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Inspection on 18/05/05 for The Elms Care Centre

Also see our care home review for The Elms Care Centre for more information

This inspection was carried out on 18th May 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home has a group of staff who have worked there for a very long time. They know that standards have slipped over the last few years and are keen to raise them to ensure they provide the very best care possible for the residents.

What has improved since the last inspection?

The recruitment of the acting manager has given the home a much-needed increase in staff morale and has halted the loss of staff. With the recruitment of a new deputy manager, with a specialty in training, the home should now be able to go forward and improve on all aspects of care for the residents.

What the care home could do better:

A full and comprehensive pre-admission assessment must be undertaken for each prospective resident, with a letter sent to them or their family advising them of the home`s ability to meet their needs before admission. Care-plans must contain all the needs of a resident and a full risk assessment. The home`s policies and procedures for the administration of medication must be followed, especially in relation to the signing of treatment charts following the administration of a drug and to ensure the safety of the drug keys in the Oakwood unit, these must be kept with the nurse in charge at all times.Activities for the residents should take place in the building where they live and in particular for those with dementia, with staff responsible for this having the training to understand their needs, wishes and feelings. The home`s complaint`s procedure must be more widely advertised so that residents and relatives know how to use. Staff require regular training on adult protection issues and senior staff need to have a knowledge of the local protocols in place in order to alert the correct agencies if an incident should take place. To ensure the safety of residents, the promotion of care staff, to a higher grade, must be within their competency and training levels and in accordance with the company`s policies. Because of the complex needs of residents with dementia, all staff who care for these residents must receive appropriate training and updates. In addition and to promote resident`s safety, handovers by staff to the next shift in each unit must be comprehensive. It has been recommended that serious consideration be given to increase the number of hours, currently 40 per week, set aside for activities, in order that the home can meet their social and recreational needs. The requirements made in this report reflect what was found during the inspection. If these issues are addressed, the residents will benefit from a more responsive and safer service with staff better trained to meet their needs.

CARE HOMES FOR OLDER PEOPLE The Elms Care Centre Elm Drive Louth Lincs LN11 0DE Lead Inspector Sue Daniells Unannounced 18 May 2005 10:00am 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 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. The Elms Care Centre C53 C04 2554 The Elms Care Centre 227595 180505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Elms Care Centre Address Elm Drive Louth Lincs LN11 0DE 01507 350100 01507 350107 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) BetterCare Group Limited Nil at present Care Home with nursing 86 Category(ies) of Old age (OP) 43 registration, with number Dementia (DE(E)) 43 of places The Elms Care Centre C53 C04 2554 The Elms Care Centre 227595 180505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: All service users who are assessed as suffering from dementia should be placed only in bedrooms within the two dementia units in the care home. Date of last inspection February 22nd 2005 Brief Description of the Service: The Elms Care Home is set in the Lincolnshire town of Louth and was owned by the BetterCare Group Ltd, which, just prior to the inspection, on the 9th May 2005, was taken over by Four Seasons Health Care Group. The Elms Care Centre now provides accommodation in 2 buildings called the Elms and Oakwood Unit. The Elms is a 2-storey building with a lift provided to enable service users to access the first floor. The building was a converted estate property, which was fully refurbished and extended in 2002. Oakwood Unit is a single storey building set in the same grounds as the Elms. There are large gardens surrounding the home and parking is provided at the side and rear of the care home. The home’s statement of purpose states that its philosophy is “people first” as its value base for all of its services. There are local transport services, which pass the care home.The home is registered as a care home providing services for 86 male or female service users over 60 years of age. The Elms Care Centre C53 C04 2554 The Elms Care Centre 227595 180505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over one day in May 2005 with the home being visited by two inspectors. They were in the home for seven hours. During the visit, and as a result of a strategy meeting between Social Services and the Commission, one inspector undertook an adult protection investigation. A