Inspection on 02/06/08 for The Elms Residential Home

This inspection was carried out on 2nd June 2008.

CSCI found this care home to be providing an Good service.

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 Residential Home 26/05/09

The Elms Residential Home 02/08/06

The Elms Residential Home 10/11/05

Similar services:

Trevayler Residential Care Home

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE The Elms Residential Home 111 Melbourne Road Ibstock Leicestershire LE67 6NN Lead Inspector Keith Charlton Unannounced Inspection 2nd June 2008 09:35 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 Residential Home DS0000063308.V365725.R02.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 Residential Home DS0000063308.V365725.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Elms Residential Home Address 111 Melbourne Road Ibstock Leicestershire LE67 6NN 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) 01530 260263 F/P 01530 260263 The Elms Residential Home Limited Manager post vacant Care Home 18 Category(ies) of Dementia (9), Mental disorder, excluding registration, with number learning disability or dementia (6), Old age, not of places falling within any other category (18) The Elms Residential Home DS0000063308.V365725.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. No one falling within category OP may be admitted into The Elms Residential Home where there are 18 persons of category OP already accommodated within the home No one falling within category DE may be admitted into The Elms Residential Home where there are 9 persons of category DE already accommodated within the home No one falling within category MD may be admitted into The Elms Residential Home where there are 6 persons of category MD already accommodated within the home The maximum number of persons accommodated within The Elms Residential Home is 18. 2nd August 2006 Date of last inspection Brief Description of the Service: The Elms is situated on Melbourne Road in the village of Ibstock. The home is within walking distance to most amenities and shops within the village. With a bus stop just outside the home, it is easily accessible both by car and public transport alike. The home offers spacious accommodation to 18 older persons and is a large modernised building with half an acre garden, mature trees and shrubs. There is ample car parking space available. The weekly fee is from £360 - £430, which was provided by the Responsible Individual on the day of the inspection. There are additional costs for hairdressing, toiletries, transport, chiropody and dry cleaning. Home’s information – Statement of Purpose, last Inspection Report etc is available on request. The Elms Residential Home DS0000063308.V365725.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for residents and their views of the service provided. The primary method of inspection used was ‘case tracking’ which involved selecting three residents and tracking the care they received through looking at their records, discussion, where possible, with them, visitors and care staff and observation of care practices. This was an unannounced Inspection. The Acting Manager and Responsible Individual were present and helped in carrying out the inspection. Planning for the Inspection included looking at notifications of significant events sent to the Commission for Social Care Inspection and the issues contained in the previous two Inspection Reports. There has only been one complaint made to the Commission for Social Care Inspection about the service since the last full inspection, which had no evidence that the allegations were correct. The Inspection took place between 9.35 and 17.00 and included a selected tour of the building, inspection of records and indirect observation of care practices. The Inspector spoke with six residents, three members of staff, two visitors, the Acting Manager and the Responsible Individual. What the service does well: There was again evidence of promoting the welfare of residents in terms of good relationships between staff and residents with staff listening and consulting with residents. Residents said generally that the care provided by staff was generally very friendly. Residents are consulted about life at the home with events and trips planned to meet their choices. Facilities used by residents are generally comfortable and homely. Staff are encouraged to have training to equip them to meet residents needs and have supervision to support them in their jobs. Residents and staff thought that the Acting Manager was doing a good job in that she was friendly and efficient. The Elms Residential Home DS0000063308.V365725.R02.S.doc Version 5.2 Page 6 Since the inspection day the Registered Provider has supplied a comprehensive Action Plan to meet the recommendations and Requirements made below. What has improved since the last inspection? What they could do better: Residents welfare could be more effectively met by staff ensuring that: All aspects of care – e.g. assistance with mobility, symptoms of mental health needs, dates of medical checks, are in Care Plans to assist staff to meet all residents needs. Activities could be further extended as per residents preferences to provide more stimulation for them. That the home has more signs to assist residents with dementia – e.g. on bathroom doors, more individually relevant pictures on residents doors, and a notice board in a communal area to provide prompts and stimulation to make everyday