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Inspection on 22/06/06 for The Elms Nursing Home

Also see our care home review for The Elms Nursing Home for more information

This inspection was carried out on 22nd June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 provided a welcoming, open and friendly atmosphere. The home has updated its quality assurance systems and it was evident that staff are receiving a range of training and development opportunities. This was confirmed by staff training schedules and from interviews held with staff. A number of positive comments were received from residents about the care they receive which included "The staff are kind and I enjoy the activities". "The staff are kind and helpful". "I am happy living here". "This is a nice place". One individual spoken to had communication difficulties, but smiled and nodded her head indicating that she was happy. The inspector had the opportunity to speak to some relatives who expressed satisfaction with the care their relative receives which included, "The staff are brilliant and supportive they always keep me up to date with any changes in my relatives condition". Another relative stated, "The staff are approachable and welcoming".

What has improved since the last inspection?

At the previous inspection the staff toilet floor was found to be slippery and this has now been resolved. Bins with covers have been provided in these areas. The pond has been covered to make it safe and window restrictors have been repaired on the staircase that lead to Lincoln unit to provide safety.

What the care home could do better:

The inspector was informed that the present care plan system in the home is going to be changed to the standex system. However three individual care plans were sampled and were not signed by the service user or their representative. A requirement was made that residents and/or their representatives should agree and sign their care plans to ensure that they are fully involved in the care planning process. One care plan had not been reviewed and a further requirement was made that care plans should be reviewed on a regular basis to ensure that they reflect current goals and changes. During the lunchtime meal it was observed that condiments were not available and one individual showed the inspector her own bottle of salt, which she kept in her bag. It was required that condiments are made available to meet the preferences of individuals who choose to have them with their meals. The inspector was informed that a number of policies and procedures were in the process of being reviewed. The inspector noted that the local safeguarding adults and whistle blowing procedures have not been updated recently and a requirement was made that this is completed to ensure that the information is up to date and that residents are protected. During a tour of the home the carpet in one sitting room was stained and should be replaced and the dining room needs redecorating and refurbishing. A requirement was made that the homes programme for redecorating and refurbishment is made available to the Commission for Social Care Inspectionidentifying the timescales when this work is to be completed. This is to ensure that residents have pleasant and comfortable communal areas to use. Calls bells were installed in bedrooms, however two individuals were not able to access their bell when they were sitting in their chairs, which were sited too far away. One individual said, "I have to wait for staff to walk by my room when I need assistance". A requirement was made that the present call alarm system is reviewed to ensure that it meets the needs of residents and they are able to call for assistance when required. The home has still not met the previous requirement in ensuring that fifty percent of care staff have gained National Vocational qualifications. However the inspector was informed that some more staff have been registered on to the programme. A requirement was made that the timescale for completing this requirement should be provided to the Commission for Social Care Inspection. Staff personal files were sampled and some did not contain two references. A requirement was made that two references must be obtained for all new staff to ensure that residents are protected by the homes recruitment policies and procedures.

