Inspection on 05/10/05 for The Elms

This inspection was carried out on 5th October 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Elms 10/04/07

The Elms 04/05/06

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 05/10/05 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.V255459.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V255459.R01.S.doc Version 5.0 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 Mrs Tania Mason Care Home 13 Category(ies) of Old age, not falling within any other category registration, with number (13) of places Elms, The DS0000020887.V255459.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Females 60 years and males 65 years and above. Date of last inspection 27th April 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 thirteen older people. 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. 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. Elms, The DS0000020887.V255459.R01.S.doc Version 5.0 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 7 hours and 45 minutes. Twelve places were occupied and one bed remained vacant. The inspection included discussions with the Care Manager, staff, service users and their relatives and friends. 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 also took place with the Care Manager regarding the progress made by the home in implementing the requirements contained in the previous inspection report dated 27 April 2005. What the service does well: The Elms – care home is registered for 13 older people. The home makes every effort to provide a good standard of care to meet the individual’s assessed needs following a care plan. The home has a good key worker and supervision system in place. The home communicates well with families, friends and representatives of all service users. The “Friends of The Elms”- a committee of service users’ relatives and friends also support the home and raise funds for service users’ entertainment and leisure activities. The service users spoken with said that they are happy and enjoy living in a homely and caring place. The service users were in the lounge engaging in their daily activities and they further commented that they were comfortable and satisfied with the care provided. The atmosphere within the home was found to be relaxed, comfortable and friendly. The friendly rapport was observed between service users and staff. Meals are varied and well balanced to meet each individual’s choices, preferences and requirements. The home provides adequate accommodation, which is being maintained to a good standard. Elms, The DS0000020887.V255459.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: The Registered Providers and the Manager must ensure that the home’s Statement of Purpose and the Service Users’ Guide are finalised and provided to al service users and copies to the Commission for Social Care Inspection (CSCI). The service users’ care plans must be kept up to date and reviewed on a monthly basis. The records of social and leisure activities enjoyed by the service users must be maintained at all times and also incorporated into individual service users’ care plans. Those members of staff who as yet not received training in NVQ, safe working practice topics and safe handling of medication must do so as a matter of priority. This training would further enable staff to improve their care practices and professionalism. All members of staff must receive formal supervision at the required intervals. All the requirements pertaining to the improvements to the home’s environment, furniture, equipment and fittings, safe working systems and risk assessments must be implemented as a matter of priority in order to have safe and comfortable environment for service users and staff. The Registered providers and the Manager must take swift action to ensure that the home is Elms, The DS0000020887.V255459.R01.S.doc Version 5.0 Page 7 adequately staffed at all times, and the Quality Assurance Development plan is developed and fully implemented. The Registered Providers have been very slow in responding positively to the requirements contained in the previous inspection report. There are few more new requirements added for their appropriate action. 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.V255459.R01.S.doc Version 5.0 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.V255459.R01.S.doc Version 5.0 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, 2, 3, 4 and 6 The home has produced a final draft Statement of Purpose for the home and a Service Users’ Guide for distribution. Service users are assessed before moving into the home. They are provided with the opportunity to visit the home to assess the quality, facilities and suitability of the home before their relatives moves in. The service users receive written statement of the terms and conditions of residency. EVIDENCE: The Registered Manager stated that the home produced drafts of the Statement of Purpose for the home and the Service Users’ Guide. These both documents would be finalised by the end of October 2005, and made available to all the service users, and in suitable format, including in large print. A sample of three service users’ care plans and files were examined at the inspection. All contained evidence that the service users received the benefit of a comprehensive assessment prior to admission. The Registered Manager also carryout assessments and these