Care Home: Elm Lodge

Similar services:

• Henry Nihill House
• Birchwood
• The Infirmary
• Orchard House Nursing Home
• St Josephs Rest Home
• Red Court Nursing Home
• Spinney (The)
• Queen Elizabeth House

What the care home does well Copies of the social services assessment for prospective residents are obtained in order to ensure the home can meet the persons needs. Staff were seen caring for residents in a gentle and professional manner, and communicating effectively, respecting their privacy and dignity. Equality and diversity is recognised and respected in the home. The home has an open visiting policy and visiting is encouraged. Visitors are made welcome and offered refreshments. Information in respect of advocacy services provision is displayed in the home. The food provision in the home is good, offering variety and choice to meet both personal preferences and religious and cultural dietary needs. The home was purpose built to a good standard, and there is evidence that any redecoration or refurbishment issues identified are addressed. The home has procedures in place for infection control and these are adhered to. The home was clean and fresh throughout. Staffing levels were appropriate for the needs of the residents on each unit, and these are kept under review on an ongoing basis. The training provision at the home is good, providing staff with the skills and knowledge to care for the residents effectively. The home has a new Manager, who has the skills and experience to manage the home effectively. Personal monies held on behalf of residents are clearly recorded and securely stored. Comments received on the CSCI surveys included: ‘I am satisfied with the support I get here’ ‘Staff are very sociable’ ‘Staff are very helpful’ What has improved since the last inspection? There has been a good improvement in the medication management at the home, with regular auditing taking place to continue monitoring this area. There had been some work carried out for ascertaining the wishes of residents and their representatives in respect of health deterioration and end of life care. The Regional Manager acknowledged that more work was needed in this area, and is planning further training for staff. Clearer systems for the management of complaints are now in place, and action has been taken to address shortfalls identified in this area both at the last inspection and during 2008. Any unexplained injuries discovered are now being promptly reported to CSCI and Ealing Social Services. There has been an improvement in the percentage of NVQ qualified staff, with over 50% now being qualified to NVQ in care level 2. The AQAA submitted to us was comprehensive and gave a clear picture of the home and the progress being made in all areas. There had been a good improvement in monitoring and auditing, especially in respect of medication management. The auditing of service user plans still needed work, and the home is introducing a tool specifically for this purpose. The head of nursing and head of care need to ensure all areas of care are being robustly monitored and action taken promptly to address any shortfalls identified. There had been an improvement in the servicing and maintenance records, however more work is still required in this area to ensure all required checks are kept up to date. Staff had received training in health & safety topics and all confirmed that there is a good level of training provided. What the care home could do better: The homes pre-admission assessment document had not always been fully completed, thus an up to date assessment was not always available. Further work is required to ensure that the service user plan documentation is up to date and personalised to the individual, so that staff have a clear picture of each residents current needs and how these are to be met. Regular auditing of the service user plans is needed to identify shortfalls and ensure they are addressed in a timely manner. Whilst there was a good provision of activities on the residential units, more work is needed to improve the activities on the nursing units, and the activities co-ordinator is working towards this. The processes in place for vetting and recruitment were not robust, and action must be taken to ensure that all required checks are carried out and documentation completed in order for recruitment practices to be robust. When the fire risk assessment is reviewed, the document must be made available in the home and the action plan to address shortfalls identified completed without delay. Although overall the maintenance and servicing records were available, some of the records were not up to date in line with home procedures and timescales. A contingency plan is needed for when the maintenance man is on leave to ensure timescales are being met. There is also a need to archive old maintenance and servicing records and certificates for ease of access to the current documentation. CARE HOMES FOR OLDER PEOPLE Elm Lodge 4a Marley Close Greenford Middlesex UB6 9UG Lead Inspector Clare Henderson Roe Unannounced Inspection 10:20 17 & 20th March 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 Elm Lodge DS0000061258.V374325.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. Elm Lodge DS0000061258.V374325.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elm Lodge Address 4a Marley Close Greenford Middlesex UB6 9UG 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) 020 8575 0259 0208 839 1160 pamela.small@servitehouses.org.uk www.servitehouses.org.uk Servite Houses Manager post vacant Care Home 75 Category(ies) of Dementia (75), Old age, not falling within any registration, with number other category (75) of places Elm Lodge DS0000061258.V374325.