Inspection on 26/05/09 for The Elms Residential Home

This inspection was carried out on 26th May 2009.

CQC found this care home to be providing an Poor service.

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

Other inspections for this house

The Elms Residential Home 02/06/08

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 17/02/2010.

Key inspection report CARE HOMES FOR OLDER PEOPLE The Elms Residential Home 111 Melbourne Road Ibstock Leicestershire LE67 6NN Lead Inspector Keith Charlton Key Unannounced Inspection 26th May 2009 09:30 DS0000063308.V375529.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. The Elms Residential Home DS0000063308.V375529.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address The Elms Residential Home DS0000063308.V375529.R01.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 Registered 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.V375529.R01.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 June 2008 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 £341 - £450, which was provided by the Manager on the day of the inspection. There are additional costs for hairdressing, toiletries, transport, chiropody and dry cleaning. The Home’s information - Statement of Purpose, last Inspection Report etc is available on request. The Elms Residential Home DS0000063308.V375529.R01.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 0 stars. This means the people who use this service experience poor quality outcomes. ‘We,’ as it appears throughout the Inspection Report, refers to ‘The Care Quality Commission. The inspection process consisted of pre-planning the inspection, which included reviewing the Annual Quality Assurance Assessment (AQAA), which is selfassessment tool completed by a representative of the service, We have sent surveys to people who use the service along with staff. When we receive these surveys back we will include the results of them if received before the final Report is published. The unannounced site visit commenced on the 26th May 2009 and was carried out by Keith Charlton. The focus of the inspection is based upon the outcomes for people who use the service. The method of inspection was ‘case tracking’. This involved identifying people with varying levels of care needs and looking at how these are being met by the staff at The Elms. Three residents were selected. Discussions were held with eight residents, three relatives, the Manager, a representative of the Company, and three members of staff. There have been three complaints to us since the last key inspection. Allegations concerning medical attention, staffing levels, service contracts for equipment, a bath hoist not being repaired, gaps in medication records, fire precautions, and domestic cover were highlighted as issues the Provider needed to take action to improve residents welfare. What the service does well: Residents and relatives said that staff were friendly and attentive in general and welcomed visitors. The food is home made and much appreciated by residents. There are now more activities on offer to interest residents and so improve their quality of life. The Elms Residential Home DS0000063308.V375529.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Residents welfare could be more effectively met by ensuring that: Assessments are detailed and contain all aspects of individual needs to make sure staff can meet those needs from day one of a person’s admission. All aspects of care – e.g. proper toileting programmes, adherence to epilepsy action staff need to take, improving nutrition if this is identified as a problem, stated dates of health checks, life history and daily living wishes etc are detailed in Care Plans, to assist staff to meet all residents needs and that there is swift access to medical services at all times as needed following falls etc. The food supply needs evidence that all residents cultural needs are met. All residents hobbies and interests need to be recorded and action is taken to meet these needs by way of more outings and more varied activities as suggested by residents/families. The Complaints Procedure needs to be clearer for residents and their representatives, so that complainants have the choice to go to the Lead Agency to reach a proper resolution. Staff need to know the full abuse procedure to protect resident effectively. The Elms Residential Home DS0000063308.V375529.R01.S.doc Version 5.2 Page 7 Maintenance issues need to be attended to quickly to provide an attractive, odour free and safe home for residents by way of the replacement of old worn furniture, carpets and decor. There were some comments regarding how busy staff were and that they could become fatigued so long staff shifts are not recommended. Staffing levels must be maintained at all times to be able to meet the needs of residents. The staff training programme becomes more comprehensive through ensuring all staff receive thorough training to increase their skills in delivering good quality care for residents. Residents must have a safe environment through management effectively, ensuring that all staff who work at the home receive proper checks before they commence employment, that effective fire safety is observed, that the security of the home is always maintained, that there are Risk Assessments for all safe working practices in place to eliminate risks for residents and that regular staff supervision is in place to support staff to give more effective care for residents. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. The Elms Residential Home DS0000063308.V375529.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 Residential Home DS0000063308.V375529.