details are documented on care plans, Elms, The DS0000020887.V255459.R01.S.doc Version 5.0 Page 10 which are drawn up by the senior staff with the assistance from service users and their relatives, and where appropriate other professionals. There was evidence to show that all service users have been provided with contracts/the statement of the terms and conditions of residency. The home has a good admission procedure, which is made available to all prospective service users and their relatives and/or representatives. The service users and/or their relatives can visit the home and if they indicate to the home of their choice, then the home formally inform them if it can meet the needs of the prospective service users. The home does not offer an intermediate care service. Elms, The DS0000020887.V255459.R01.S.doc Version 5.0 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 staff within the home is aware and sensitive to the needs of each and all service users and meet their needs in a professional manner. There is a clear and consistent care planning system in place, which provides the information the staff requires to meet the service users’ health and care needs. EVIDENCE: It was evidenced that all service users undergo a comprehensive assessment of their needs prior to admission to the 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. Three service users’ care plans were examined in detail and it was noted that these needed updating. It was also noted that the monthly reviews showed changes in the care needs but the care plans did not reflect this change. Therefore, the Registered Manager must ensure that the identified changes in care and health needs of service users and the proposed interventions to meet the changed care and health needs must be clearly set out so that the carers are aware what, when and how to Elms, The DS0000020887.V255459.R01.S.doc Version 5.0 Page 12 assist and care for the service users. The Registered Manager stated that al the care plans would be updated within two weeks. The daily care recording formats were also examined and it was noted that the quality and details of recording has steadily improved. The Registered Manager stated that the staff would be asked to continue to make further improvements in care recordings. The home also ensures that nutritional screening is being undertaken, including weight gain and loss records are maintained and appropriate action is taken if required. The home also maintained records of all health care checks. Case tracking demonstrated an effective review process together with the home’s ability to meet the changing needs as they occur. The service users’ health is closely monitored and appropriate medical care services are sought as and when required. 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 and al of them commented positively about their care and they felt that they have been provided with everything they need. Four service users stated that “the carers are hard working people and they look after us very well”. The Remaining four service users said “the carers are always there to help”. The service users generally felt that the home is comfortable, warm and kept neat and tidy. The Registered Manager stated that four carers including those senior carers, who are responsible for the administration and safe handling of medicines have completed their training in safe handling of medication. The remaining carers are to commence this mode of training in October 2005 through Distance Learning with Walsall College. Elms, The DS0000020887.V255459.R01.S.doc Version 5.0 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 Elms provides a good quality of care and promotes individual lifestyles for service users in residence. The service users maintain contacts where they wish with the families, friends and the local community. Service users are positively helped to exercise choice and control over their lives and daily living. Meals at The Elms are of good quality and homely type offering both choice and variety and catering for special needs. EVIDENCE: It was evidenced that the home provides an activities programme in accordance with the service users’ choices, preferences and capacities in relation to – social and leisure activities and cultural interests. However, it was noted that the records of activities enjoyed by the service users are not being recorded consistently and appropriately. The Registered Manager stated that the staff would be asked to record accurately all the activities provided and incorporated into all individual service users’ care plans. All the service users spoken to stated that they are in regular contact with their friends and family members, and spoke about their visitors’ involvement and Elms, The DS0000020887.V255459.R01.S.doc Version 5.0 Page 14 interest in their daily care matters. The visitors’ book kept in the home showed a considerable activity. The relatives of two service users stated that they visit the home at various times of the day as they wish. All the relatives and friends who spoke to the Inspector said they are given warm and friendly welcome by the staff whenever they visit. The service users also keep contacts with the local community – for example, church services, shops, pubs and park. 