CARE HOMES FOR OLDER PEOPLE The Elms Nursing Home The Whitepost Health Care Centre Ranelagh Road Redhill Surrey RH1 6YY Lead Inspector Lisa Johnson Unannounced Inspection 22nd June 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 The Elms Nursing Home DS0000013358.V301041.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 Nursing Home DS0000013358.V301041.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Elms Nursing Home Address The Whitepost Health Care Centre Ranelagh Road Redhill Surrey RH1 6YY 01737 764664 01737 780710 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) Dr P J David Mrs S P David Margeret Candy Care Home 49 Category(ies) of Dementia - over 65 years of age (17), Old age, registration, with number not falling within any other category (44), of places Physical disability (5), Sensory Impairment over 65 years of age (1) The Elms Nursing Home DS0000013358.V301041.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Of the 49 (forty nine) persons accommodated, 44 (forty four) will be within the category (OP). Up to 17 (seventeen) may also be in the category DE(E). Only 1 (one) will be in the category SI(E). Up to 5 (five) persons may be accommodated in the (PD) category within the age range of 40-65 years. The home may offer day care providing this does not impinge on the accommodated service users. 1st November 2005 Date of last inspection Brief Description of the Service: The Elms is a registered care home providing nursing care for 49 residents. The home can accommodate up to 44 older people (over 65 years) and 5 younger adults from 40-65 years. Up to 17 residents can be accommodated with a diagnosis of Dementia. The home is situated in a residential road in Redhill and is in the same site as another home separated from The Elms by internal doors. The Elms is owned and run by the Whitepost Health Care Group who also run other similar establishments. There are parking facilities and the home is close to local shops. Public transport can be accessed within walking distance to the home. The weekly fees are from £550-£750 per week. The Elms Nursing Home DS0000013358.V301041.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes first key inspection carried out in 2006/2007.The unannounced inspection took place over nine hours and was carried out by Mrs. L Johnson A full tour of the premises was undertaken and care plans, staff files and policies and procedures were sampled. The inspector spoke to five relatives and six members of staff. The inspector spoke to four residents to gain their views on the care provided in the home and spent time with two other residents who due to communication difficulties were unable to give their views about the care and support that they receive in the home. Other information was gained from observation of residents within the home. A number of comment cards were sent to residents and relatives to obtain their views on the service provided. The responses received are included in this report. The inspector would like to thank the residents, relatives and staff for their hospitality and cooperation during this inspection. What the service does well: The home provided a welcoming, open and friendly atmosphere. The home has updated its quality assurance systems and it was evident that staff are receiving a range of training and development opportunities. This was confirmed by staff training schedules and from interviews held with staff. A number of positive comments were received from residents about the care they receive which included “The staff are kind and I enjoy the activities”. “The staff are kind and helpful”. “I am happy living here”. “This is a nice place”. One individual spoken to had communication difficulties, but smiled and nodded her head indicating that she was happy. The inspector had the opportunity to speak to some relatives who expressed satisfaction with the care their relative receives which included, “The staff are brilliant and supportive they always keep me up to date with any changes in The Elms Nursing Home DS0000013358.V301041.R01.S.doc Version 5.2 Page 6 my relatives condition”. Another relative stated, “The staff are approachable and welcoming”. What has improved since the last inspection? What they could do better: The inspector was informed that the present care plan system in the home is going to be changed to the standex system. However three individual care plans were sampled and were not signed by the service user or their representative. A requirement was made that residents and/or their representatives should agree and sign their care plans to ensure that they are fully involved in the care planning process. One care plan had not been reviewed and a further requirement was made that care plans should be reviewed on a regular basis to ensure that they reflect current goals and changes. During the lunchtime meal it was observed that condiments were not available and one individual showed the inspector her own bottle of salt, which she kept in her bag. It was required that condiments are made available to meet the preferences of individuals who choose to have them with their meals. The inspector was informed that a number of policies and procedures were in the process of being reviewed. The inspector noted that the local safeguarding adults and whistle blowing procedures have not been updated recently and a requirement was made that this is completed to ensure that the information is up to date and that residents are protected. During a tour of the home the carpet in one sitting room was stained and should be replaced and the dining