Inspection on 04/05/06 for The Elms

This inspection was carried out on 4th May 2006.

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 but made no statutory requirements on the home.

Other inspections for this house

The Elms 10/04/07

The Elms 05/10/05

The Elms 27/04/05

The Elms 16/11/04

The Elms 17/06/04

The Elms 23/01/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Elms, The The Elms 13 Regent Street Bilston Wolverhampton West Midlands WV14 6AH Lead Inspector Bhag Jassal Unannounced Inspection 4th May 2006 09:00 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 Elms, The DS0000020887.V290242.R01.S.doc Version 5.1 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. Elms, The DS0000020887.V290242.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Elms, The Address The Elms 13 Regent Street Bilston Wolverhampton West Midlands WV14 6AH 01902 491890 01902 491890 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) Mr Jagjit Singh Surae Mrs Charn Kaur Surae Susan Nelhams Care Home 13 Category(ies) of Old age, not falling within any other category registration, with number (13) of places Elms, The DS0000020887.V290242.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Females 60 years and males 65 years and above. Date of last inspection 5th October 2005 Brief Description of the Service: The Elms is a large detached property situated in a residential area of Bilston. The home is currently registered for 13 older people by the joint- owners Mr and Mrs Surae. There are eleven single bedrooms, four of these with en-suite facilities and one double bedroom. The home has an adequate garden and car park space at the rear of the building. There are adequate number of bathrooms/showers and WCs. There is a lounge and a dining room, which have been recently redecorated. The kitchen is fully equipped. There is a laundry room. The Home is in close proximity to all of the local amenities, which includes the health, leisure and community centres, a park, a library, shops and a market and access to public transport i.e. buses and Metro. At the time of this inspection fees for care ranged from a minimum £319.00 per week up-to a maximum of £328.00. per week. Elms, The DS0000020887.V290242.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and started at 9.00 am and lasted 8 hours. All 13 places were occupied. The inspection included discussions with the Registered Manager, Ms Susan Nelhams, staff, service users and their relatives/visitors. The daily routines were observed and service users and staff records, policies and procedures were examined. Inspection of premises both inside and outside and facilities was also undertaken. Discussion took with the Registered Manager regarding the progress made by the Home in implementing the requirements contained in the previous inspection report dated 5th October 2005. What the service does well: The Elms care home is registered for 13 older people. The Home makes every effort to provide individuals with a good standard of care to meet the assessed needs following a care plan. The Home has a good key worker system and staff supervision system in place. The home communicates well with the families/friends and representatives of the service users. The visitors’ book indicated a lot of activity. The service users spoken with said that they are happy and content with living in a homely and caring place. The service users were in lounge engaging in their daily activities and they further commented that they were comfortable and satisfied with the care provided. Four service users’ relatives also stated that they are more than happy with the care being offered by the Home. The standard of food is good with meals being varied and offering choice to accommodate individual preferences. Comments by service users and relatives included, “…My relative is very happy and well cared for.”, “ …We as a family, are very happy with the care our relative is receiving. ” The staff are always friendly and kind to us.” and “…I really enjoy the old time music…”. Overall the atmosphere within the Home was observed to be relaxed, comfortable and friendly. Friendly rapport was also observed between service users and staff. Elms, The DS0000020887.V290242.R01.S.doc Version 5.1 Page 6 The home provides a good standard of accommodation, which is being well maintained, is safe, secure and of a good standard. What has improved since the last inspection? What they could do better: The Home must continue to update the service users’ needs and risk assessments and care plans. Those members of staff who as yet have not received training in safe working practice topics, NVQ Level 2 and safe handling of medication must do so as a matter of priority. This training would enable staff to improve further their care practices and professionalism. There are several issues relating to the environment, which must be addressed as a matter of priority. The Registered Providers and the Registered Manager must take swift action to progress further the Home’s Annual Quality Assurance development plan and outcomes for the service users. Elms, The DS0000020887.V290242.R01.S.doc Version 5.1 Page 7 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. Elms, The DS0000020887.V290242.R01.S.doc Version 5.1 Page 8 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 Elms, The DS0000020887.V290242.R01.