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. It was evidenced that the home provided a varied, wholesome and nutritious diet. The meals provided during lunchtime on the day of inspection were well received by the service users. The Registered Manager stated that the menu is changed on a regular basis and in consultation with the service users. Several service users told the Inspector that the food was very nice, tasty and well prepared. Four other service users also stated that the food was very good and offering a good variety. Cook is well trained in food safety and hygiene matters. The kitchen is well equipped and kept clean and tidy. There was adequate food stocked I the home. Elms, The DS0000020887.V255459.R01.S.doc Version 5.0 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18 The home Concerns and complaints are dealt with promptly and professionally. The service users’ legal rights are protected as appropriately. The service users are protected from abuse by the home’s policies and procedures. The arrangements for the protection of service users from abuse are satisfactory. EVIDENCE: The home has a good Complaints Procedure, which is referred to for information in the home’s Service Uses’ Guide and in the Statement of Purpose for the home. There is a system of recording concerns or complaints. It was noted that there have no complaints directed to the Commission for Social Care Inspection (CSCI). Several service users told the Inspector that their views and comments are always listened to by the Registered Manager and the senior carers. The home has a policy and procedure in place with regard to the protection of service users from all forms of abuse. The Registered Manager stated that all members of staff have been made aware of the adult abuse and protection issues through induction and supervision arrangements. It was evidenced from the staff training records that six members of staff have undertaken training in protection from abuse. The Registered Manager stated that the remaining staff also would receive this mode of training shortly. Elms, The DS0000020887.V255459.R01.S.doc Version 5.0 Page 16 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, 22, 24, 25 and 26 The general standard of environment is good providing service users with a homely place to live. The standard of cleanliness reflects the ongoing cleaning schedule, which maintains this standard throughout the home. EVIDENCE: The home offers a comfortable and well-maintained environment to all service users. The home has ample space for dining and lounge areas. Both of these areas have been redecorated and new dining furniture has been purchased. New carpet in the dining has been fitted. One of the recommendations arising from the inspection report of the Environmental Health Officer dated 11 May 2005 is still outstanding and the Registered Manager must take appropriate action to complete it as a matter of priority. It was also 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 remaining recommendations contained in the inspection report dated 15 November 2004 of the Fire Safety Officer. The car Elms, The DS0000020887.V255459.R01.S.doc Version 5.0 Page 17 park is still to be resurfaced and exterior of the premises still remains to be repainted. The damaged floor covering in the kitchen still not replaced. The home has provided suitable aids and adaptations in the home to meet the general and specific needs of all the service users. There are adequate numbers of bathrooms/showers and WCs in the home. However, the bathroom on the ground floor still remained to be repaired/replacement. The extractor fans in WCs must be repaired/replaced and maintained in working order at all times. It was evidenced that the home has undertaken a risk assessment of the premises and facilities by an Occupational Therapist and a copy of the report was made available for inspection. The Registered Providers need to provide adequate storage space for aids and equipment, including wheelchairs. The surplus or unused items of furniture and equipment must be removed from the staff room and the service users’ payphone area must be kept accessible for them at all times. There is a good standard of furniture and fittings provided in the service users ‘ bedrooms. However, the Registered Manager must ensure that suitable tables and lockable facility in a number of bedrooms must be provided. The radiators in several bedrooms and en-suite facilities must be covered appropriately and urgently in the interest of safety of the service users. The window in bedroom 11 still remained to be repainted. A net curtains needs to be provided in bedroom 2 and 11 in the interest of privacy, and the wall behind the bed in bedroom 2 in need of repainting. The overhead light in double bedroom must be repaired/replaced. The temperature in hot water outlets was tested and it was found to be above (for example 46 to 51degrees C) the required level of close to 43 degrees C. The Registered Providers must ensure that the temperature in all the hot water outlets throughout the home is maintained at the required level of close to 43 degrees C at all times and weekly tests are carried out and any defects identified must be rectified at once and appropriate records maintained at all times. During the 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. The registered Manager stated that several members of staff have completed training in infection control. The staff is also made aware through induction training of the dangers of cross-infection. Elms, The DS0000020887.V255459.R01.S.doc