room needs redecorating and refurbishing. A requirement was made that the homes programme for redecorating and refurbishment is made available to the Commission for Social Care Inspection The Elms Nursing Home DS0000013358.V301041.R01.S.doc Version 5.2 Page 7 identifying the timescales when this work is to be completed. This is to ensure that residents have pleasant and comfortable communal areas to use. Calls bells were installed in bedrooms, however two individuals were not able to access their bell when they were sitting in their chairs, which were sited too far away. One individual said, “I have to wait for staff to walk by my room when I need assistance”. A requirement was made that the present call alarm system is reviewed to ensure that it meets the needs of residents and they are able to call for assistance when required. The home has still not met the previous requirement in ensuring that fifty percent of care staff have gained National Vocational qualifications. However the inspector was informed that some more staff have been registered on to the programme. A requirement was made that the timescale for completing this requirement should be provided to the Commission for Social Care Inspection. Staff personal files were sampled and some did not contain two references. A requirement was made that two references must be obtained for all new staff to ensure that residents are protected by the homes recruitment policies and procedures. 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 Nursing Home DS0000013358.V301041.R01.S.doc Version 5.2 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 The Elms Nursing Home DS0000013358.V301041.R01.S.doc Version 5.2 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): 2, 3 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service is able to demonstrate that pre admission assessments are completed prior to any individual moving into the home. The home does not support individuals with intermediate care. EVIDENCE: The home makes arrangements to visit prospective residents and pre admission assessments are completed and opportunities are available for individuals to visit the service. Three residents assessments were sampled one of which included an individual who had been recently admitted to the home. The assessments recorded in detail the health, personal, emotional, social and equipment requirements of the individual. There is an admission pack in place with records containing past and present details of each resident. The inspector spoke to one individual who had recently moved into the home who stated, “This is a nice place”. The Elms Nursing Home DS0000013358.V301041.R01.S.doc Version 5.2 Page 10 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 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents health and personal cate needs are met. Residents have access to a range of specialist services. Residents are protected by the homes medication policy and procedures and their privacy and dignity is respected. EVIDENCE: A key nurse whose names were displayed in bedrooms supports each resident. Three care plans were sampled including a plan for a new individual who had recently been admitted into the home. Care plans were based on full detailed including health, personal, emotional and social needs. Nutritional, pressure area, manual handling, and mobility assessments had been completed. The outcomes of these assessments were recorded in the care plan. The Waterlow assessment concluded that one individual who was at risk of developing pressure sores and had been supplied with appropriate equipment. Daily records were examined which detailed the care needs that individual’s received. The deputy manager informed the inspector that the home was in the process of introducing the standex system of care planning. The Elms Nursing Home DS0000013358.V301041.R01.S.doc Version 5.2 Page 11 There was evidence to suggest that care plans are reviewed and updated however this was not the case for one plan examined. A requirement was made that care plans are reviewed and updated to reflect any changing needs of the individual. Plans sampled were not signed by residents and a further requirement was made that residents and/or their representative should sign their individual plan to ensure that they are fully involved in the process. Where this cannot be achieved this should be recorded in the individuals plan. Residents have access to a range of specialist professionals including for example the GP who visits weekly, chiropody, physiotherapy, dietician, tissue viability, diabetic and wound care nurses. All specialist visits and consultations received were recorded and maintained in with individual’s records. During a tour of the home a number of residents were receiving personal care and residents privacy was maintained by keeping doors shut and some residents were receiving visits from their relatives who were seen visiting in private in individuals rooms. One person was involved in a care review meeting, which was being held in the conservatory to respect the individual’s confidentiality and privacy. Staff were observed to speak to residents respectfully. Two written comments received from residents confirm that their privacy is respected. The homes medication administration systems were examined and records were maintained adequately. Photographs of individuals were available with their medication card. Medicines were stored appropriately including the controlled drugs kept in the home. A homely remedies list was completed. The home has received a recent audit from the pharmacist