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 with Nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Dementia - Code DE Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 75 15th & 16th April 2008 2. Date of last inspection Brief Description of the Service: The home has been purpose built and is situated in a residential area of Greenford, easily accessed via public transport and the A40. There are shops within reasonable walking distance to the home. The home comprises of 5 units, each of which can accommodate 15 residents. All bedrooms are single with en suite toilet, wash hand basin and shower facilities. Each unit has a communal sitting/dining area with a kitchen area plus a separate quiet/activities room. Each unit is individually staffed. The home accommodates residents placed by the Borough of Ealing. With regard to the fee rates for the home, the Major Projects Manager for Ealing Council has provided the following information: Elm Lodge was developed under the Governments Private Finance Initiative and capital costs are met in this way. Ealing Council pays a Unitary Charge, which covers all the services the Council receives from Ealing Care Alliance. It covers the costs of care and the provision of facilities management services to the day care service and accommodation. It is not possible to separate these out to identify how much each residential care and nursing care placement costs. The fee payable to the Council by residents who fund themselves in full is £495.00 per week for residential care. Elm Lodge DS0000061258.V374325.R01.S.doc Version 5.2 Page 5 The fee payable to the Council by residents who fund themselves in full is £627.00 per week for nursing care. Deducted from that will be the free nursing care amount of £125.00 (high) and £83.00 (medium and low). Elm Lodge DS0000061258.V374325.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This was an unannounced inspection carried out as part of the regulatory process. A total of 18 hours was spent on the inspection process, and was carried out by 2 Inspectors. We carried out a tour of the home, and service user plans, medication records & management, staff rosters, staff records, financial & administration records and maintenance & servicing records were viewed. 20 residents, 14 staff, 1 healthcare professional and 5 visitors were spoken with as part of the inspection process. The pre-inspection Annual Quality Assurance Assessment (AQAA) document completed by the home, plus comment cards from residents and staff have also been used to inform this report. It must be noted that it is sometimes difficult to ascertain the views of residents with dementia care needs. What the service does well: Copies of the social services assessment for prospective residents are obtained in order to ensure the home can meet the persons needs. Staff were seen caring for residents in a gentle and professional manner, and communicating effectively, respecting their privacy and dignity. Equality and diversity is recognised and respected in the home. The home has an open visiting policy and visiting is encouraged. Visitors are made welcome and offered refreshments. Information in respect of advocacy services provision is displayed in the home. The food provision in the home is good, offering variety and choice to meet both personal preferences and religious and cultural dietary needs. The home was purpose built to a good standard, and there is evidence that any redecoration or refurbishment issues identified are addressed. The home has procedures in place for infection control and these are adhered to. The home was clean and fresh throughout. Staffing levels were appropriate for the needs of the residents on each unit, and these are kept under review on an ongoing basis. The training provision at the home is good, providing staff with the skills and knowledge to care for the residents effectively. The home has a new Manager, who has the skills and experience to manage the home effectively. Personal monies held on behalf of residents are clearly recorded and securely stored. Comments received on the CSCI surveys included: ‘I am satisfied with the support I get here’ ‘Staff are very sociable’ ‘Staff are very helpful’ Elm Lodge DS0000061258.V374325.R01.S.doc Version 5.2 Page 7 What has improved since the last inspection? What they could do better: The homes pre-admission assessment document had not always been fully completed, thus an up to date assessment was not always available. Further work is required to ensure that the service user plan documentation is up to date and personalised to the individual, so that staff have a clear picture of each residents current needs and how these are to be met. Regular auditing of the service user plans is needed to identify shortfalls and ensure they are addressed in a timely manner. Whilst there was a good provision of activities on the residential units, more work is needed to improve the activities on the nursing units, and the activities co-ordinator is working towards this. The processes in place for vetting and recruitment were not robust, and action must be taken to ensure that all required checks are carried out and documentation completed in order for recruitment practices to be robust. When the fire risk assessment is reviewed, the document must be made available in the home and the action plan to address shortfalls identified completed without delay. Although overall the maintenance and servicing records were available, some of the records were not up to date in line with home procedures and timescales. A contingency plan is needed for when the maintenance man is on leave to ensure timescales are being met. There is also a need to archive old maintenance and servicing records and certificates for ease of access to the current documentation. Elm Lodge DS0000061258.V374325.R01.S.doc Version 5.2 Page 8 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. Elm Lodge DS0000061258.V374325.R01.S.doc Version 5.2 Page 9 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 Elm Lodge DS0000061258.V374325.R01.S.doc Version 5.2 Page 10 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. Standard 6 does not apply to the home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are assessed by social services prior to admission to the home, to ascertain that the home is appropriate to meet their needs. The homes assessing processes are not always completed, and more work is needed in this area. EVIDENCE: We sampled pre-admission assessments on all five units. On the nursing units the pre-admission assessments were incomplete and contained very brief information. On the residential units the pre-admission assessments overall had been well completed. We were informed that referrals are received from Ealing Social Services along with a completed needs assessment. Once this information has been received a pre-admission visit is made to the resident to ascertain whether the home is able to meet their needs. We were informed at the inspection that a decision had been made that only the heads of care or the Manager was to carry out the pre-admission assessment. Elm Lodge DS0000061258.V374325.