took place with the manager regarding the need to formulate care plans and insure reviews take place regularly so all care plans accurately reflect residents needs and meet sturtory requirements in a format that reduces the number of files and staff time. Risk assessments seen indicate staff had highlighted potential risks to residents in and outside the home and action required to minimise these risks. The moving and handling risk assessment for one person had been initially completed 2006 and a review date given of 2007. Taking into account the increasing frailty, poor health and complexity of the residents moving and handling needs more reguler reviews should be taking place. Three of the residents accommodated have profound learning disabilities as well as physical and communication difficulties. A recommendation was made at the time of the last inspection that an advocate should be sort for these residents. The manager stated that he had taken action to address this but had been told by the organisation concerned residents in Elwis house were a low priority and it would not be possible in the near future to attain advocacy support for them. Records pertaining to personal allowance were examined for two residents. Records were being maintained appropriately and the written records tallied with the amount of money being held by staff for safekeeping. Elwis House, 1 DS0000025617.V338078.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff treat residents with respect. Residents benefit from nutritious food. Finding appropriate and meaningful activities at home and in the community for residents to participate in would enhance their quality of life and well being. EVIDENCE: None of the current resident group is able to seek employment or full time education. Two requirements were made following the last CSCI inspection firstly to ascertain appropriate and meaningful activities for residents and to ensure that staff maintain an accurate record keeping track data information regarding activities undertaken by residents. Elwis House, 1 DS0000025617.V338078.R01.S.doc Version 5.2 Page 13 Three residents records were examined in relation to activities. only one person is supported to attend activities outside the home on a regular basis. The manager stated staff have been investigating the possibbility of part time adult education courses that may interest the resident. The activities record for another person indicated over a month the person had received one visitor, been personal shopping once and house shopping once. Records seen indicated that the resident enjoyed listening to music and reading his books, however failing eye sight means this is a limited option now and staff need to review and find alternative activities for him and the other residents who needs are changing. A weekly activity plan was seen for one resident, however staff stated the resident was not able to participate in the activities anymore and an alternative plan needed to be devised. One resident is currently confined to bed as his hoist is not working and staff had put on a music CD for him to listen too. Two other residents were in the lounge and an age appropriate programme was on TV. The keeping track data information record states it is to used to monitor if resident /provider goals are being met. However as there are no goals set in care plans relating to activities for resident the document is not being used effectively. The format does not give room for staff to record if activities have been enjoyed or not, which would help staff with reviews, future planning and meeting residents needs. It is recommended that that the provider reviews the current system of recording information regarding residents activities. The manager stated that a sister from a local church visits residents in the home to undertake Holy Communion. A relative expressed concern that she is often as she would wish. Discussion took possibility of the residents key worker relative and forwarding copies of reviews no longer able to visit her brother as place with the manager regarding the maintaining regular contact with the that have taken place. Another relative spoken with stated that she felt appropriate activities were provided for her sister. A recommendation was made at the time of the last inspection that residents should be given the opportunity of having at least a seven day holiday each year included in the contract price. The manger stated the placing authority had declined to fund this however PLUS had agreed to fund a holiday for two of the less frail people living in the house. The inspector observed good interaction with residents in the home, staff spoke to residents in a friendly, relaxed reassuring manner. Elwis House, 1 DS0000025617.V338078.R01.S.doc Version 5.2 Page 14 Staff maintain a record of food and drink provided to residents in their individual daily records. Elwis House, 1 DS0000025617.V338078.