who had made some recommendations, which were being responded to. The Elms Nursing Home DS0000013358.V301041.R01.S.doc Version 5.2 Page 12 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a range of activities, but should consider how it is meeting the needs of all individuals in the home. Residents maintain contact with their family and friends. Residents are offered a well balanced diet and residents are supported to exercise choice. EVIDENCE: An activities programme was available and was displayed on notice boards in the home. A new activities coordinator is in post and was seen to be carrying out arts and crafts and flower arranging with residents who were observed to be enjoying the activities and was positively interacting with individuals. There is an entertainment programme and the home is in the process of making arrangements for a summer barbecue. One younger person living in the home accesses the local college. The inspector spoke to the day activities coordinator who is in the process of making arrangements for some outings and activities are also provided in the garden on warm days. The coordinator was keen to expand the activities, as there are a number of individuals who are unable to attend group activities due to health issues, but time available does not always allow this, as she is the The Elms Nursing Home DS0000013358.V301041.R01.S.doc Version 5.2 Page 13 only person in post. It is strongly recommended that the individual needs of residents who are unable to attend activities are supported and this should be recorded in the activities programme and individual plan. Residents maintain links with families and friends who are able visit at any time. At the time of the inspection some individuals were seen receiving visitors in their rooms. The Friends of White post supports the home. One relative spoken to stated “ I am made to feel welcome and staff keep me up to date with any changes affecting my relative”. Two written comments received from relatives concluded that they are also made to feel welcome when visiting the home and they are able to visit their relative in private. A number of residents were seen to have personal possessions on display in their bedrooms. The inspector was informed that there are some individuals who are Roman Catholic and arrangements are in place for them to receive and have access to Holy Communion. A board was available in the dining room that recorded the staff that were on duty with the daily menu and activities for the day. There is a four weekly menu in place. The weekly menu was displayed in the home. The menu provides choices with a vegetarian option available. The inspector was informed that residents could be provided with alternatives if the menu was not to their liking and one individual had chosen to have a salad for her lunch. Residents were receiving breakfast in their rooms in the morning and the lunchtime meal was well presented and nutritious. Homemade biscuits were available for mid afternoon tea. Residents spoken to were generally happy with the meals on offer. The mealtime was relaxed with staff providing support where necessary. The inspector noted that salt and pepper was not available on the table. One resident was observed to keep a salt pot in her bag for her personal use It was required that arrangements should be made available for condiments to be in place so that residents can make choice to have these with their meals if they so wish. The Elms Nursing Home DS0000013358.V301041.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is able to demonstrate that there is complaints procedure in place and that the views of residents are listened to. Policies and procedures were in place that ensures that residents are protected from abuse. EVIDENCE: There was a complaints procedure in place and records were maintained by the home and there was evidence to suggest that complaints are followed up and responded to by the registered manager. The deputy manager informed the inspector of a recent complaint that was referred appropriately under the local authority safeguarding adult’s multi agency procedure. Some positive comments were received from residents such as “staff are kind and approachable”. One individual stated that the deputy manager “ is friendly and asks if I am alright and do I need any help”. One relative spoken to said the home is “brilliant and staff are approachable”. Two written comments received from residents confirm that they feel safe and would know who they could talk to if they had concerns about their care. Two further relative comments confirm that they are happy with the care their relative receives. The inspector was informed that the registered manager is a safeguarding adults trainer and it was clear that a number staff spoken to by the inspector have received training in safeguarding adults. One member of staff spoken to was clear in their responses as to the appropriate action they would take if they ever witnessed any abuse. A flow chart was on display in the office The Elms Nursing Home DS0000013358.V301041.R01.S.doc Version 5.2 Page 15 detailing the procedures. Policies and procedures were in place including whistle blowing, however these procedures should be reviewed and updated to ensure that they contain any changes. The Elms Nursing Home DS0000013358.V301041.R01.S.doc Version 5.2 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, 22 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Improvements are needed to ensure a comfortable, well-maintained environment for residents. The home was clean and hygienic at the