Inspection on 25/10/07 for The Elms Nursing Home

This inspection was carried out on 25th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Elms Nursing Home 20/10/08

The Elms Nursing Home 22/06/06

The Elms Nursing Home 25/07/05

The Elms Nursing Home 25/04/05

The Elms Nursing Home 01/09/04

The Elms Nursing Home 09/06/04

Similar services:

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

The Shelley

Thorndene

Springfield House

Sutton Lodge Nursing Home

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

CARE HOMES FOR OLDER PEOPLE The Elms Nursing Home The Whitepost Health Care Centre Ranelagh Road Redhill Surrey RH1 6YY Lead Inspector Robert Pettiford Unannounced Inspection 08:50 25 October 2007 th 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.V346734.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.V346734.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 michaelfaulkner@whiteposthealthcare.co.uk 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 Michael Faulkner Care Home 49 Category(ies) of Dementia - over 65 years of age (0), Old age, registration, with number not falling within any other category (0), of places Physical disability (0) The Elms Nursing Home DS0000013358.V346734.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home nursing - (N) to residents of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - (OP) Dementia - (DE) 2. Physical disability - (PD) The maximum number of residents to be accommodated is 49. Date of last inspection 22nd June 2006 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.V346734.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Inspector agreed and explained the inspection process with the Registered Manager present during the inspection. The focus of the inspection was to assess The Elms Nursing Home in accordance with the Care Home Regulations 2001 and the National Minimum Standards for Older Persons. In some instances the judgement of compliance was based solely on verbal responses given by those spoken with. The Inspector used a varied method of gathering evidence to complete this inspection, pre-inspection information such as the previous report and discussion and correspondence with the registered provider was used in the planning process to support the inspector to explore any issues of concern and verify practice and service provision. The home had completed an annual quality assurance assessment questionnaire which was received prior the site visit to the home. This provided the Inspector with information relating to What the home considers it does well, What we could do better, What has improved within the last 12 months and plans for improvement. Survey questionnaires were sent to the home prior to the inspection. Documentation and records were read. Time was spent reading a sample of written policies and procedures, reviewing care plans and records kept within the home. Other area’s viewed included risk assessments, pre-admission assessments, menus, rota’s, training records and recruitment records. In addition a full environmental tour took place. The Inspector identified six residents for case tracking, assessing the available information held in the home pertaining to the care provision. In addition the Inspector met with the residents, which gave him a good opportunity to observe the quality of care within the home and quality of life enjoyed. What the service does well: It is evident through the inspector talking to members of staff that the emotional health of the residents is of a high priority to the home and that staff are pro-active in maintaining and supporting residents with their emotional needs in order to maintain their quality of life. The inspector visited the home at 8:50AM. During the inspection the inspector noted that residents were seen making choices about their lives and were seen to be part of the decision process where possible. A relaxed atmosphere was noted with the residents interacting with staff. The inspector also had the opportunity to speak with a few residents who expressed satisfaction with the care offered and given. The Elms Nursing Home DS0000013358.V346734.R01.S.doc Version 5.2 Page 6 Quality assurance was discussed and the views and opinions of many of the resident’s relatives sought. They confirmed a great deal of satisfaction in living within the home and felt confident that their views and opinions were valued by the staff and management. The manager confirmed that the home does undertake quality assurance by means of asking residents / relatives to complete questionnaires in addition to healthcare professionals. This enables the home to ensure it is meeting the goals that are set out in the Statement of Purpose. The home benefits from three activity coordinators working a total of 56 hours per week. Residents are encouraged to take part in a variety of activities as their interest and capacity allows. The home has sought the views of residents and considered their varied interests and abilities when arranging activities. The home employs a dedicated cook who prepares and cooks freshly food for the residents. The Inspector viewed residents eating their midday meal. From observation, records viewed and comments made by residents it was evident that residents had been offered a choice of menus that met their dietary needs and individual preferences. What has improved since the last inspection? What they could do better: Shortfalls were noted with regard to :The care plans were not regularly updated. Risk assessments additionally in some cases were not signed, dated or reviewed at sufficient intervals to ensure that the care plans were updated to manage any change in needs. Daily notes did not follow guidance issued by the United Kingdom Central Council for Nursing, Midwifery and Health Visiting in that they were not accurately timed and signed, with the signature printed alongside the first entry