partial tour of all three units of the home took place and staff and care records were inspected. Nineteen relative/visitor comment cards were received and one from a resident. Four residents were “case tracked” – a system which looks at the needs of the resident and follows this through by talking to the resident concerned and the staff who deliver the care. Six members of staff were spoken to. A pre-inspection questionnaire was also filled in by the acting manager prior to the inspection date. What the service does well: What has improved since the last inspection? What they could do better: A full and comprehensive pre-admission assessment must be undertaken for each prospective resident, with a letter sent to them or their family advising them of the home’s ability to meet their needs before admission. Care-plans must contain all the needs of a resident and a full risk assessment. The home’s policies and procedures for the administration of medication must be followed, especially in relation to the signing of treatment charts following the administration of a drug and to ensure the safety of the drug keys in the Oakwood unit, these must be kept with the nurse in charge at all times. The Elms Care Centre C53 C04 2554 The Elms Care Centre 227595 180505 Stage 4.doc Version 1.30 Page 6 Activities for the residents should take place in the building where they live and in particular for those with dementia, with staff responsible for this having the training to understand their needs, wishes and feelings. The home’s complaint’s procedure must be more widely advertised so that residents and relatives know how to use. Staff require regular training on adult protection issues and senior staff need to have a knowledge of the local protocols in place in order to alert the correct agencies if an incident should take place. To ensure the safety of residents, the promotion of care staff, to a higher grade, must be within their competency and training levels and in accordance with the company’s policies. Because of the complex needs of residents with dementia, all staff who care for these residents must receive appropriate training and updates. In addition and to promote resident’s safety, handovers by staff to the next shift in each unit must be comprehensive. It has been recommended that serious consideration be given to increase the number of hours, currently 40 per week, set aside for activities, in order that the home can meet their social and recreational needs. The requirements made in this report reflect what was found during the inspection. If these issues are addressed, the residents will benefit from a more responsive and safer service with staff better trained to meet their needs. 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 Elms Care Centre C53 C04 2554 The Elms Care Centre 227595 180505 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection The Elms Care Centre C53 C04 2554 The Elms Care Centre 227595 180505 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 and 4. The home does not currently undertake intermedicate care and therefore Standard 6 does not apply to the home. Pre-admission assessments, although undertaken, are not comprehensive in content, which may put the resident at risk. Before admission, letters to prospective residents or their families are not sent to advise them that the home can or cannot meet their current needs. EVIDENCE: Of the two pre-admission assessments examined during the inspection, both had completed forms for the aspects of daily living, for example, eating, dressing, communication, etc in evidence, although there was no evidence of the home’s own pre-admission assessment documentation available. This puts residents at possible risk owing to the fact that a comprehensive assessment must be made in order that the home can advise prospective residents or their relatives that the home can or cannot meet their needs. Currently, the home does not inform families or their relatives in writing that the home can meet their needs. The Elms Care Centre C53 C04 2554 The Elms Care Centre 227595 180505 Stage 4.doc Version 1.30 Page 9 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 standard(s) 7, 9,and 10 The care-planning process is comprehensive, although risk assessments must be done more thoroughly in order to prevent possible harm to residents. The administration and correct storage of medication requires attention to ensure that residents are not at risk. Staff are aware of the importance of protecting residents privacy and dignity. EVIDENCE: Four care-plans were examined during the inspection and all were seen to be comprehensive in their content and included moving and handling, risk assessments, nutritional scores and tissue viability scores although no weight had been recorded in one plan on the resident’s admission. Photographs were also in evidence to aid identification. However, one care plan did not have a risk assessment in place for the use of bed rails, which puts the resident at potential risk from harm. Reviews of all plans had been carried out on a monthly basis and plans had been drawn up with input from either the resident or their representative. The Elms Care Centre C53 C04 2554 The Elms Care Centre 227595 180505 Stage 4.doc Version 1.30 Page 10 “Boots” is used by the home for the dispensing of medication and their community pharmacist undertakes visits on a regular basis. Drugs are dispensed in “blister packs” using their monitored dosage system. Only qualified nurses or senior carers who have undertaken a course on medication are able to dispense the drugs. Medication trolleys are attached to a wall when not in use. Controlled drugs were checked and found to correspond to the balance shown in the Controlled Drug register and photographs are placed on each drug sheet to aid identification. On looking at the drug charts it was found that a signature was missing from one and the date of opening eye drops for one resident was missing. As it was not known when the drops were opened for use and 28 days could have elapsed since then, the drops were discarded. It was also found on the Oakwood unit that the drug keys were not always kept with the nurse-in-charge of the unit; this was rectified during the visit but will be made a requirement at the end of this report. A “key-worker” system is in place in the home so that residents have the opportunity to create a good rapport with a certain member of staff on a regular basis. It was found that staff were aware of the need to provide privacy and dignity to the residents; they spoke of the need to keep curtains closed whilst the resident was washing and dressing and described how they would bed bath a resident. The majority of rooms in the home are for single occupancy and an effective call bell system is in operation throughout the home. Service user stated that their privacy and dignity were upheld. The Elms Care Centre C53 C04 2554 The Elms Care Centre 227595 180505 Stage 4.doc Version 1.30 Page 11 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 standard(s) 12 The home does not always match resident’s expectations and preferences although it is flexible to resident’s patterns of daily life. Even though activities are provided, 40 hours a week is not considered sufficient for the number and different needs of the residents within the home. EVIDENCE: Residents stated that they could get up and go to bed whenever they liked and they were able to either stay in their rooms or sit in the communal lounges during the day. Most of the residents in the Oakwood unit were in the communal areas during the inspection. Two relatives spoke of their concern over the lack of activities for the residents in the home. “more daytime activities would benefit the residents” and “my **** is never taken anywhere in her wheelchair unless I do it……” One temporary resident stated that “I find being here totally and utterly boring” but another resident told an inspector “…….. it’s excellent here” Two members of staff are responsible for co-ordinating and organising the activities in the home; both are employed for 20 hrs per week. The inspectors were informed that they try to see all the residents every day. One of these staff also drives the minibus and takes residents to the dentist and collects The Elms Care Centre C53 C04 2554 The Elms Care Centre 227595 180505 Stage 4.doc Version 1.30 Page 12 things for the home from the town. However, it was found that the minibus had not been taxed and had therefore not been used for seven weeks. One carer in the Oakwood unit stated that the residents spent most of the time asleep and that they have to go over to the Elms unit for musical exercises, hairdressing and to access the external entertainers who visit the home: this means residents having to go outside of the buildings. One of the activity staff spends most of her time on the Oakwood unit but neither of the staff responsible for providing activities has had any training on the needs or abilities of people with dementia. Activities offered include cards, dominoes, and noughts and crosses as well as board and ball games and hand massages. However, both of these staff felt that carers should also get involved in the activities too. There is a large print library of books available and Holy Communion is offered to the residents once a month. The Elms Care Centre C53 C04 2554 The Elms Care Centre 227595 180505 Stage 4.doc Version 1.30 Page 13 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 standard(s) 16 and 18 The home does not ensure that all the residents and their relatives are aware of the complaints procedure and know how to use it. Although there are procedures in place for dealing with adult abuse, senior members of staff may not be aware of their responsibilities. EVIDENCE: The home has a complaints policy and procedure and discussion with staff found that they would encourage and assist them if they wished to make a complaint. A complaints book detailing the nature of the complaint, the investigation and the outcome was available in the home. Staff spoken to said that they would try and resolve any minor problems before it was made an official complaint. Twelve residents and/or relatives comment cards stated that they were not aware of the complaints procedure and one stated that missing items of laundry was something that was always being complained about. It was found that all staff members had received adult abuse awareness training in 2004. and staff spoken to were aware of the different forms of abuse. Staff said that