time of the visit. EVIDENCE: The home is spacious and there are a number of sitting areas available including a conservatory. There was evidence of refurbishment work in progress. Some windows have been replaced and during a tour of the home there was some bedrooms that were vacant which have been redecorated and refurbished. There is a pleasant garden to the rear of the home, which is well maintained with seating and a gazebo in stalled for the use of residents to enjoy in the summer. However the carpet in the upstairs sitting room needs replacing as it was stained and the dining room requires redecoration and refurbishment. A requirement was made that the Commission for Social Care The Elms Nursing Home DS0000013358.V301041.R01.S.doc Version 5.2 Page 17 Inspection is informed of the date when this work is to be competed to ensure that residents have comfortable and pleasant communal areas to use. During the inspection the inspector was informed by a resident and relative that sometimes there is not always enough hot water and it runs out. A recommendation was made that this is monitored. The home provides a variety of aids and equipment in the home. There is an lift, grab rails were observed throughout the home and moving and handling equipment was available. The home provides call bells however these were placed next to beds and two residents informed the inspector that when they are sitting in their chairs they cannot access the bell as it does not reach if they require assistance and have to wait for staff to come by. A requirement was made that the present call bell system is reviewed to ensure that these are accessible to meet the needs of residents. During this inspection the home was found to be clean and hygienic. There were no pervading odours. Communal bathrooms and toilets were adequately provided with appropriate hand washing facilities. Hand disinfecting solution was provided in the reception for visitors to use prior to entering and leaving the home. The inspector was informed that an infection control audit has been completed. A tour of the kitchen was conducted where cleaning schedules were in place, food was stored appropriately and temperature records were appropriately maintained. The home received an inspection from environmental health earlier this year when a number of requirements were made and action has been taken to address these issues with a further follow up inspection being undertaken later in the summer. Separate laundry facilities are in place and it was clear from talking to staff and examining training schedules that staff have received training in infection control. The Elms Nursing Home DS0000013358.V301041.R01.S.doc Version 5.2 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, & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The staffing levels in the home are sufficient to meet the needs of residents and the staff were competent to do their jobs, although further training is required in National Vocational Qualifications. Improvement was needed to ensure safe and appropriate recruitment practices to protect residents. EVIDENCE: The staff rota was examined and it was concluded that that staffing levels in the home were satisfactory. There were thirty-four residents in the home and during the inspection there was two registered nurses and six carers on duty plus the deputy manager. The home also employs a day care coordinator ancillary, maintenance, administration staff and a chef. However at the previous inspection a recommendation was made that a review should take place to monitor the time that nursing and care staff are dealing with tea rounds and during this inspection this was observed not to have taken place. The inspector was informed that it could take up to an hour to provide tea. A further recommendation was made that this review is completed. The home has made some progress in responding to the previous requirement that fifty percent of staff have obtained National Qualifications (Level2). The inspector was informed that some individuals have been registered on the programme. However the original requirement remains unmet and a further requirement was made that this is achieved to ensure that residents are supported by appropriately qualified staff. The Elms Nursing Home DS0000013358.V301041.R01.S.doc Version 5.2 Page 19 Three staff files were sampled which were maintained by the human resources department. Police checks were available and the inspector was informed that new person commences employment until the enhanced police checks received. Protection of vulnerable adults (POVA) first checks are completed if anybody needs to be in post urgently. However some files contained only one reference. The inspector was informed that there are delays with referees responding. However a requirement was made that two references must be obtained to ensure that residents continue are protected by the homes recruitment policies and practices. A training schedule was in place identifying staff training and copy was supplied to the inspector. There is a coordinator in post and it was evident that training is taking place for first aid and resuscitation for the nurses with an appointed person in place. Mandatory training received included infection control, fire training, moving and handling and safeguarding adults. Other training that has been organised included mental health act, dementia awareness, Control of harmful substances (COSHH) bereavement, National Vocational Qualification induction, food hygiene, health and safety and catheterisation, nasal gastric and peg feeding. There