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents health needs are met. Residents can be assured their privacy and dignity will be met. Procdures in relation to the storage and recording of medication must be followed to protect residents and staff. EVIDENCE: All staff were seen to respect residents privacy and dignity when assisting with personal care. Records seen indicate residents receive good support from health care professionals. The District Nurse has been visiting a resident with a pressure area on a regular basis. Discussion took place with staff regarding the possibility of involving the nurse in drawing up an appropriate care plan to help provide all staff with appropriate guidance. Three of the residents living in the house are non-weight bearing. records seen in relation to the resident with the pressure area indicated he had not been Elwis House, 1 DS0000025617.V338078.R01.S.doc Version 5.2 Page 16 weighed since 2005, the manager stated that in the past the local health authority had lent the home sit on scales but this arrangement was no longer possible. Residents should be regularly weighed as part of monitoring nutritional needs and moving and handling assessments. Two cabinets are provided for the purpose of storing medication, one for current use and another for stock. The cabinet housing stock was open when the inspector arrived and although it was then locked the cabinet was again left open later in the day. The manager stated that generally MAR sheets are photocopied. It was not possible to identify who residents were from the images on the record and clear photographs should be place on each persons MAR sheet. A number of entries made were hand written by staff and discussion took place regarding the need for two members of staff to sign these entries to reduce the risk of error. One resident has been prescribed medication to relief agitation on a PRN basis, it was good to see that in the majority of instances staff had recorded the behaviour exhibited by the resident that necessitated the need for the medication to be administered. Staff stated the community pharmacist undertakes routine audits of the system. Elwis House, 1 DS0000025617.V338078.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a procedure in place to deal with any concerns brought to the providers attention. Adult protection training helps safeguard the residents living in the home. EVIDENCE: The home has a complaints procedure which was updated last year. Records seen indicate the home have received no complaints regarding the care or service provided in the home since the last inspection and the CSCI have received none. A relative spoken with stated that she was aware of the organisations complaints procedure and that when she had cause to raise concerns in the past she felt these have been addressed appropriately and to her satisfaction. Staff stated that adult protection was covered as part of the organisations induction period; staff spoken with had an understanding of the term whistle blowing and stated they felt able to speak to senior staff if they had any concerns. The manager stated that all staff receive additional annual training. Elwis House, 1 DS0000025617.V338078.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are provided with a clean homelike environment. Action must be taken to ensure that equipment essential to residents health and well being is operational. EVIDENCE: All residents are provided with a single bedroom. Bedroom were found to be individually personalised. Bedrooms are large enough to accommodate any hoists that staff need to use to assist residents. On the first visit made to the home staff stated that the hoist for one person had broken down and this had been reported to the engineer, the hoist had still not been repaired when the second visit was undertaken five days later. This could potentially affect the health of the resident as well as affecting the quality of life for the person concerned.The provider must address the issue of Elwis House, 1 DS0000025617.V338078.R01.S.doc Version 5.2 Page 19 the unsatisfactory response time with the engineer to prevent a delay of this length occurring again. One bedroom is en-suite and the home also has two toilets, two bathrooms and a shower. There is a communal kitchen/dining room, and a large separate lounge all appropriately furnished for the purpose. There are double doors leading from the lounge to the garden which have a considerable gap at the bottom of the door and daylight is clearly visible, this same problem also affects the door from one of the residents bedrooms to the garden. Staff stated it was a particular problem in the colder weather and they have to use kitchen paper etc to block up the gaps to reduce the cold draft coming through. Action is required to address this issue. All areas of the home were clean and free from unpleasant odours. Elwis House, 1 DS0000025617.V338078.