they would report it immediately to the manager. The Commission had received a report of alleged abuse by a member of care staff at the end of March 2005 but there had been a delay in notifying Social Services because of the acting manager being on annual leave at the time. The police had been notified and investigated the matter. It had been found that no criminal act had taken place and during the inspection the complainant and the person who had been accused of the incident were spoken to. During the The Elms Care Centre C53 C04 2554 The Elms Care Centre 227595 180505 Stage 4.doc Version 1.30 Page 14 discussions it was found that there had been a personal issue between the two members of staff. No evidence was found to uphold the allegation and therefore the matter was closed and the verdict inconclusive. The Elms Care Centre C53 C04 2554 The Elms Care Centre 227595 180505 Stage 4.doc Version 1.30 Page 15 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 standard(s) 26 The home has infection control procedures in place and is kept clean and pleasant by a dedicated team of cleaners. However more care needs to be taken over the returning of clean clothes. EVIDENCE: The inspectors spent time in both of the buildings during the inspection. The cleaning for the centre is contracted out to a firm specialising in this type of work. The cleaners work in two teams, one for the Elms unit and the other for the Oakwood unit, both teams working in the mornings between the hours of 0830 hrs and 1330 hrs. The teams were seen to be well organised and they had a good rapport with both the carers and the residents. On the day of inspection all communal rooms appeared clean and pleasant as did the resident’ rooms that were visited. Residents were complimentary of the cleaning in the home and could find no fault. The Elms Care Centre C53 C04 2554 The Elms Care Centre 227595 180505 Stage 4.doc Version 1.30 Page 16 Infection control policies and procedures are in place to ensure that residents are not at risk. The laundry facilities are suitable for a large home with commercial machines used for both washing and drying linen and clothes. Washing machines have a “sluice” wash available for any soiled articles. As has been mentioned previously, it appears that items of clothes do get “lost” in the system which causes distress to the residents or their families. The Elms Care Centre C53 C04 2554 The Elms Care Centre 227595 180505 Stage 4.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 and 30. Staffing levels are sufficient to meet the current needs of the residents but this will have to be monitored closely as occupancy levels rise. Recruitment policies are in place to protect the residents. In the recent past staff have been promoted beyond their level of competency, however training has been given a much higher profile than in the recent past so that staff have the knowledge to care for the residents in a safe way. EVIDENCE: Occupancy at the time of the inspection was 62; 40 in the main house and 22 in Oakwood. Duty rotas showed that the home is staffed in three distinct areas: Elms main house with residents requiring nursing or personal care, Elms annexe for residents with dementia requiring personal care only and the Oakwood unit, for residents with dementia in need of nursing care. A total of 9 staff (2 nurses and 7 carers) are on duty in The Elms during the morning falling to 7 in the afternoon. At night this falls to I nurse and 3 carers. Oakwood has 2 nurses and 3 carers all day and 1 nurse and 1 carer at night. During recent months, several staff had left the home, however a new acting manager is in place and this has stopped. The home has also recently stopped using a large amount of agency staff and has its own “bank” staff (staff who work on an irregular basis, dependent upon the needs of the home) who are available to cover shifts when necessary. The Elms Care Centre C53 C04 2554 The Elms Care Centre 227595 180505 Stage 4.doc Version 1.30 Page 18 The residents spoken to during the inspection were complimentary of the staff with comments such as “they look after me well” and “I couldn’t wish for anything better” being made. One resident commented that “ some are not warm, sympathetic or friendly” The comment cards received from residents and relatives indicated that 9 felt there were enough staff on duty and 11 said that sometimes there wasn’t. One relative commented that they did not see staff when they visited. Staff felt that there were enough of them to meet the resident’s current needs. There is some concern that some members of care staff have been promoted to more senior positions but have not met the criteria laid down by the company; one carer had been promoted to that of senior carer but had not achieved National Vocational Training (NVQ) Level 3 in care. Recruitment policies and procedures were in evidence and the files for 2 members of staff were examined during the inspection. They were found to be complete, in that all the information needed to meet the Regulations for the recruitment of staff were found to be present including enhanced criminal records bureau checks. It was found through discussion with staff that training had improved since the new acting manager had been in post and more was