and not include abbreviations. The inspector viewed the storage arrangements and some records including Medication Administration Record (MAR) sheets, and the protocols for the administration of “PRN/As Required” Medication. The medication was seen to be stored appropriately, but not wholly administered in accordance to current guidance. The Elms Nursing Home DS0000013358.V346734.R01.S.doc Version 5.2 Page 7 The inspector is of the opinion that sufficient care staff were on duty to support residents with their needs for the majority of the day. However the manager was requested to review staffing to ensure sufficient staff were on duty at night to meet all of the residents needs. From documentary evidence seen the standard of staff training were adequate overall with the majority of staff completing basic courses but however at present only 25 of the care staff have achieved an NVQ (National Vocational Qualification) Level 2 or above. It was recommended that this be reviewed. The training manager was unable to currently confirm that the home has a development programme for all new staff, which meets Sector Skill’s council’s workforce training targets. It was recommended that this be reviewed. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. The Elms Nursing Home DS0000013358.V346734.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.V346734.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3,6, Quality in this outcome area is Good This judgement has been made using available evidence including a visit to this service. Residents can feel confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. Intermediate care is not provided EVIDENCE: Residents can be confident that the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. The Elms Nursing Home DS0000013358.V346734.R01.S.doc Version 5.2 Page 10 Records held showed that residents have an assessment, which identifies their individual needs prior to or on admission to the home. The information is provided by the residents, their families and health / social care professionals. The assessment focuses on achieving positive outcomes for people and this includes ensuring that the facilities, staffing and specialist services provided by the home meet needs of the individual. Before agreeing admission the service carefully considers the needs assessment for each individual prospective person and the capacity of the home to meet their needs. The assessment process recognises the importance of promoting equality and diversity rather than just meeting needs in a reactive manner, although in practice the home might be encountering difficulties and barriers in translating ideas into practice. The inspector requested that the home reviews it equalities and diversity policy and considers carrying out an equalities impact assessment. This is requested to ensure that all of the information and policies relating to residents are inclusive to all members of the community and comply with all current legislation and good practice. Intermediate care is not provided. The Elms Nursing Home DS0000013358.V346734.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents benefit overall from having individual plans that identify their physical and medical needs, but not enough detail was given to ensuring that plans of care and risk assessments are regularly updated and reviewed. Residents can feel confident that they are fully supported with their healthcare needs. Residents cannot feel confident that their wellbeing will be protected by the home’s policy and procedures with regard to the handling and administration of medication. Residents can be confident that they will be treated with respect and dignity and their rights to make decisions about their lives and are respected as they wish or their capacity allows. EVIDENCE: The Elms Nursing Home DS0000013358.V346734.R01.S.doc Version 5.2 Page 12 The inspector viewed and discussed with the manager the care records relating to six residents at the home. In the care plans viewed there was sufficient detail and guidelines in respect of the support needed to meet their needs. The care plans were not however regularly updated. Risk assessments additionally in some cases were not signed, dated or reviewed at sufficient intervals to ensure that the care plans were updated to manage any change in needs. Daily notes did not follow guidance issued by the United Kingdom Central Council for Nursing, Midwifery and Health Visiting in that they were not accurately timed and signed, with the signature printed alongside the first entry and not include abbreviations. Whilst it was accepted through discussions with residents, and feedback from relatives they were happy with the standards of care received and generally had a high opinion of the home, the care plan documentation suggested otherwise due to lack of review. Evidence was available that residents or relatives where possible were involved in drawing up personal care plans in the documentation and that they are consulted in reviewing and amending such care plans as their capacity allows. Some of the care plans viewed were signed by a resident or a representative. However this was not the case for all care plans viewed. The inspector viewed a sample of care records and specific health care records relating to several residents. Records viewed confirmed that residents had access to a range of health care inputs as and when required. Subsequent evidence was received following the inspection that residents had access to a range of regular healthcare checks, such as opticians and chiropodists etc. The documentation seen confirmed that all residents have a Doctor and visits from other health professionals are arranged and enabled. The health care issues of the residents were seen recorded in the daily notes. The inspector visited the home at 8:50AM. During the inspection the inspector noted that residents were seen