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The provider must monitor staffing levels in the home to ensure that sufficient staff are employed to meet the increasing needs of people accommodated. Without written documents it is not possible for the provider to evidence that safe and sound recruitment procedures are in place to protect residents. EVIDENCE: On the first day of the inspection one member of staff was on duty alone in the house with three residents all of whom required assistance from staff in relation to moving and handling. The other member of staff on duty had taken a resident bowling. In addition to undertaking care duties staff are responsible for arranging activities, cooking, cleaning and all other domestic and administration tasks. Three of the residents now have health difficulties associated with old age and staffing levels should be reviewed to ensure that sufficient staff are on duty by Elwis House, 1 DS0000025617.V338078.R01.S.doc Version 5.2 Page 21 day and night to provide care and maintain the health, safety and well being of residents and staff in the home. The home operates a key worker system and staff spoken with were clear about their roles and responsibilities. All staff working in the home complete an induction course that complies with LDAF standards. Staff spoken with stated they were provided with good training opportunities. However the only copies of certificates seen were for the manager and a member of staff who has worked in the home a number of years. Other staff stated they had undertaken statutory training and copies of certificates had been submitted as part of their LDAF course work. There are eight members of staff working in the home two hold an NVQ2 qualification in care and two other people are currently undertaking the course. Records seen indicate that staff receive regular supervision and an annual appraisal. A requirement was made following the last two inspections in relation to recruitment of staff working in the home and the availability of records in relation to this. On the first occasion the inspector visited the home the manager was not on duty and it was therefore not possible to access this information. A second visit was made by appointment with the manager to view relevant documentation. A sample of two files was selected in relation to staff most recently employed to work in the home. The manager stated that all records in relation to recruitment in accordance with schedule 2 of the Care Home Regulations are held at head office, with the home keeping a record listing the information held for each member of staff. However schedule two states that this information must be kept in the home and available for inspection. It was therefore not possible to conclude that the provider has undertaken appropriate employment checks to safeguard residents in the home. Elwis House, 1 DS0000025617.V338078.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40,41 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The provider needs to develop quality assurance systems to monitor and improve the service provided. The responsible person must ensure that records are available in the home for inspection to indicate that appropriate health and safety checks are undertaken to protect residents and staff working in the home. EVIDENCE: Since the last inspection the manager has been registered with the CSCI. He has a number of years experience working with the resident group accommodated and is currently undertaking an NVQ 4 in care and management. Elwis House, 1 DS0000025617.V338078.R01.S.doc Version 5.2 Page 23 The manager stated that the home receives regular monthly audits from PLUS in accordance with regulation 26 of the Care Standards Act 2000. A copy of this report must be forwarded to the CSCI and to date this has not happened, this matter must be addressed. The manager stated that a resident living in another service managed by PLUS visits Elwis house on a regular basis to feed back to the management committee. However the provider does not routinely ascertain the views of the people living in the home, their representatives or other relevant stakeholders to enable them to work towards improving the service they provide. Correction fluid has been used to amend medication records and the staff rota. Discussion took place with staff regarding the fact that these are legal documents and a more appropriate way of amending records was discussed. Records seen indicates that regular checks are undertaken to the fire alarm system and staff spoken with stated they receive regular training in relation to action to be taken in the event of a fire. Only a minimal number of portable electrical appliances displayed evidence that safety checks have been carried out. Staff spoken with thought this information was retained by the electrician responsible for undertaking the task and discussion took place regarding the need for evidence to be available in the home to indicate safety checks are routinely undertaken. The manager stated that a training matrix was maintained to ensure that staff routinely receive training updates in relation to moving and handling, first aid, food hygiene and other statutory training. A requirement was made at the time of the last inspection that staff should ensure that hazardous substances remained secure at all times. on the day of the inspection all hazardous substances were being appropriately stored. Elwis House, 1 DS0000025617.V338078.