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 The quality assessment in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The Home provides clear and accurate information to prospective service users on services provided, enabling them to make a properly informed choice about the Home. The Home has a good pre-admission needs assessment procedure for both privately funded service users and those placed by the Local Authorities. EVIDENCE: The Home provides clear and accurate information to prospective service users on the services provided, in the form of a Service Users’ Guide and Statement of Purpose for the Home enabling them to make a properly informed choice about the Home. ‘Case Tracking’ involving the review of three service users’ care plans/files, (i.e. those relating to two most recently admitted service users and one other Elms, The DS0000020887.V290242.R01.S.doc Version 5.1 Page 10 selected at random), demonstrated all potential service users have their care needs assessed by the Registered Manager prior to their admission to the Home. Assessment details are documented on the service users’ care plans. The care plans are drawn up by the senior carers with the assistance from the service users, their relatives and where appropriate other professionals. The home does not provide intermediate care service. Elms, The DS0000020887.V290242.R01.S.doc Version 5.1 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 The quality assessment in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The staff within the Home are aware of and sensitive to the needs of each and all service users and meeting their needs in a professional manner. There are clear and consistent care plans in place, which provides the information the staff requires to meet the service users’ health and care needs. The storage, administration and disposal of medicines are in accordance with accepted good practice. EVIDENCE: It was evidenced that all service users undergo a comprehensive assessment of their needs prior to admission to the care home. A care plan is produced, which is based on the assessment of needs. The Home operates a key worker system, which helps to ensure that the recommendations arising from the care plans and monthly reviews are implemented. Elms, The DS0000020887.V290242.R01.S.doc Version 5.1 Page 12 Three service users’ care plans were examined in detail and it was noted that the short-term and long-term goals and appropriate interventions required to put them into action to meet the individual service users’ needs are identified. It was noted that the care plans are being reviewed on a monthly basis. The daily care recording formats were also examined and it was noted that the quality and detail of recording has steadily improved since the last inspection. The Registered Manager stated that the staff will be closely supervised and supported to make further improvements in daily care recordings. The ‘case tracking’ demonstrated an effective review process together with the Home’s ability to meet the changing needs as they occur. It was evident that the service users’ health is closely monitored and appropriate medical care services are sought as and when required. Records of all health checks are recorded on the individual service users’ care plans/files. It was observed on the day of inspection that no personal care interventions were taken in communal areas. In addition, consultation with health and social care professionals are carried out in the service users’ bedrooms. The Inspector spoke to at some length with several service users, who were able to have meaningful conversations. Four service users stated that “the carers are hard working people and they look after us very well”. The remaining three service users said “the carers are always there to help”. The service generally felt that the Home is comfortable, warm, kept neat and tidy. It was evidenced from the staff training records and from discussions with the staff and the Registered Manager that nine members of care staff have completed their training in safe handling of medication. There are four senior carers out of these nine members of staff, who are responsible for the safe handling and administration of medication to service users. It is the Home’s policy that only the senior carers would be responsible for the safe handling and administration of medication. The Registered Manager stated that the remaining carers will also receive this mode of training shortly, subject to places becoming available at the local college. It was evidenced that the medication cupboard is kept under lock and key; and that the storage, administration and disposal of medicines are in accordance with the accepted good practice and guidance. Elms, The DS0000020887.V290242.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13, 14 and 15 The quality assessment in this outcome area is good. The judgement has been made using available evidence, including a visit to this service. Social and leisure opportunities are provided, which are consistent with the service users’ preferences and capabilities. The Home facilitates achievement of desired lifestyle through service users’ conducting the pattern of their day, where possible, as they wish, including contact with family and friends, and continuation of religious practices. There is a daily choice of attractive and nutritious meals. EVIDENCE: It was evidenced that the Home now provides an activities programme in accordance with the service users’ choices, preferences and capacities in relation to social, leisure and cultural interests. The records of activities enjoyed by the service users are now being appropriately maintained. The Registered Manager stated that the staff will be asked to ensure that the activities enjoyed by the service users are appropriately incorporated into their individual care plans. Elms, The DS0000020887.V290242.R01.S.doc Version 5.1 Page 14 Individual care records, and discussions with service users, demonstrated that the service users are able to choose which of the programmed ‘events’ they wished to partake. In addition, the Inspector was shown an ‘Activities Book’, which recorded attendance/involvement by the service users. Activities include local trips, with relatives and/or staff, traditional games such as dominoes, bingo, music and dancing, entertainment by visiting musicians and singers-including old-time sing-along, which the service users informed the Inspector they particularly enjoy, musical chairs, quizzes and seasonal celebrations. Birthday celebrations for individual service users are a regular