making choices about their lives and were seen to be part of the decision process where possible. A relaxed atmosphere was noted with the residents interacting with staff. The inspector also had the opportunity to speak with a few residents who expressed satisfaction with the care offered and given. The inspector viewed the storage arrangements and some records including Medication Administration Record (MAR) sheets, and the protocols for the administration of “PRN/As Required” Medication. The medication was seen to be stored appropriately, but not wholly administered in accordance to current guidance. The Elms Nursing Home DS0000013358.V346734.R01.S.doc Version 5.2 Page 13 Several areas of concern were brought to light during the inspection of the medication. During a tour of the home the inspector witnessed a drugs round taking place. On the drugs trolley a pestle (crusher) was observed with residue of a tablet sticking to the end. It was therefore apparent that this had been used for crushing or breaking tablets. The Nurse administering the medication commented that some residents had difficulty in swallowing the tablets. The manager present at the time was requested to ensure that this practice did not continue and the resident’s medication was reviewed to ensure that they were prescribed in a suitable form. The home has two clinical / medication rooms one on the ground floor and one on the first. Both had medication cabinets and sinks with soap and towels. The ground floor room was small and overcrowded and was in the view of the inspector in need of some degree of re – organisation. Both rooms had exposed dressings stored on top of cupboards which could be a hazard with regard to risks of infection. The MAR sheets observed were on the whole completed correctly. However PRN medication was not written up on the back of the sheet and it was unclear in some instances whether some PRN medication was being used as a regular medication. PRN protocols were not written up for each PRN. Such guidance provides Nurses with an agreed protocol / guidance to ensure that any clinical decisions to give PRN is done in a consistent manner by all Nurses. The Manager was requested to review some of the resident’s medication with their Doctor to ensure that PRN was not being given inappropriately and review the homely remedy policy to ensure that it is appropriate for all residents within the home. The inspector commented on the home’s drug disposal policy and asked the manager to review to ensure it meets with current guidance. The manager was additionally requested to review the home’s practice to ensure that it complies with current guidance issued by The Royal Pharmaceutical Society of Great Britain (RPSGB) 2007, The Handling of Medicines in Social Care, this provides professional pharmaceutical guidance for staff working in every area of social care to improve the safety and quality of medicines. Facilities and procedures at the Home seek to ensure residents’ privacy and dignity at all times and when providing health and personal care. Staff was observed to address residents in a respectful manner and were observed to knock and seek permission before entering residents’ rooms. The Elms Nursing Home DS0000013358.V346734.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15, Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Resident’s social and recreational interest and needs are provided for with a range of activities organised and are supported to maintain contact with family and friends, which ensures they continue to receive stimulation and emotional support. The dietary needs of residents are well catered for and their views and opinions are sought regarding the choice of meals served if possible. Residents feel confident that they are enabled to exercise choice and control over their lives as their capacity allows. EVIDENCE: The home benefits from three activity coordinators working a total of 56 hours per week. Residents are encouraged to take park in a variety of activities as their interest and capacity allows. The home has sought the views of residents and considered their varied interests and abilities when arranging activities. The activities and plans are resident focussed, regularly reviewed, and can be quickly changed to meet individual residents needs. The Elms Nursing Home DS0000013358.V346734.R01.S.doc Version 5.2 Page 15 Residents are actively encouraged to keep in contact with family and friends living in the community. Visitors are welcome at any time and facilities are available for them to have a drink or a meal. Residents can choose to entertain visitors in their own rooms or perhaps a lounge or garden areas. The home employs a dedicated cook who prepares and cooks freshly food for the residents. The Inspector viewed residents eating their midday meal. From observation, records viewed and comments made by residents it was evident that residents had been offered a choice of menus that met their dietary needs and individual preferences. The food provided for the residents was found to be varied and nutritious and of a high quality. The chef meets the residents regularly to ensure he has feedback about the meals provided. People who spoke with the Inspector at this inspection said they enjoyed the food. The menu for lunch was displayed on a board in the main foyer of the home. Meal times are flexible where possible to suit resident’s needs, often residents have meals in their rooms. Residents are able to choose where to eat, and also have facility to have drinks, meals and snacks made for them as and when requested. During the inspection food storage areas were viewed along with quantity and quality of food. A good variety of food was found including meat, vegetables tins and fresh fruit. The kitchen and storage areas were seen to be well organised and clean. The Elms Nursing Home DS0000013358.V346734.