living clearer. That two choices are always recorded in the records for lunch every day, as per the National Minimum Standard, so that more meal choice is seen to be available. Another medication cupboard needs to be obtained to strengthen medication security. The Elms Residential Home DS0000063308.V365725.R02.S.doc Version 5.2 Page 7 There were some comments regarding how busy staff were, especially when there are only two care staff on duty in the late afternoon, so an increase in staffing would mean swifter care and increased supervision to be able to care for residents with increased care needs – e.g. with dementia or confusion/ residents who wander/were at risk of falls. An office area would be useful to assist the Manager in carrying out management duties in a more confidential and private manner and it would be easier to secure all private residents information to ensure their privacy is fully protected. The Complaints Procedure needs to be clearer for residents and their representatives so that any complaint is dealt with fully. The staff training programme is generally comprehensive though would aid staff understanding if training on all residents conditions – mental health, challenging behaviour, parkinsons disease, diabetes, strokes etc – were added to the programme. Regarding the carrying out of Quality Assurance of the service it was again recommended that quality assurance results be published to give more information to all stakeholders. Monies records need to be kept up to date to ensure that residents monies are accountable and properly protected. 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 Residential Home DS0000063308.V365725.R02.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 Residential Home DS0000063308.V365725.R02.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 are assessed before admission so that staff are able to meet their needs. EVIDENCE: Residents said that someone from the home came to see them before admission and they were encouraged to visit. An assessment was inspected and whilst it contained good detail of relevant information as to residents needs it did not include all aspects of medical checks – dates of dental, optical, hearing etc to ensure these are followed up in a timely manner so residents health needs are fully promoted, as per the National Minimum Standard. The Elms Residential Home DS0000063308.V365725.R02.S.doc Version 5.2 Page 10 The Registered Provider said that assessments are carried out for all prospective residents as per the policy contained in information about the service. Assessments were seen on file – this allows staff to be aware of a new resident’s needs. The service does not offer intermediate care. The Elms Residential Home DS0000063308.V365725.R02.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. The individual needs and choices of residents living in the home are met though this needs to be extended. EVIDENCE: None of the residents spoken with said that they could recall having Care Plans. However a relative said she had seen a Care Plan and this was found to having been signed by her. Residents need to be reminded they can see their Care Plans and discuss them if they wished to ensure that their needs are accurately recorded. Care Plans seen by the inspector contained information as to the physical, social and medical needs of service users. However one Care Plan identifed a care need that a resident needed assistance of staff to walk but this resident The Elms Residential Home DS0000063308.V365725.R02.S.doc Version 5.2 Page 12 was observed by the inspector to be walking on her own. Another Care Plan stated that the resident had delusions without stating the diagnosis and symptoms – the Responsible Individual said any such needs would be accurately recorded in future to assist with staff awareness regarding care needs. Risk assessments were found to be a part of the plans so that staff know how to keep residents safe. Staff said that they had not read all residents Care Plans which is needed to ensure they were aware of all help needed for residents. Monthly reviews of residents needs were noted in Care Plans to be sure they are kept up to date. There was one comment that a resident had sometimes not been properly attended to after using the toilet. The Responsible Individual said this would be followed up. Residents said when they felt ill then staff would swiftly summon medical assistance – residents contacts with medical personnel were documented in their Care Plans. Accident records were viewed which showed that medical services were properly referred to on all occasions except one when there had been a head injury. The Responsible Individual said that this happened in the past and will not reoccur in the future. The inspector observed that staff were friendly and respectful to residents and encouraged in a friendly manner at the residents pace. There were very positive comments about the staff from all parties spoken with and only one isolated comment that staff could be curt on occasion, but no evidence supplied to the inspector to back up this statement. The visitors the inspector spoke with said she thought the staff were caring and friendly and did a good job. The visiting nurse said that staff communication was good and residents always looked to be well cared for. The Responsible Individual confirmed that only senior staff issue medication and had some recently undertaken medication training. Medication record sheets