feature. All service users spoken to by the Inspector - stated that they are in regular contact with their friends and family members, and spoke about their visitors’ involvements and interest in their daily care matters. The ‘Visitors Book’ kept in the Home showed a considerable activity. The relatives of three service users stated that they visit the Home at various times of the day as they wish. All relatives and friends of who spoke to the Inspector said that they are given warm and friendly welcome by the staff whenever they visited. The service users also keep contacts with the local community- for example, church services, shops, pubs and park. There is a Committee of service users’ friends and relatives - “The Friends of The Elms”, who raise funds for leisure activities for the service users. The Registered Manager stated that the service users are positively encouraged and helped to exercise their choice and control over their lives and daily living, subject to risk assessments in terms of safety, security and capacity to make decisions. The service users and their relatives are informed of the availability pf the Advocacy Service based at the local Age Concern. The information about the Advocacy Service is included in the Home’s Service Users’ Guide. It was evidenced that the Home provided a varied, wholesome and nutritious diet. The meals provided during the lunchtime on the day of inspection were well received by the service users. It was observed that those service users who needed assistance in feeding, were assisted by staff. The Registered Manager and the cook stated that menu is changed on a regular basis and in consultation with the service users, through meetings. Several service users told the Inspector that the food was nice, tasty and well prepared. The general consensus of service users was the range, quality and choice of food provided was very good, and the Home caters for those service users who have individual preferences and/or special requirements. Elms, The DS0000020887.V290242.R01.S.doc Version 5.1 Page 15 The kitchen is well equipped and kept clean and tidy. Catering staff are well trained in food safety and hygiene matters. There was adequate stock of food in the Home. Elms, The DS0000020887.V290242.R01.S.doc Version 5.1 Page 16 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The quality assessment in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The interests of service users are protected through ready access to information relating to advocacy services and the Home’s Complaints Procedure. The home has good adult protection policies and procedures in place. Staff are aware of their role in protecting service users from abuse. EVIDENCE: The Home has a good Complaints Procedure, which is referred to for information in the Home’s Service Users’ Guide and the Statement of Purpose for the Home. There is a system/format of recording concerns or complaints. It was noted that there have been no complaints directed to the Commission for Social Care Inspection (CSCI). Several service users told the Inspector that their views and concerns are always listened to by the Manager and the senior carers. Four relatives of service users visiting the Home also told the Inspector that if they were concerned about any aspects of the care and health of their elderly relatives living at The Elms, they would expect the Manager to deal with the matter there and then. But all relatives stated that they had no occasion to raise concerns or make complaints. The manager and senior staff are very good in responding to the needs of service users. Elms, The DS0000020887.V290242.R01.S.doc Version 5.1 Page 17 There are policies and procedures in place intended to provide protection for vulnerable people. These fully meet the requirements of this Standard and staff training files confirmed the topic is covered both at induction and specific detailed training course. Elms, The DS0000020887.V290242.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 24, and 25 The quality assessment in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The Home provides a generally safe, well-maintained environment with communal rooms, and bedrooms, which are well decorated and furnishings being in good order and presenting a ‘domestic’ ambience. The garden is easily accessible at all times of the year. Specialist equipment, consistent with meeting the assessed care needs of service users and the demands of tasks carried out by care staff are provided and appropriately serviced and maintained. The cleanliness and general state of repair in the Home is good. EVIDENCE: The Home offers a comfortable and well-maintained environment to all service users. The Home has adequate communal space – one lounge and a dining room, and both of these areas have been recently redecorated, and new dining Elms, The DS0000020887.V290242.R01.S.doc Version 5.1 Page 19 furniture has been purchased. New carpet in the dining room has been fitted. The Home is safe and is suitable for its stated purpose. However, it was noted that there are still a number of areas, which the Registered Providers have failed to address by the timescales agreed by them. The Registered Providers must take appropriate action to address the following outstanding requirements from the previous inspection report: *The car park area is still to be resurfaced, *Exterior of the premises still remains to be repainted, *The damaged floor covering in the kitchen still to be replaced, *The bathroom on the ground floor still remained to be repaired/replaced, *Suitable tables and lockable facility in a number of bedrooms still to be provided, *The radiator in the WC on the first floor still remained to be suitably covered. Hot water in the service users’ bedrooms and in the communal areas are fitted with thermostatically controlled mixture valves. Hot water temperature is tested on a weekly basis and appropriate records are maintained. However, it was noted the hot water temperature