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18, Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has a effective complaints system in place and residents and families are aware of its contents. Residents are protected by adult protection policies and procedures EVIDENCE: The home had a written complaints procedure, which was seen in the foyer. Residents spoken with felt free to voice their concerns. The home has received two complaints in the last 12 months. Following a review of a complaint received from the last inspection the manager had evidenced that it had been taken seriously and dealt with in an appropriate manner. The Elms Nursing Home DS0000013358.V346734.R01.S.doc Version 5.2 Page 17 The inspector viewed and discussed copies of the Home’s Policy for the Protection of Residents and staff “Whistle blowing” procedure. These include procedures for the reporting of suspicion or evidence of abuse with a format for the recording of any allegations and action to be taken. Full training has been provided for the majority of staff. More courses are planned to ensure all staff receive the training required to protect residents from abuse. Criminal Record Bureau Checks (CRB) have been obtained for all staff. The Registered Manager is aware of his obligations with regard to ensuring the safety of Residents and protecting them from abuse. The Elms Nursing Home DS0000013358.V346734.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,22,26, Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Resident’s benefit from living in a home that provides for a homely environment which provides safe access to comfortable indoor and outdoor communal areas and is in good decorative order. EVIDENCE: The management and staff encourage residents to see the home as their own home. Personal items were found in many of the resident’s rooms to make them feel more homely. The home has been in the process of being refurbished with new carpets and decoration throughout many parts of the home. It provides a very well maintained, safe, comfortable home. The Elms Nursing Home DS0000013358.V346734.R01.S.doc Version 5.2 Page 19 As well as a good selection of general aids such as hoists and variable height beds, the home also ensures that equipment is individualised for each service user and all staff members are trained in the safe use of aids and equipment. All residents are assessed for their need to have equipment or aids before they move into the home and these are provided to them on admission. The home has a variety of bathroom washing facilities, two of which have a standard bath. The manager is requested to obtain an occupational health assessment to ensure that all bathrooms are suitable for the needs of the residents. No requirement has been made at this time. The home uses slings for the hoists in different sizes. For reason of infection control and the risk of cross contamination the manager was requested to consult with current guidance to ensure they are following best practice. There is a selection of communal areas, according to the numbers of residents, this means that residents have a choice of place to sit quietly, meet with family and friends or be actively engaged with other residents. The home was found to be is well lit, clean and tidy and smell fresh at the time of inspection. The management has a proactive infection control policy. Staff wear protective clothing (gloves & aprons) when providing personal care or handling soiled linen. There are separate staff hand washing facilities in the staff room and the service kitchen where both soap and alcohol gel are readily available. Very soiled linen is placed in blue plastic bags then into red bags, notifying the laundry staff that it is contaminated. The Elms Nursing Home DS0000013358.V346734.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. 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. Residents can feel confident that their care, social and emotional needs are fully promoted by the employment of care staff in sufficient numbers to meet their needs during the day. However staffing levels at night were in need of review. Staff are trained on the whole to the required standards. Residents are fully protected by the recruitment procedures within the home. EVIDENCE: The home is divided into three areas Lincoln, Watson and York. The staffing levels at time of inspection given by the manager were. Lincoln currently has seventeen residents. Three AM staff, two PM. One qualified Nurse AM and PM. Watson currently has six residents. One AM staff, one PM. One qualified Nurse AM and PM The Elms Nursing Home DS0000013358.V346734.R01.S.doc Version 5.2 Page 21 York currently has seventeen residents. Three AM staff, two PM, One qualified Nurse AM and PM. Four support staff, one qualified Nurse cover all three areas at night. Staff also float from each area dependent on need. The ratios of care staff to residents are determined according to the assessed needs of residents. Following discussions with the managers, a review of the rota and observations made during the inspection. The inspector is of the opinion that sufficient care staff were on duty to support residents with their needs for the majority of the day. However the manager was requested to review staffing to ensure sufficient staff were on duty at night to meet all of the residents needs. Residents spoken with were happy and content with the level of support provided. Relatives who had completed comment cards confirmed this in that they felt that their relatives were adequately supported with their needs. The home employs a number of ancillary staff in the view of the inspector who work as cleaners, laundry, cooks, gardener/ maintenance staff. Thus allowing care staff the time to meet the needs of residents. The staff training records indicated undertaken training. Individual and group staff training needs had been identified. From documentary evidence