were found to be fully signed and the medication folder contained useful information such as the Policies and Procedures for giving medication, photos of residents to ensure medication went to the right person and details of allergies to protect residents from being given the wrong type of medication. Medication was seen to be properly issued to residents except it was handled by a staff member who did not wear gloves, thereby increasing infection risks. The Responsible Individual said this would be followed up to ensure it did not happen again. The Elms Residential Home DS0000063308.V365725.R02.S.doc Version 5.2 Page 13 No residents asked wanted to self medicate and all appreciated the staff holding their tablets and giving them at prescribed times. Medication is kept securely in the medication trolley which is securely attached to a wall though a more robust cabinet is required for special medication. The Responsible Individual said this would be swiftly ordered through the pharmacist. The Elms Residential Home DS0000063308.V365725.R02.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents living at the home have opportunities for activities though this needs extending, and meals continue to be seen as very good. EVIDENCE: Residents again said that they were generally satisfied with the range of activities on offer though there were a few comments that there should be more activities. An actvity file is kept to show what is done though there were gaps in this for a week or so showing nothing had been offered. The Responsible Individual said this was not the case and would reming staff to record all activities. The inspector saw that bingo was done during the inspection and some residents said they didn’t have to take part as they wanted to watch TV instead, thereby showing that their choice was respected. Another resident was seen to be helped by staff to have a walk in the garden. The Residents Meeting notes showed that residents can go on outings and this was confirmed by the Activity folder for e.g. bingo, quizzes and light exercise sessions. The Quality Assurance surveys requested more activities – simple The Elms Residential Home DS0000063308.V365725.R02.S.doc Version 5.2 Page 15 painting sessions and armchair exercise. This needs to be acted on by management. Residents said they liked being outside and enjoying the garden, which they went when the weather was good. The inspector saw that a resident walked around the garden on her own. Residents can go out if they wish and attend clubs and staff can take them out for a walk in the village. Residents said that their visitors were made welcome by staff and this was supported by visitors comments. Residents said there were no rules, e.g. going to bed and getting up times, whether to stay in their rooms or go to the lounge etc., and staff respected this. There was a comment that staff took charge of residents alcohol. Residents should be given this choice if there are no pressing risks. Staff said that it was important that residents were able to keep their independence so they could still do things for themselves. This was confirmed by comments made by residents. Residents again said that they enjoyed the food and there was a choice each day. Food records showed there were a variety of vegetables offered. Records did not always show a choice of food. The Responsible Individual said this would be corrected. The food tasted was found to be of a very good standard with a three course meal offered with choices for each course. Three vegetables were included for one choice followed by homemade desserts. Residents are asked their opinion of the food at their meetings, which was recorded in the notes. This gives them the opportunity to comment and the management then can change the menu accordingly. The inspector spoke to the cook and it was obvious that she takes pride in the food served and tries different foods and introduces different flavours, e.g. through the use of garlic etc. Staff were observed to assist residents to eat in a friendly way at the residents pace. The Elms Residential Home DS0000063308.V365725.R02.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. Residents views are listened to and acted upon and they and their representatives can be confident their concerns will be properly attended. EVIDENCE: Residents and relatives spoken with thought that if there was a problem then they were confident the management would sort it out. A Complaints Book is kept. There have been a number of complaints in the past year though there was evidence of investigations of complaints on file that had been properly followed up. The Complaints Procedure is generally satisfactory but does not give the complainant the opportunity to go to the lead Agency, the local Social Service Department, as per the National Minimum Standard. It also states that all complaints need to be made to the home first – the National Minimum Standard states complainants can choose to go to the lead agency first. The Responsible Individual said these issues would be followed up. Care staff spoken with were not fully aware of the full procedure regarding of which Agencies to contact if the in house arrangement failed. The Responsible The Elms Residential Home DS0000063308.V365725.R02.S.doc Version 5.2 Page 17 Individual said these issues would be followed up to ensure staff were aware of the full procedure. It is recommended that a short procedural statement be drawn up and displayed to help staff to follow the correct procedure and so be able to fully protect residents welfare if the situation happens. The Elms Residential Home DS0000063308.V365725.R02.