in several bedrooms was below (measured between 32 Degrees C to 46 Degrees C). The Registered Providers must ensure that the temperature of hot water supply in all hot water outlets is maintained at the required level of close to 43 Degrees C at all times. The broken door to the gas boiler in the bathroom on the first floor must be repaired/replaced appropriately for the safety of service users and staff. The self-closure devices on several bedroom and inter-connecting doors must be checked on a more regular basis to ensure that they properly close to their rebates. The broken main gate to the car park and patio/garden areas must be repaired/replaced appropriately. During the day of inspection, the Home was found to be clean, tidy and free from any unpleasant odour. The Home has good policies and procedures in place regarding infection control. It was noted from the staff training records that several members of staff have completed their training in infection control. In addition, all members of staff have received induction training and they are made aware of the danger of cross-infection. Elms, The DS0000020887.V290242.R01.S.doc Version 5.1 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 The quality assessment in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Staff numbers on duty and age, ethnic and skill-mix were sufficient to meet the assessed care needs of current 13 service users. Recruitment and employment practices are consistent with safeguarding of service users. The commitment of the Home in providing training for all members of staff is satisfactory, and in accordance with individual staff member’s learning needs. EVIDENCE: The information provided by the Registered Manager and available staff rotas showed that the Home at present is adequately staffed to care for 13 service users with varying degrees of dependency levels and differing needs. The staff rotas also demonstrated that staffing numbers, ethnic make-up, and skill-mix enable a service provision, which meets the care needs of service users. Two service users who were able to have meaningful conversations stated that they have confidence in the staff that care for them. The remaining five service users spoken to were generally satisfied that the care they receive meet their needs. These service users felt that staff are trained and able to Elms, The DS0000020887.V290242.R01.S.doc Version 5.1 Page 21 deliver their care needs, and they are clear regarding their role and what is expected of them. A review of employment files of two recently appointed members of staff and a third one selected at random, provided evidence of compliance with Standard, and Schedule 2 of the Care Homes Regulations 2001. All the relevant checks i.e. CRB and POVA on staff have been carried out. An examination of training records evidenced that majority of staff having received training in safe working practice topics, for example, moving and handling, fire safety, first-aid, food hygiene, infection control and health and safety. It was noted that all staff have received induction training, and new members of staff also undergoing the Skills for Care Council’s Induction/Foundation training. Several members of staff have received training in adult protection from abuse. The Registered Manager stated that carers are being enrolled to undertake training in Dementia care. The Registered Providers should consider providing specialist training for staff in Dementia care, management of challenging behaviours, and disability awareness. A requirement, cited at the previous inspection, related to the Home working towards the target of 50 of care staff attaining a minimum of NVQ Level 2 qualification. It was noted that 6 carers out of 16 have completed their NVQ Level 2 training and the remaining 10 carers are to commence this mode of training on 8th May 2006. There are two senior carers, who have completed their NVQ Level 3 qualification. However, the Registered Providers must ensure that a minimum ratio of 50 trained members of care staff NVQ Level 2 or equivalent is provided in the Home. Elms, The DS0000020887.V290242.R01.S.doc Version 5.1 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38 The quality assessment in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The home is well managed by the Registered Manager, Susan Nelhams, and provides an ambience, which is warm, friendly, and inclusive with the key purpose being ‘the best interests of service users’. Operationally, it is well organised with lines of accountability being clearly defined and observed. The views of service users and others interested parties are sought by the Home and acted upon. Service users are safe guarded by the financial procedures operated in the Home. All staff are subject to effective support and regular supervision, and appeared involved in their work. Generally health and safety, policies and practices were satisfactory. Elms, The DS0000020887.V290242.R01.S.doc Version 5.1 Page 23 EVIDENCE: The Registered Manager, Mrs Susan Nelhams has completed her NVQ Level 4 in care and management qualification in March 2006. It was noted that Mrs Nelhams has introduced a number of changes in order to improve further the care practices and recording formats to enhance the good quality of care for the service users. The Registered Manager train and develops staff, who are competent to care for older people. The service is planned to be user focused, and the Home generally works in partnership with families of service users and other professionals. These practices were confirmed by staff and service users relatives during their meetings held with the Inspector. It was evidenced that the Home as yet not fully developed an annual quality assurance development plan for the Home. The Registered Manager stated that she has prepared draft questionnaires for service users and their relatives/friends with the view to obtaining their feedback on the services and facilities provided by The Elms. Mrs