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at The Elms have had some of their needs assessed before moving into the home but this needs to be more thorough to meet all of their needs. EVIDENCE: We case tracked a person living in the home who had moved into The Elms recently. We checked that her family had received information to help with the choice of home, and she said she thought her relative had received enough information. We also checked that this person had her needs properly assessed prior to moving in, to ensure that the staff at the The Elms Residential Home DS0000063308.V375529.R01.S.doc Version 5.2 Page 10 home could meet their needs and we found that the assessment system format was in place though important details had been left out such as past health checks and hobbies/interests and food preferences had not been included, which is useful to improve the health and daily quality of life for people. The Elms Residential Home DS0000063308.V375529.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People at The Elms receive adequate health and social care practice. EVIDENCE: Residents spoken with could not recall having a care plan. We checked the care plans of three people living at the home who were case tracked. Plans showed detail regarding the support required by staff to ensure the physical health of people living at the home, and there was some information to inform staff of the residents personal history, though no information of preferred daily living routines of residents to ensure their social and emotional well being is fully supported. Some Plans showed residents needs had been identified, e.g. staff to know how to deal with epilepsy, but then no action plan for staff as to how to do this, and a nutritional assessment for a resident identified a risk of malnutrition, but no action plan to address this. The Elms Residential Home DS0000063308.V375529.R01.S.doc Version 5.2 Page 12 Continence information was recorded though this was basic and detailed assessments had not been completed. It was recommended that a referral to a specialist nurse was done to work out the individual needs of residents, especially those with dementia, who usually cannot ask staff for assistance when they need to go, so staff can prompt before they needed to go to the toilet, especially as we saw a reference to toileting in staff meeting notes that pads should not be an excuse not to toilet residents. There were gaps on health check recording insofar as appointments for sight and teeth had not been recorded so that residents could have waited too long before having these appointments. A relative confirmed that staff did not always act quickly if there were any health issues regarding her mother and the Provider has been asked to investigate this issue. Staff said they were asked by management to read Care Plans and there was evidence that staff signed to state they had done this, so that they can understand and act on residents needs. Accident records were checked and medical services were mostly but not always contacted when a resident had a potentially serious injury and staff who had not been authorised by the District Nurse applied bandages for burns etc which could harm residents health. We spent time watching staff interaction with people living at The Elms. We saw staff being friendly and caring to people throughout the day with residents confirming that staff respected the dignity and privacy by knocking on bedroom doors, supplying preferred same sex care staff for personal care etc. Staff were seen to assist residents in various ways - giving choices for breakfast, encouraging residents in activities etc. The Elms Residential Home DS0000063308.V375529.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents cannot always have a relaxed lifestyle of their choosing. EVIDENCE: Residents said that they were largely satisfied with the current activities. A resident said There are quite a lot of activities here. We saw that there is a current list of activities displayed on a board in the dining room. Residents said they had of games and quizzes, and there were trips out to the local shops. A resident was offered a trip out when we visited. There is also TV, and we witnessed age appropriate music being played in the dining room and residents said staff took them out to the garden in good weather, which we also saw being done. There were no specific activities for dementia residents though a staff member said that memory boxes had been set up to help residents with reminiscence The Elms Residential Home DS0000063308.V375529.R01.S.doc Version 5.2 Page 14 and the Manager said she had attended training on providing specialist activities. There were some comments that there needs to be more one to one time with residents, especially residents with dementia, and there needs to be more outings. A relatives survey suggested a number on activities - music and movement, knitting, school children visiting, film night, nostalgia talks etc. The relations between staff and residents were observed to be relaxed. Residents said there were no rules though one resident said you had to get up for breakfast. This encouragement was also said by staff to happen and staff meeting notes confirmed it as well. A relatives survey also stated that it would be nice if residents could stay up for an hour longer. The Manager agreed this did not fully meet the residents right to choose and said this would be reviewed. Visitors are welcomed at The Elms and we were informed by visiting relatives that they could come at any reasonable time and they were always greeted in a friendly way by staff. Residents largely said they enjoyed the food: The food is nice and tasty as it is home cooked and there is always a choice, one resident said. Lunch was a choice of two hot dinners and a resident said she was offered an alternative to these choices as well. Food was well presented and looked appetising, and was followed by a home cooked dessert. Three vegetables were served - this choice showed a commitment to healthy eating. Food records showed a good variety of traditional food served. A residents Care Plan stated that this person ate only vegetarian and fish dishes. However menus did not show this choice each day. The Elms Residential Home DS0000063308.V375529.