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): 19,26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents see facilities as homely and comfortable. EVIDENCE: Residents all said that they liked their bedrooms and they could bring in their own things. These were observed to be personalised and homely by the inspector, with personal items of residents furniture, pictures, photographs etc. The lounge was comfortable and furnished in a homely fashion. The back garden area looked attractive spacious and there was a table and chairs out so residents could sit there and appreciate the garden if they chose. . The Elms Residential Home DS0000063308.V365725.R02.S.doc Version 5.2 Page 19 There is signing to the environment to assist with residents with dementia, e.g. photos on doors to make them more recognisable. It is recommended that this process is extended - same colour doors for bathrooms, notice of time, day, weather in the lounge etc Odour control was of a good standard, apart from odour in a small toilet on the first floor, and did not have toilet paper or a towel in it. The Responsible Individual said this would be dealt with. The dining room carpet was stained. The Responsible Individual said that the carpet had been changed but staining occurred due to residents having accidents. The Responsible Individual was asked to look at alternative flooring that could be easily and effectively cleaned, to ensure a homely environment for residents. Since the last inspection a domestic staff has been employed to ensure hygiene standards are maintained though this is for five days, not seven days a week. The only office is located on the first floor of the annex in the grounds of the home – the Registered Manager recognised this was not ideal in the past and said she thought an area on the landing could be created to give easier access for residents and their visitors, and ensure proper confidentiality for records. This has not yet been carried out. A resident wanted to have a bigger bedroom. The Responsible Individual said that she would be offered this when a bigger bedroom becomes available. There was a comment that doorways for wheelchair users were not big enough and there was evidence from damage to paintwork that this was the case. The Responsible Individual said that damage would be repaired and she would look into whether planning permission could be granted to widen doorways. The Elms Residential Home DS0000063308.V365725.R02.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. Staffing levels need to be reviewed to ensure they fully meet residents needs. Recruitment procedures are in place to properly protect residents welfare. Staff training systems are in place to plan to equip staff to meet residents needs though more training needs now to be carried out. EVIDENCE: There were some comments that staff were very busy and took time to help residents. The staffing rota demonstrated that staffing has been increased since the last inspection - there are three care staff on duty with the Acting Manager until after lunch. This then drops down to two staff from 4.00 pm to 6.00pm. The Responsible Individual said she would look towards increasing staff for this two hour period, though the Acting Manager is often still on duty at this time, though this was not indicated on the rota. There are three staff on from 6.00pm to 8.00pm and two waking staff at night. The staffing review needs to look at providing domestic cover seven days a week and covering more of the day for domestic assistance, as currently this is The Elms Residential Home DS0000063308.V365725.R02.S.doc Version 5.2 Page 21 only covered until lunchtime. This will help with care staff not being called upon to carry out domestic duties so they can concentrate on residents needs. Staff said there had been training in the last twelve months. Records and notices displayed in the lounge seen by the inspector showed this. There was also evidence of induction training for new staff - the recognised Skills for Care induction pack was recorded as being used in a staff record. Specific training on residents conditions – stroke care, diabetes, parkinsons disease, sight impairment, mental health conditions etc, is still needed. The Acting Manager said she would either do this in house or ask the District Nurse to carry it out. Staff said they were encouraged to undertake National Vocational Qualification level training. Recruitment records were inspected with Criminal Records Bureau /Protection of Vulnerable Adults checks in place, and written references in place. There was a poor work reference from one staff member’s previous employer. The Acting Manager was strongly recommended to obtain another work reference if this proves to be the case in future, to ensure that residents are fully protected from potentially unsuitable staff and have a proper check of competency etc. The Elms Residential Home DS0000063308.V365725.R02.