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 2 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 N/A 13 2 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 2 X 2 3 X Elwis House, 1 DS0000025617.V338078.R01.S.doc Version 5.2 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(1) Requirement The registered person must after consultation with the resident or their representative prepare a written plan as to how the residents needs in respect of health and welfare are to be met. Previous timescale 15/01/07 not met The registered person must ensure that reviews of care plans give clear evidence of monitoring, evaluation, review and update of objectives. Target dates of 01/05/05, 30/04/06, 31/03/07 not met. The registered person must after consultation with the resident or their advocates make arrangements to enable them to engage in local, social and community activities. Develop a program of activities arranged by or on behalf of the care home, provide facilities for recreation DS0000025617.V338078.R01.S.doc Timescale for action 31/08/07 2 YA6 15 (1) & (2) 31/07/07 3 YA14 16(2)(m)(n) 31/08/07 Elwis House, 1 Version 5.2 Page 26 4. YA14 15,16(2) (m) & (n) including, having regard to the needs of the residents, activities in relation to recreation. Timescale of 31/03/07 not met The Registered Manager must ensure that the ‘Keeping Track’ forms are completed consistently so that the home (and the Commission) can fully assess if service users are doing enough during their week. Target date of 30/04/06, 28/02/07 not met. The registered provider must ensure that all statutory checks, to ensure suitability of staff, are conducted and inform the decision to appoint. In particular the registered provider must ensure that: - All previous work and education history is obtained and any gaps explored. - Appropriate references are consistently sought and received before applicants start work. - Existing files are reviewed. - Appropriate steps are taken to ensure that the checks are consistent with the requirements of the national minimum standards and regulations and the home’s own policy. Target date of 31/03/06 not met. The registered person must ensure that all 31/07/07 3. YA34 19 31/07/07 4. YA41 17 31/07/07 Elwis House, 1 DS0000025617.V338078.R01.S.doc Version 5.2 Page 27 5. YA39 24(1)(2) & (3) documentation required by regulation is available in the home at all times.target date not met 31/01/07. The Registered Individuals 30/06/07 must ensure that full consultation takes place with service users, their families and other stakeholders asking them how they feel about all aspects of the service they are offered. This consultation must occur at least annually and must be recorded. Target date of 31/03/06 not met. The Registered Individuals must ensure that there is an individual annual development plan in place for the home that is based on the views of service users, relatives and other stakeholders and shows how the home aims to improve in the forthcoming year. Target date of 31/03/06, not met. 30/06/07 6. YA39 24(1)(2) & (3) 7 8. YA20 YA39 13(2) 26(4)(c) Staff must ensure that 02/07/07 medication is kept secure at all times. Where the registered 31/07/07 provider is an individual but not in day-to-day charge of the home he shall visit the home in accordance with Regulation 26. The registered provider must supply a copy of the report record to be made under paragraph 4(c) to the commission. DS0000025617.V338078.R01.S.doc Version 5.2 Page 28 Elwis House, 1 9 YA24 23(2)(b) 10 YA33 18 The registered provider must ensure that the premises used as a care home are of sound construction and kept in good state of repair externally and internally. In this instance the requirement relates to the poor condition of the patio doors leading from the lounge and residents bedroom. The registered person must undertake a review of residents dependency levels to ensure that a sufficient number of staff are employed to meet the care, health, safety and well-being of the residents accommodated. 31/10/07 01/08/07 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. Refer to Standard YA6 Good Practice Recommendations It is recommended that relevant health care professionals are involved in the formation of care plans where specialist knowledge is necessary, in this instance appropriate practice to be followed in relation to caring for a person with a pressure area. It is recommended that the provider reviews and updates documentation and the format of care plans and other records pertaining to residents. It is recommended that sit on scales are made available for the non weight bearing residents to enable staff to monitor the weight of residents for the purpose of nutritional screening and moving and handling assessments. It is recommended that two members of staff sign DS0000025617.V338078.R01.S.doc Version 5.2 Page 29 2. 3. YA6 YA19 4 YA20 Elwis House, 1 5 YA29 6 YA40 handwritten entries on the MAR To minimise the risk of error. It is recommended that the provider liaises with the organisation responsible for maintaining equipment in the home regarding the unsatisfactory response time in relation to a broken down hoist. Correction fluid had been used on some records. Staff need to be reminded of the appropriate way of amending a written error. The responsible person should be able to provide evidence that appropriate safety and maintenance checks are undertaken to equipment in the home. 7 YA42 Elwis House, 1 DS0000025617.V338078.R01.S.doc Version 5.2 Page 30 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. 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