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16.18. People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents are not fully protected from abuse. EVIDENCE: Residents said if they had a complaint they thought that Stella, the Manager, would sort it out. A relative said she had cause to complain and thought the management had tried to get the issue resolved but on another issue it took staff too long to act on medical concerns. We passed on this information to management for them to investigate this situation. A resident said, I have never needed to complain but I think they would sort it out. We saw that there had not been any complaints recorded since the last inspection in the complaints book, The Complaints procedure still needs to be altered so that complainants can refer their complaint to the Lead Agency, the Social Services Department, not just the home. The Elms Residential Home DS0000063308.V375529.R01.S.doc Version 5.2 Page 16 We talked to staff to find out how much they knew about protecting people in the home from abuse. Records showed they had received training about safeguarding adults from abuse, and they knew the in house procedure, but not all Agencies to whistle blow to if the in house procedure failed. The Manager said this would be followed up. We looked at the staff recruitment records to see whether all the proper checks had been made on staff before they started employment at The Elms and legal checks were not in place for two staff at the time of their commencing employment to help management reach the judgement that people were safe to start employment, though legal checks are now in place. We sent the Responsible Individual a warning letter about this issue as the Commission will not accept staff being employed without these checks being in place and we will take enforcement action if this situation occurs again. Residents are not fully protected from abuse. The Elms Residential Home DS0000063308.V375529.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19,26. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at The Elms live in a generally homely but not fully maintained environment. EVIDENCE: Residents said they liked their bedrooms: I was able to bring some of my things in to make my bedroom homely, one resident said. There were some remarks that the decor was tired and the home needed repainting, which was also reflected in surveys that the home has done. Decor needed attention in the small lounge as it was torn and paintwork scuffed. there was scuffed paintwork to some areas of skirting as well. The Elms Residential Home DS0000063308.V375529.R01.S.doc Version 5.2 Page 18 Lounge space is limited in the main lounge. There is a conservatory though there were some remarks that this cannot be used in warm weather as there are no blinds to keep this space cool and there are draughts in colder weather as doors are not draught proof. We saw people at The Elms living in a largely clean environment though two bedrooms were odouress and there were some stained bedroom carpets and a torn carpet in one bedroom and a stained dining room carpet and some old worn easy chairs in some bedrooms and easy chairs beginning to look worn in the lounge. The service needs to review signs around the home to improve the environment to further help residents with dementia, e.g. colour coding toilet doors, pictures of residents favourite scenes on bedroom doors etc to make facilities clearer, and orientate residents to go to their own bedrooms etc. There are radiator covers fitted throughout to ensure that residents are protected from burn risks. Residents said they loved sitting or walking in the large gardens and appreciated the garden. The Elms Residential Home DS0000063308.V375529.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. People using the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staffing levels need to be maintained and staff training extended to ensure residents needs are always met. Staff recruitment must ensure proper legal checks are carried out. EVIDENCE: Residents said that staff were largely friendly and caring towards them: You cannot fault the staff. They are always cheerful and we can have a laugh with them’, one resident said. There were a small number of remarks that staff could get annoyed though residents said this was because they sometimes had to work fourteen hour shifts and they were tired. The Manager confirmed that she and other staff had worked long shifts at times. The staff rota usually, but not always, showed three care staff plus a member of management on duty throughout the day/evening with two awake staff members on at night, plus a cook and a domestic worker. As the staff have to deal with a number of high dependency residents who need two care staff to help one resident this means that care staffing needs to be maintained at all The Elms Residential Home DS0000063308.V375529.R01.S.doc Version 5.2 Page 20 times. There needs to be consideration to extending domestic hours to the afternoon as well to ensure care staff can concentrate on meeting the needs of residents. A staff member said that although she had only been working at the home for a short time she had been encouraged by management to do further training and was now doing a NVQ 3 course in the future and had already completed a number of training courses and a thorough induction, though she had not yet received training on dementia or other residents conditions - stroke, epilepsy, diabetes, parkinsons disease etc. From information obtained from the Manager we saw that approx 75 of staff have NVQ training needed to ensure a good range of knowledge to meet residents needs. We found that staff have been on a number of training events to help update their practice on areas such as Moving and Handling, Fire Safety, Infection Control etc though some issues regarding residents health conditions were missing from the Training Matrix we saw - e.g. not all staff have had dementia training, Sight and Hearing Impairment, Stroke, Mental Health conditions, Diabetes etc. We asked that these topics be added to the training programme and the manager said this would be done. Staff records showed that proper checks had not been carried out to protect residents from unsuitable staff. The Elms Residential Home DS0000063308.V375529.