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 & 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service user plans are in place, however some information is quite general and may lead to residents needs not being fully met. Medication are now being well managed at the home, thus protecting residents. Staff care for residents in a gentle and professional manner, respecting their privacy and dignity. Work is ongoing to ascertain the wishes of each individual in respect of health deterioration and end of life care, to ensure these wishes are known and can be respected. EVIDENCE: Service user plans were sampled on each unit. The home uses a computerised care plan template for all five units. On the nursing units there was some evidence of individualisation but this was not consistent throughout the care plans viewed. For one resident it was recorded that there was a specific medical condition to manage when in fact the resident did not have this medical condition. The preferences of residents in respect of the gender of the carers attending to their personal care needs had been recorded. We noted Elm Lodge DS0000061258.V374325.R01.S.doc Version 5.2 Page 12 that for one resident who had been in the home for over a month that there had been no review of the care plan, plus the risk management plans had not been completed. For residents with dementia care needs the information in the care plans was very general. There was evidence of residents and relatives involvement in the formulation and review of the care plan. On Regent Street a care plan for one resident could not be located. For another resident care plans were in place and were in the process of being reviewed. However we could not find evidence of the updated care plan as it was in the process of being typed up. On Oxford Street the care plans had been reviewed monthly up to January 2009 and the risk management up to March 2009. It was explained that the updates for the care plans had been written, but the printer had been out of order. We recommended where the residents needs have changed and an update of the care plan is required, then the staff should handwrite the update. On the second day of inspection action had been taken to address the shortfalls identified in the care plans. In addition a new audit tool for the service user plans had been formulated and trialled, and once this tool has been reviewed it will be put in use on all units. Risk assessments for falls were seen and there was evidence of updating following a fall. The document in use for risk assessing the use of bedrails needed to be reviewed as it was a generic risk assessment document and not specific to the use of bedrails. Staff had worked to try and include information to show why the bedrails were needed, however a dedicated risk assessment and consent form for this purpose was required. Following the inspection a comprehensive bedrail risk assessment template has been formulated and introduced, confirmation of which has been forwarded to CSCI. Assessments for skin, moving and handling, nutrition and falls were available. Wound management was viewed on the nursing units. There was evidence of ongoing wound assessment and dressing regimes in place. For one resident the pressure sore risk assessment was inaccurate and did not identify the wound, and this was corrected at the time of the inspection. Other pressure sore risk assessments viewed were accurate. Turning charts were in place for residents with wounds. Pressure relieving equipment was seen in use, however the documentation did not identify the specific equipment to be used for each individual. Care plans for pain management were not in place however for one resident the staff had implemented a pain assessment tool. Moving and handling assessments did not identify specific equipment that was being used to move residents. Continence assessments were not in place on the nursing units, and we were shown a blank assessment tool, which is to be implemented. The medication records and management were sampled. All receipts, administration and disposals had been clearly recorded. For each resident a front sheet with a photograph, name, allergy information and other relevant information was available. A list of staff signatures and initials was in place. All liquid medications, eye drops and boxed medication had been dated when Elm Lodge DS0000061258.V374325.R01.S.doc Version 5.2 Page 13 opened. The controlled drugs register was up to date and medications were correctly recorded and signed for. We noted that controlled drugs were being returned to the pharmacist and not being disposed of at the home. This was fed back to the Manager who dealt with it at the time of inspection. All other medications were being disposed of at the home in line with Waste Regulations. Lancing devices for professional use were being used for blood glucose monitoring. Stock balances were checked for some boxed medications and stock amounts tallied with the administration records. Where entries are handwritten on the Medication Administration Record (MAR), these had been signed by two members of staff. With the exception of Baker Street the staff had been recording room and fridge temperatures daily, and on other units some maximum temperature readings were above the recognised safe range, however the actual temperatures being recorded were within safe range. The Manager has since confirmed that monitoring is taking place on each unit and any shortfalls found are being addressed. For residents on Warfarin therapy evidence of the current dosage is kept with the MAR sheet. The home has a lot of residents who are admitted for respite care who are admitted at different times of