was evidence of training certificates on staff individual files and staff interviews confirmed that that they have received a range of training and development also including nasal gastric and peg feeding. The Elms Nursing Home DS0000013358.V301041.R01.S.doc Version 5.2 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 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager has appropriate qualifications and experience to manage the home and is able to demonstrate that the home is implementing quality assurance systems. Improvement is needed in ensuring that policies and procedures are updated. The home is able to demonstrate that the financial interests of residents are protected. The health and safety of residents is protected. EVIDENCE: At the time of the inspection the registered manager was absent and arrangements had been put in place for the management of the home with a person identified in the position of acting manager. The deputy manager was in charge on the day of the inspection who was a qualified nurse and informed the inspector that he held a National vocational Qualification (Level 4 in care The Elms Nursing Home DS0000013358.V301041.R01.S.doc Version 5.2 Page 21 and management). The inspector was informed that regular team meetings are held. Staff generally felt that the line management supported them especially with training and development. The home implements quality assurance questionnaires, which had recently been sent out again. The inspector was provided a copy of the format. The manager holds weekly evening surgeries for residents and relatives to be able to raise issues and provide feedback. The home also supplies a newsletter and provides a suggestion box, which was on display in the reception. The Commission for Social Care Inspection report was displayed in the reception, however two relatives spoken to were not aware it was there and had not seen it. It was recommended that the home makes relatives aware of the report and moves the report to a more accessible position. The inspector was informed that policies and procedures are discussed at the senior team meetings with a representative from health and safety these are then cascaded through to unit meetings. A number of the policies and procedures sampled have not been updated for some time and the inspector was informed that some procedures are in the process of being reviewed. The inspector noted in particular the homes safeguarding adults and whistle blowing procedures. A requirement was made that policies and procedures should be regularly reviewed and updated in light of changing legislation and good practice Some residents manage their own finances or these are managed by relatives. The home holds small amounts of spending money for some individuals, this is usually for paying for items such as hairdressing. Monies are held in the administration office and kept in a safe. Receipts for expenditure are maintained with two staff checking. Maintenance records were sampled for hoists, water and legionella, annual maintenance testing, with gas and electrical testing completed. Health and safety appliances are checked. The Fire book was examined with weekly alarm checks being recorded. The Elms Nursing Home DS0000013358.V301041.R01.S.doc Version 5.2 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 X 3 3 X 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X 2 X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 The Elms Nursing Home DS0000013358.V301041.R01.S.doc Version 5.2 Page 23 Yes Are there any outstanding requirements from the last inspection? The Elms Nursing Home DS0000013358.V301041.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 15 (2)(a)(b) (c) Requirement a) The registered person must ensure that residents and/or their representative agree and sign their individual plan. b) Care plans must be regularly reviewed to ensure that they reflect any change in needs Two references must be available on staff files for all staff employed in the home. The accessibility of the present call alarm systems in residents bedrooms must be reviewed. a) The carpet in the sitting room must be replaced. b) The dining room on the ground floor must be redecorated and refurbished. c) A programme for the redecoration and refurbishment for the home must be supplied to the Commission for Social Care Inspection. The registered person must ensure that fifty percent of care staff have gained National Vocational Qualifications (level 2) (Previous requirement 30/8/05 not met) All policies and procedures must be reviewed and updated including the local safeguarding adult procedure. DS0000013358.V301041.R01.S.doc Timescale for action 22/08/06 2. 3 4 OP29 OP22 OP19 15 (5)(b) Scedule2 23 (2)(n) 23 (2)(d) 04/08/06 04/08/06 22/09/06 5 OP28 18(1)(a) 22/09/06 6 OP33 17(3)(a) 22/09/06 The Elms Nursing Home Version 5.2 Page 25 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 OP12 Good Practice Recommendations It is strongly recommended that the individual needs of residents who are unable to attend activities are supported and this should be recorded in the activities programme and individual plan It is recommended that condiments are made available for residents to meet the preferences of individuals. The care hours spent on undertaking tea rounds should be reviewed. 2. 3 OP15 OP27 The Elms Nursing Home DS0000013358.V301041.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Nursing Home DS0000013358.V301041.R01.S.doc Version 5.2 Page 27 - 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. 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