seen the standard of staff training were adequate overall with the majority of staff completing basic courses. However at present only 45 of the care staff have achieved an NVQ (National Vocational Qualification) Level 2 or equivalent. Seven staff are currently training for their NVQ level 2 and once complete this will raise the percentage of care staff with a qualification to 82 . Dementia training has been provided within the home to enable staff to further support residents with their needs. The training manager was unable to currently confirm that the home has a development programme for all new staff, which meets Sector Skill’s Council’s workforce training targets and ensures staff fulfill the aims of the home and meet the changing needs of residents, and that all members of staff receive induction training to specification within 6 weeks of appointment to their posts, and foundation training within 6 months. The training manager is currently developing a new induction programme, which will address this outstanding issue. The Elms Nursing Home DS0000013358.V346734.R01.S.doc Version 5.2 Page 22 The home showed that it undertakes a recruitment practice including submission of an application form detailing all previous work history, requests proof of identity and copies of qualification certificates, seeks two written references, and confirms work status. The home’s recruitment files observed were seen to include all the information as required under schedule 2 of the Care Home Regulations 2001. The home was requested however to review its staff files to ensure compliance. The Elms Nursing Home DS0000013358.V346734.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 33,38 Quality in this outcome group is adequate Residents and or their relatives can be confident that their views and opinions effect how the home is run. However continued failure to comply with requirements set at previous inspections within agreed timescales could place residents at risk. Residents can feel confident that their health and safety is protected EVIDENCE: Quality assurance was discussed and the views and opinions of many of the resident’s relatives sought. They confirmed a great deal of satisfaction in living within the home and felt confident that their views and opinions were valued by the staff and management. The manager confirmed that the home does undertake quality assurance by means of asking residents / relatives to complete questionnaires in addition to healthcare professionals. This enables The Elms Nursing Home DS0000013358.V346734.R01.S.doc Version 5.2 Page 24 the home to ensure it is meeting the goals that are set out in the Statement of Purpose. The registered provider of the home does visit the home regularly and complete what is known as a Regulation 26 visit (Statutory documented visits by the provider to monitor standards within the home). This requires the owner / provider to assess the quality of care within the home and ensure that it is meeting with the required National Minimum Standards. Such visits need to focus on outcomes for residents with regard to quality of care, staffing, adult protection, audits of policies and procedures and that they are followed, staff training, Activities, Health and Safety etc. along with speaking to staff and residents. The managers present at the inspection were requested to speak with the provider to ensure that such documented visits also monitor if requirements from previous inspections are met. This is due to failure to comply with requirements set at previous inspections within agreed timescales. The inspector viewed records relating to Health and Safety Procedures, maintenance and servicing, and risk assessments. The inspector viewed the Fire Log book, which was up-to-date. The inspector was able to evidence that checks and servicing of fire safety equipment / emergency lighting had been undertaken at the required frequency. The maintenance manager spoken with was however requested to ensure that the electrical hard wiring had been check and maintained in accordance to the required guidance. This he agreed to do. The Elms Nursing Home DS0000013358.V346734.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x 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 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 x 3 x x x 3 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 2 x x x x 3 The Elms Nursing Home DS0000013358.V346734.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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 Care plans and risk assessment must be regularly reviewed to ensure that they reflect any change in needs. This requirement is outstanding from the last inspection dated 22/06/06 further non compliance could result in enforcement action 3 OP9 13(2) The registered person ensures that there is a policy and staff adhere to procedures, for the receipt, recording, storage, handling, administration and disposal of medicines The Registered person is requested to provide details to the Commission on how the home ensures that the bathroom facilities satisfactorily meet the assessed needs of all of the residents and a plan of action should those needs not be fully met. 25/12/07 Timescale for action 25/01/08 4 OP22 16((1)(2) 23(2)(n) 25/12/07 The Elms Nursing Home DS0000013358.V346734.R01.S.doc Version 5.2 Page 27 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 OP28 Good Practice Recommendations It is recommended that the registered person ensures that at least fifty percent of care staff have gained National Vocational Qualifications (level 2) It is recommended that that there is a staff training and development programme which meets Skills for Care workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 2 OP30 The Elms Nursing Home DS0000013358.V346734.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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