the month with their own supply of medications. Following discussion on the first day of inspection an auditing tool specifically for respite medications monitoring was introduced to ensure stock levels are always maintained. There was evidence of regular auditing and there was clear evidence that medication management had improved and that medications are being well managed at the home. Staff were seen caring for residents in a gentle, caring and professional manner. Residents spoken with were happy with the care they are receiving at the home and positive comments were also received from visitors and healthcare professionals. Bedrooms viewed were very personalised and looked homely. Residents personal clothing is labelled and residents were well groomed and dressed, reflecting individuality. Service user plans viewed did not always provide details of residents’ wishes in the event of health deterioration and end of life. In some instances information was clear, however other records viewed were very brief and in some instances had not been completed. By the second day of inspection further progress had been made to discuss this sensitive topic and document the outcome, with some records viewed being very comprehensive and specific to the individual. We were informed by the Regional Manager that training had been agreed with the palliative care nurse specialist for Ealing PCT and that this was to be implemented throughout the Servite Homes in Ealing in the near future. Staff spoken with confirmed that the need to ascertain the wishes of residents and their families in respect of health deterioration and end of life care had been discussed and that they were implementing this. It was agreed that should this be a topic that people state they are not ready to discuss, this can also be documented. Elm Lodge DS0000061258.V374325.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. Overall the activity provision for the home is good, meeting the interests and abilities of the residents, with more work needed on the nursing units. The home has an open visiting policy, thus encouraging residents to maintain contact with family and friends. Advocacy arrangements are in place, thus ensuring the residents rights, choices and opinions are heard and respected. The food provision in the home is of a good standard, offering variety and choice, to meet the resident’s individual needs and preferences. EVIDENCE: The home has a full-time activities co-ordinator who is responsible for ensuring that activities are carried out on all the units by care staff. Each unit has an activities room with a variety of games and items for reminiscence therapy. Activities programmes were on display throughout the home and there was evidence of outings, trips and outside entertainers coming into the home. There was also information displayed in respect of various religious services taking place in the home. We noted on the nursing units that televisions were on loudly and that there was little engagement of residents in activities. Care plans for activities were available, and it was clear that the longer a resident had been at the home the more personalised the information was. We spoke Elm Lodge DS0000061258.V374325.R01.S.doc Version 5.2 Page 15 with the activities co-ordinator who explained that there is now an Activities Committee, with herself and one member of staff from each unit on it, and they meet every 2 weeks to discuss the activity provision and look at what improvements can be made in various areas. The activities co-ordinator said that she has different activity programmes for the nursing and residential units, and there are more 1:1 activities carried out on the nursing units, where the residents are more frail and may choose to spend more time in their rooms. We discussed the lack of activities on the nursing units on the first day of inspection. Outings were being planned in association with the interests and wishes of the residents. Activities form part of the discussion at relatives meetings, and recent feedback had been positive. The home has an open visiting policy and visiting is encouraged. Visitors spoken with said that they are made welcome at the home and refreshments are offered. Residents can choose to receive visitors in their own bedrooms or in one of the communal rooms, as they so wish. Information regarding advocacy services was displayed in the main entrance of the home, to include Alzheimer’s Concern. Information regarding financial services is also available. The Regional Manager explained that as all residents are placed via Social Services, they also can request advocacy help from the Borough. We viewed the kitchen and it was clean and tidy. There is a written and a picture book 4 week menu, and this is displayed in the reception area and on each of the units. Residents confirmed that they are offered a choice of meals, and there was evidence of this being recorded. Caribbean and Asian menus are also available and are provided for residents, plus the kitchen receives a copy of the residents profile form, which identifies personal likes, dislikes, allergies, special dietary information and any relevant additional information. It was clear that the kitchen staff were aware of the differing dietary needs of the residents. Residents expressed their satisfaction with the food provision at the home, and the only concern expressed was that the food is sometimes lukewarm when received. This was discussed with the Manager and the system for serving residents is to be reviewed to improve this finding. The home currently has attained a ‘3 star’ good rating in the ‘Scores on Doors’ scheme following inspection by Environmental Health. Food is being appropriately stored and there was a good supply of fresh fruit, salad and vegetables available. We were told that the soups are always homemade. We sampled the meat and vegetarian lunchtime meals and they were well presented and tasty. Elm Lodge DS0000061258.V374325.