Version 5.0 Page 18 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 home is not adequately staffed, which could have impact on the quality of care provided and the ability of the home to meet the needs of 13 service users. The home continues to support staff to complete training. The home has good staff recruitment policies and procedures. EVIDENCE: The information provided by the Registered Manager and the available staff rotas showed that the home at present is not adequately staffed to care for 12 service users. The home currently provides one senior carer and two carers on duty throughout the day and two night carers on wakeful duty and a senior carer/assistant manager/manager on call and a cook cover seven days a week and a cleaner for five days a week. The carers are expected to cover daily laundry duties and catering duty at teatimes and cleaning duties at the week ends as well. The above staffing levels at present are minimum to meet the varying and differing needs of 12 service users. The Registered Manager’s hours are in addition to the above staffing hours and considered to be supernumerary to allow her to manage the home effectively and efficiently. The Registered Providers must ensure that adequate domestic cover (i.e. 10 hours per week) is provided at the weekends in order to allow carers to actually carryout their caring duties. Elms, The DS0000020887.V255459.R01.S.doc Version 5.0 Page 19 It was evidenced from the staff training records that three carers have completed their NVQ Level 2 training and four are currently undertaking this mode of training and the remaining members of staff would also be enrolled shortly. The Registered Manager stated that two new members of staff as yet not received the TOPSS Induction and Foundation training. The staff training records showed that several members of staff have completed training in safe working practice topics (for example, moving and handling, food hygiene, firstaid, COSHH, infection control and health and safety), and those members of staff who as yet not received this mode of training must do so as a matter of priority. It was also noted that five members of staff have undertaken some form of training in dementia care, adult protection and two carers completed training in the management of challenging behaviours. However, the Registered Providers should consider providing this specialist training to all remainder of staff as a matter of good practice. Discussion with the Registered Manager and the examination of the most recently recruited members of staff files demonstrated that thorough recruitment procedures had been followed in line with the home’s recruitment policy. Two written references and Enhanced CRB and POVA checks are being obtained before new members of staff are appointed. The Registered Manager and the Registered providers are very aware that any member of staff with criminal records would not be employed in accordance with the Department od Health Guidance issued in July 2004. Elms, The DS0000020887.V255459.R01.S.doc Version 5.0 Page 20 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 home is managed by an experienced Registered Manager, who lead a staff group with a great deal of confidence. The staff is clear of their roles and responsibilities. Good systems of communication are in place to seek views of service users and their families and friends. Money is well managed on behalf of the service uses by the Registered Manager. The staff is regularly supervised to enable them to carryout their work professionally. Health, safety and welfare of service users and staff are promoted by safe working systems put in place by the Registered Providers and the Manager. EVIDENCE: The Registered Manager is currently undertaking her NVQ Level 4 in care and management training course and hope to complete by the end of March 2006. Elms, The DS0000020887.V255459.R01.S.doc Version 5.0 Page 21 It was evidenced that the home as yet not developed an annual quality assurance development plan for the home. The Registered Manager stated that she is currently working on the implementation of this standard shortly. Monies held at the home on behalf of the service users are handled in line with the home’s policy of handling service users’ money. A sample of three service users’ money was checked and found to be satisfactory. The records of all financial transactions are appropriately maintained. It was evidenced that not all members of staff have received the required numbers of formal supervision meetings during the last twelve months. The Registered Manager stated that she has not been able to provide the required levels of staff supervision. During the Inspector’s meeting with the staff on duty, they also confirmed that they have not received regular and formal supervision at the required intervals. Accidents and fire prevention records were examined, which found to be appropriately maintained. Matters pertaining to fire safety and environmental health were found not to be fully satisfactory and all the outstanding issues from the previous inspection report still to be appropriately addressed. The new members of staff must receive TOPSS induction and foundation training; and all those members of staff who as yet not received training in safe working practices topics must do so as a matter of priority. The fire risk assessments must also be undertaken, reviewed and kept up to date. Elms, The