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Management systems are not fully in place to protect the health and safety of Residents. EVIDENCE: Stella Beccles is the Manager of the home. Stella said she hoped to complete her Award in management skills in the near future. Staff said they were supported by Stella in their work. The Elms Residential Home DS0000063308.V375529.R01.S.doc Version 5.2 Page 22 Satisfaction questionnaires were sent around the home last year, which were seen to be positive in general though some comments regarding activities were not translated into the action plan. Written records re finances for residents are properly in place and monies were checked for two residents and totals found to be correct. There was evidence of residents discussing relevant issues - activities, food etc though meetings have not been frequent. Safe working practices were observed as we went around the home - e.g. gloves worn for the medication round but there were no towels or soap in bathrooms and the back garden was frequently entered by children retrieving a ball so walls/fences need to be risk assessed to ensure security. Staff informed us that they were able to tell management of the problems they were facing and there were meetings and supervision to support them though supervision was not frequent. Fire records were in place though there had been no fire drill between April 2008 and April 2009 - the Manager said she had forgotten to do them. They must be done frequently to ensure staff know how to protect residents from fire. Staff were asked re the fire drill and one forgot the need to sound the alarm. There is a fire door on the first floor which is kept shut though releases with the fire alarms. It also has a rail across it which is a partial barrier and the step down from the fire door to the staircase is angled and not a wide width, so is a potential tripping hazard. The Manager and provider was asked to Risk Assess this. There was a Heath and Safety folder with Risk Assessments to keep residents safe. Radiators have covers on them to prevent burning injuries to residents. Hot water tested by us and found to be 42c so the National Standard is observed to keep residents safe from scalding injuries. The Elms Residential Home DS0000063308.V375529.R01.S.doc Version 5.2 Page 23 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 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 1 X X X X X X 2 STAFFING Standard No Score 27 1 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 3 X 3 X X 1 The Elms Residential Home DS0000063308.V375529.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement Care plans must include all relevant care details – e.g. individual toileting programmes, detailed epilepsy information etc to have a care plan which supports their individual requirements to ensure their condition is managed effectively. The Registered Provider must always ensure residents have swift access to Medical Services. This was a requirement of the 4/7/2008 Random Inspection. 3. OP18 13 Proper checks need to be in place to prevent potentially unsuitable staff from commencing employment to prevent risk to residents. Maintenance facilities must be dealt with swiftly in respect of décor, furniture and carpets to ensure an attractive and safe environment. DS0000063308.V375529.R01.S.doc Timescale for action 25/08/09 2. OP8 12 25/06/09 28/05/09 4. OP19 19 26/10/09 The Elms Residential Home Version 5.2 Page 25 5. OP27 18 Staffing levels must be maintained at all times to meet residents needs. This was a requirement of the 4/7/2008 Random Inspection. 26/06/09 6. OP30 18 Staff training on all relevant issues needs to be supplied. This was a requirement of the 4/7/2008 Random Inspection. 26/09/09 7. OP31 8 Effective management must be in place to meet legal requirements and ensure that the home fully runs for the benefit of residents. Proper Health and Safety systems must be in place, e.g. the fire safety systems in the home must always be in place to protect residents from harm; infection control needs to be maintained by towels and soap being in bathrooms to ensure proper hand washing, security of the premises needs to be in place etc. This was a requirement of the 4/7/2008 Random Inspection. 26/09/09 8. OP38 13 25/06/09 The Elms Residential Home DS0000063308.V375529.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP3 OP9 OP12 Good Practice Recommendations Assessments of prospective residents must include all relevant details. Medication supplies need to be reviewed and reduced accordingly as there is a large stock. All residents interests need to be recorded and acted upon and residents outings introduced for those interested. That a staff member has training on providing proper activities to residents with dementia. Residents need to have a choice of what they wish to do, e.g. getting up/going to bed times. `` All residents food preferences need to be acted on. The complaints procedure to be revised to include the option to go to the Lead Agency first. Facilities need to be kept stain and odour free. 4. 5. 6. 7. OP14 OP15 OP16 OP26 The Elms Residential Home DS0000063308.V375529.R01.S.doc Version 5.2 Page 27 Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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