planned. National Vocational Training levels 2 and 3 in care had also been planned and staff thought that the new acting manager had improved the care that the residents received. A new deputy manager started on May 23rd; who has responsibility for all training needs. The Elms Care Centre C53 C04 2554 The Elms Care Centre 227595 180505 Stage 4.doc Version 1.30 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 and 35 The home’s management has improved quite dramatically since the last inspection although improved hand-over times in the Oakwood Unit would benefit the staff and residents alike. The home has a robust process for taking care of any resident’s monies, which can be audited. EVIDENCE: The acting manager has been in post since the end of January 2005 and has already made an impact upon the way the home is run and on the morale of staff. Two members of staff commented that staff morale had improved but acknowledged that this could improve more. Another staff member said that the management had improved and the home was getting back to the way it was a number of years ago. One member of staff stated that “I am happy, we work as a team. Recruitment has improved and we have supervision every two months now” The Elms Care Centre C53 C04 2554 The Elms Care Centre 227595 180505 Stage 4.doc Version 1.30 Page 20 Another member of staff said that they would prefer it if more details about new residents in Oakwood could be given to them at “handover” of the shift and then they would have a better understating of their needs. It was found that the home does not look after anyone’s pension book on their behalf; it is not company policy. Amounts of money held by the home for residents were seen in a ledger. It was found that relatives of one resident owed the home in excess of £100. However, all the appropriate agencies (police, social services and pensions) are involved and aware of the situation. The monies of the other 2 residents were accurate in accordance with the ledger. Resident’s personal monies are kept in one bank account with individual accounts records kept for each resident. The Elms Care Centre C53 C04 2554 The Elms Care Centre 227595 180505 Stage 4.doc Version 1.30 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 2 x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 x COMPLAINTS AND PROTECTION x x x x x x x 3 STAFFING Standard No Score 27 2 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 x 2 2 x x x x x x x The Elms Care Centre C53 C04 2554 The Elms Care Centre 227595 180505 Stage 4.doc Version 1.30 Page 22 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 3 Regulation 14 Requirement A full and comprehensive preadmission assessment must be undertaken for each prospective resident. Care plans must contain all the care needs of a resident and indicate any activity/procedure that a service user may be at risk from, for example the use of bed rails. Medication sheets must be signed immediately after the resident has taken the medication. To ensure the safety and welfare of residents, drug keys must be kept on the person in charge of a shift and not left in places in the home. Activities must be made available for all residents, with particular emphasis on those with problems associated with dementia, and according to the residents wishes and feelings The home must supply a written copy of the complaints procedure to all residents and to any person acting on their behalf, if they so wish. All members of staff must Timescale for action July 31st 2005 July 31st 2005 2. 7 14 3. 9 17 May 18th 2005 May 18th 2005 4. 9 13 5. 12 12,16, 23 September 30th 2005 6. 16 22 July 31st 2005 7. 18 13 July 31st Page 23 The Elms Care Centre C53 C04 2554 The Elms Care Centre 227595 180505 Stage 4.doc Version 1.30 8. 30 12,13, 18 9. 10. 31 31 12 12 11. 4 14 receive training on the issues relating to adult abuse on a regular basis and be aware that senior staff must put into place the Lincolnshire guidelines (February 2005) for such an incident. Staff must only be promoted within their level of competency, and in accordance with company protocols, to ensure residents safety. All staff who deal with residents with dementia must receive appropriate training. Periods of hand-over in each unit must be comprehensive in order to ensure the health, safety and welfare of staff and residents. The home must advise the prospective resident and/or their family that it can or cannot meet their needs following the preadmission assessment and before admission. 2005 August 31st 2005 July 31st 2005 July 31st 2005 July 31st 2005 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 12 Good Practice Recommendations it is recommended as good practice that activity hours available to the residents are, increased to ensure that they have their social and recreational needs catered for. The Elms Care Centre C53 C04 2554 The Elms Care Centre 227595 180505 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection Unity House, The Point Weaver Road, off Whisby Road Lincoln LN6 3QN 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 The Elms Care Centre C53 C04 2554 The Elms Care Centre 227595 180505 Stage 4.doc Version 1.30 Page 25 - 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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