DS0000020887.V255459.R01.S.doc Version 5.0 Page 22 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 2 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 1 3 2 2 X 2 2 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 2 X 1 Elms, The DS0000020887.V255459.R01.S.doc Version 5.0 Page 23 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 OP1 Regulation 4(1)(2) Schedule 1 5 (1)(2) Requirement The Registered Providers must provide the finalised Statement of Purpose for the home as a matter of priority. The Registered Providers must provide the finalised Service Users’ Guide and in relevant language and suitable format, including in large print for the indented residents. The Registered Manager must ensure that the service users’ care plans are kept up to date and reviewed on a monthly basis; and that appropriate action is taken to improve the quality of daily (day and night) care recordings. The Registered manager must ensure that appropriate records must be maintained of all the social and leisure activities enjoyed by the service users; and also incorporated into the individual service users’ care plans. The Registered Providers must ensure that all of the outstanding recommendations and DS0000020887.V255459.R01.S.doc Timescale for action 30/11/05 2 OP1 30/11/05 3 OP7 15 31/12/05 4 OP12 12,14 & 16 31/12/05 5 OP19 23 31/01/06 Elms, The Version 5.0 Page 24 6 OP21 23 7 OP22 23 8 OP24 16 & 23 9 OP25 13 & 23 requirements contained in the respective inspection reports dated 15 November 2004 of the Fire Safety Officer, and 11 May 2005 of the Environmental Health Officer are implemented as a matter of priority; and 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 and the window to bedroom 11 must be repainted. The Registered Providers must ensure that bathroom on the ground, which is presently unusable by the service users must be appropriately repaired or replaced as a matter of priority; and that the extractor fans in all the WCs must be repaired or replaced and maintained in working order at all times. The Registered Providers must provide adequate storage space for aids and equipment in the home and must remove from the staff room all the unused items of furniture and equipment and the service users’ payphone area must also be kept free and accessible for their use at all times. The Registered Providers must provide suitable lockable facility and tables in all the bedrooms; and that net curtains are provided in bedrooms 2 and 11 in the interest of privacy, and the wall behind the bed in bedroom 2 is appropriately repainted. The Registered Providers must ensure that suitable covers are provided for all the radiator in the home, and that the hot DS0000020887.V255459.R01.S.doc 31/01/06 31/01/06 31/01/06 31/01/06 Elms, The Version 5.0 Page 25 10 OP27 18 11 OP30 12, 13 & 18 12 OP31 9 13 OP33 24 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, and the overhead light in double bedroom must be repaired or replaced. The Registered Providers must provide adequate domestic cover (10 hours per week) at the weekend in order to allow carers to actually carryout their caring duties. The Registered Providers must ensure that all new members of staff receive the TOPSS Induction and Foundation training; and that those members of staff who as yet 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 as a matter of priority. The Registered Providers must ensure that the Registered Manager completes her NVQ Level 4 qualification in care and management by 31 March 2006. The Registered Manager and the 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 DS0000020887.V255459.R01.S.doc 15/01/06 31/01/06 31/01/06 28/02/06 Elms, The Version 5.0 Page 26 14 OP36 15 OP38 facilities provided by the home through suitable questionnaires 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 Manager must ensure that all staff receive their formal supervision at least six times a year and all records appropriately maintained. 12, 13, 17 The Registered Providers must & 23 ensure that all new members of staff must receive Induction and Foundation training and updates to meet the TOPSS specifications on all safe working practice topics; and that Fire Risk Assessments must also be undertaken, reviewed and kept updated as a matter of priority; and that all those members of staff who as yet NOT received training in moving and handling, fire safety, health and safety, first-aid, food hygiene, COSHH, and infection control must do so as a matter of priority. 31/12/05 31/01/06 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 2 Refer to Standard OP28 OP30 Good Practice Recommendations The Registered Providers are being made aware that a minimum ratio of 50 trained members of care staff NVQ Level 2 or equivalent is to be achieved by the end of 2005. The Registered Providers should consider making provision for specialist training in adult protection from abuse, DS0000020887.V255459.R01.S.doc Version 5.0 Page 27 Elms, The 3 OP9 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 not received this mode of training as a matter of good practice. Elms, The DS0000020887.V255459.R01.S.doc Version 5.0 Page 28 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. Extracts may not be used or reproduced without the express permission of CSCI Elms, The DS0000020887.V255459.R01.S.doc Version 5.0 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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