Nelhams stated that the work on implementing all the elements of this Standard has already commenced and she will complete this work by the end of July 2006. The Registered Manager assists a number of service users with their small amounts of money. There is a safe in the Home for storage of money and valuables. A sample of three service users’ money was checked and found to be satisfactory. The Registered Manager stated that the financial affairs of service users are managed by their families. It was evidenced from three staff files that all staff are supervised at the required intervals. Records of supervision meetings were examined during the inspection. The Registered Manager also holds regular meetings with staff. Accidents and fire prevention records were thoroughly examined, which were found to be appropriately maintained. Matters pertaining to fire safety and environmental health were found to be satisfactory and all the issues identified in the recent inspection reports of the Fire Safety Officer and the Environmental Health Officer have been appropriately implemented. However, the Registered Providers must ensure that all the self-closure devices on the service users’ bedrooms doors and inter-connecting doors are checked on a more regular basis to ensure that they properly close to their rebates. The temperature of all hot water outlets must be checked on weekly basis to Elms, The DS0000020887.V290242.R01.S.doc Version 5.1 Page 24 ensure that the hot water supply is maintained at all times at the required temperature level of close to 43 Degrees C. The Registered Providers must ensure that all those members of staff who as yet have not received training in safe working practice topics must do so as soon as practicable. (See NMS OP30 above). Elms, The DS0000020887.V290242.R01.S.doc Version 5.1 Page 25 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 17 X 18 3 2 X 2 X X 2 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 1 X 3 3 X 2 Elms, The DS0000020887.V290242.R01.S.doc Version 5.1 Page 26 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 Standard OP19 Regulation 23 Requirement Timescale for action 30/09/06 2 OP21 23 3 OP24 16 & 23 The Registered Providers must ensure that the car park area is resurfaced, and the exterior of the premises is repainted, and the damaged floor covering in the kitchen is appropriately replaced. The broken main gate to the car park and patio/garden areas must be repaired/replaced appropriately in the interest of safety and security of the Home and service users. The Registered Providers must 30/06/06 ensure that bathroom on the ground, which is presently unusable by the service users must be appropriately repaired or replaced; and that the extractor fans in all the WCs must be repaired and maintained in working order at all times; and that the broken door to the gas boiler/central heating system housed in the bathroom on the first floor must be repaired/replaced appropriately. The Registered Providers must 15/06/06 provide suitable lockable facility and tables in several bedrooms. DS0000020887.V290242.R01.S.doc Version 5.1 Elms, The Page 27 4 OP25 13 & 23 The Registered Providers must ensure that suitable cover is provided for the radiator in the WC on the first floor, and that the hot water temperature in all the hot water outlets must be maintained at the required level of close to 43 Degrees C at all the times and all the tests records must be maintained up to date at all the times. The Registered Providers must ensure that the self- closure devices on several service users’ bedroom doors and interconnecting doors are checked on a more regular basis to ensure that they properly close to their rebates. The Registered Providers must ensure that all those members of staff who as yet have NOT received their training in safe working practice topics (i.e. moving and handling, first-aid, food hygiene, health and safety, fire safe, COSHH and infection control) must do so. (See NMS OP38 below) 15/05/06 5 OP38 23 30/06/06 6 OP30 12, 13 & 18 09/09/06 7 OP33 24 The Registered Manager and the 31/07/06 Registered Providers must ensure that the home has an effective annual Quality Assurance development plan based on the outcomes for service users in which standards and indicators to be achieved are clearly defined and regularly monitored; and the annual quality assurance development plan is produced and fully implemented, including obtaining feedback on the services and facilities provided by the home through suitable questionnaires DS0000020887.V290242.R01.S.doc Version 5.1 Page 28 Elms, The 8 OP28 9 OP38 from the service users, their relatives and other stakeholders as appropriate, and a report is made available in the Home and to the CSCI. 18 The Registered Providers must 31/10/06 ensure that a minimum ratio of 50 trained members of care staff NVQ Level 2 or equivalent is provided in the Home. 12, 13, 17 The Registered Providers must 09/09/06 & 23 ensure that all staff receive updates to meet the Skills for Care Council’s specifications on all safe working practice topics; and that all those members of staff who as yet have NOT received training in moving and handling, fire safety, health and safety, first-aid, food hygiene, COSHH, and infection control must do so. 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 OP30 Good Practice Recommendations The Registered Providers should consider making provision for specialist training in management of challenging behaviours, dementia care, and disability awareness. The Registered Providers should consider providing training in safe handling of medication to care staff who as yet have not received this mode of training as a matter of good practice. 2 OP9 Elms, The DS0000020887.V290242.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Wolverhampton Area Office 2nd Floor St. Davids Court Union Street Wolverhampton WV1 3JE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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