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Management systems are in place to protect the health and safety of residents. EVIDENCE: The Acting Manager is currently applying to the Commission for Social Care Inspection for registration as Registered Manager of the home. She has had previous relevant experience. Residents, visitors and staff spoken to said that the home was well run and they could not think of many improvements that were needed, apart from increased staffing levels and activities. The Elms Residential Home DS0000063308.V365725.R02.S.doc Version 5.2 Page 23 The inspector observed that some residents information was on open display. This compromises confidentiality. The Responsible Individual said this issue would be followed up. There was evidence on records that staff are supervised and supported. Staff also said this was the case. There are also residents meetings to ensure that there is a forum to air views and preferences, put forward suggestions etc, though the Responsible Individual was asked to increase their regularity as residents meetings in particular had an eight month gap between meetings. Also to invite residents representatives to the meetings as most residents are not able to effectively put forward their views. Staff Meetings have been held and were well recorded though these were not frequent for care staff. The Responsible Individual agreed to follow up the need to have more meetings, which will provide more support for staff and ensure practice issues are regularly discussed. A Quality Assurance system was in place with completed surveys carried out for 2007. It is recommended that they are also given to other interested parties - e.g. GPs, Social Workers, District Nurses etc, and this would be followed up. Residents monies records were found to be properly kept in one instance with running balances, though two signatures had not often been recorded to show that transactions are witnessed. On another record the Acting Manager said she was behind on recording so this balance could not be properly checked. The Responsible Individual needs to ensure this is followed up. Fire Precautions: System testing was on the required monthly schedules for emergency lighting and weekly fire bell testing was also carried out. Fire drills are carried out on a regular basis of at least every three months. There was also a fire risk assessment on file, which helps to ensure that proper fire safety systems are in place to protect residents. Staff members were asked the fire procedure though they were not fully aware of the whole procedure. A linen cupboard fire door was unlocked to the first floor. The Responsible Individual said these issues would be followed up. There is a Health and Safety folder with Risk Assessments for safe working practices so residents can be properly protected from any potential dangers in the home though there were no Risk Assessments for radiators without covers on them. The Responsible Individual stated this would de done and radiator covers fitted if needed. The Elms Residential Home DS0000063308.V365725.R02.S.doc Version 5.2 Page 24 Regarding Health and Safety training all staff are expected to complete fire training, infection control training, moving and handling training, first aid and food hygiene training. There were written Risk Assessments for safe working practices and these were evidenced in the Health and Safety records though there needs to be Risk Assessments carried out for uncovered radiators and this acted on as needed to protect residents from burning surfaces. The Elms Residential Home DS0000063308.V365725.R02.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 1 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X X X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 2 The Elms Residential Home DS0000063308.V365725.R02.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 OP8 Regulation 13 Requirement Residents with potentially serious injuries must always be reported to Medical Services to ensure that their health is fully protected. There needs to be a more robust storage system for certain medications. Timescale for action 06/07/08 2. OP9 13 06/08/08 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 OP7 Good Practice Recommendations Care Plans need to fully contain residents needs and to ensure that staff have read all residents plans so care is fully provided. A fuller Activities Programme needs to be provided to protect residents from boredom. 2. OP12 The Elms Residential Home DS0000063308.V365725.R02.S.doc Version 5.2 Page 27 3. 4. 5. OP16 OP18 OP26 The Complaints Procedure needs to be altered so that it is clear which Agency can follow up any concerns. Staff need to be aware of the Safeguarding Procedure so as to keep residents safe. All parts of the home need to be clean and it is recommended that the dining room flooring is changed to more appropriate flooring that is safe and attractive but does not stain. The Registered Provider need to review the staffing levels, and further increase them if necessary, to ensure residents needs are met at all times. Staff training on residents conditions needs to be in place so that staff have the skills to meet all residents needs. Residents monies records must be up to date to ensure they are properly kept. All health and safety issues need to be in place – staff understanding of the fire procedure, fire doors kept closed as needed and Risk Assessment for radiator covers. 6. OP27 7. 8. 9. OP30 OP35 OP38 The Elms Residential Home DS0000063308.V365725.R02.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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. Extracts may not be used or reproduced without the express permission of CSCI The Elms Residential Home DS0000063308.V365725.R02.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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