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. There are robust systems in place for the management of complaints and for adult protection concerns, which are now being followed, thus safeguarding residents. EVIDENCE: In the last 12 months the home has had 11 complaints. At the last inspection issues were raised regarding complaints not being responded to within appropriate timescales. Further issues in respect of complaint management had become apparent during 2008. This is now being addressed and recent complaint documentation evidenced that complaints are being promptly and comprehensively acknowledged, and then an investigation instigated with a view to responding to the complainant within a clear timescale. At the last inspection there were issues with the non-reporting of unexplained injuries. Staff are now clear to report any such injuries to us and to Social Services. Representatives spoken with said that they were kept informed of any concerns, to include any injuries that may occur, however minor. Staff spoken with confirmed that they had received training in safeguarding adults and were clear on reporting, to include Whistle Blowing. Elm Lodge DS0000061258.V374325.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. 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. The environment is being maintained to a good standard, thus providing residents with a homely and comfortable place to live in. Infection control procedures are in place and are adhered to, thus protecting residents, staff and visitors. EVIDENCE: The home is purpose built and was opened in 2006. All bedrooms have quality en suite facilities to include a wash hand basin, toilet and shower. The décor throughout is of a good standard and there is evidence of maintenance and repairs being carried out. The redecoration and refurbishment programme will come into play when the home has been open for 5 years. There is, however, a budget available for any areas of expenditure, for example, where some carpets have been replaced with more suitable flooring for the resident living in Elm Lodge DS0000061258.V374325.R01.S.doc Version 5.2 Page 18 the room. We carried out a tour of the home and it is being maintained to a good standard throughout. We viewed the laundry room, which has 2 washing machines with sluice programmes for infection control, plus 2 tumble dryers. The room is spacious, and was clean and tidy. Protective clothing is available to include gloves and aprons, and the home has infection control policies and procedures in place, plus good practice instructions and information on display in the laundry. The cleanliness of the home is maintained to a high standard, and with one minor exception that is being addressed, the home smelled fresh throughout. Elm Lodge DS0000061258.V374325.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is appropriately staffed and staffing levels are kept under review, thus ensuring that the needs of the residents can be met at all times. The systems in place for vetting and recruitment are not robust and could therefore place residents at risk. Training provision in the home is good, thus providing staff with the skills and knowledge to meet the residents’ needs effectively. EVIDENCE: At the time of inspection the home was being appropriately staffed to meet the needs of the residents. The staffing is based on resident dependency, with each unit being staffed to meet the assessed needs of the residents, plus the Head of Nursing and Head of Care are in full time supernumerary posts. The Manager is very aware of the current reliance on agency staff to maintain the staffing numbers, and ensures that where possible the same agency staff attend the home in order to provide continuity of care for the residents. The home was clean and fresh throughout, and ancillary staff are employed in such numbers as to meet the needs of the residents and the home in general. According to the homes AQAA 20 of the permanent care staff are qualified to NVQ level 2 or above, with a further 8 currently undergoing their training. This will provide over 50 of the permanent staff with NVQ training in care. Elm Lodge DS0000061258.V374325.R01.S.doc Version 5.2 Page 20 We viewed 3 sets of staff employment records. A completed application form, confirmation of the healthcare questionnaires being completed plus the Criminal Records Bureau reference numbers were available in the files viewed. In 2 instances only one reference was available, and head office confirmed that only one had been requested. In one instance a reference had not been obtained from the most recent employer. No photographs of the staff were available on the files. It was explained that all the recruitment documentation plus pre-employment checks are held and carried out by head office. This gives cause for concern as it was clear that head office were not following Schedule 2 of the Care Homes Regulations 2001 as they should be. The Regional Manager said that this would be addressed as a matter of priority. Servite Houses have an induction training that includes the Skills for Care common induction standards. Staff spoken to confirmed that they had completed induction training, and also that they receive training in topics relevant to the needs and diagnoses of the residents. This is also evidenced in the training matrix. Ten staff on the dementia care units had undertaken a course in dementia care mapping, and there was evidence that staff were putting the learning into practice, to include effective interaction with the residents. Elm Lodge DS0000061258.V374325.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. 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. The Manager has the skills, experience and knowledge to manage the home effectively. Systems for quality assurance are in place, thus providing an effective ongoing process of procedure and practice review. Resident monies are well managed and securely stored. Overall systems for the management of health and safety throughout the home are good, thus safeguarding residents, staff and visitors. EVIDENCE: The Manager has been in post for 3 weeks. He is a first level registered nurse, with general and mental health qualifications. He has completed the Registered Managers Award and has over 2 years experience in managing care homes for older people, plus experience in working in a rehabilitation unit. The Manager Elm Lodge DS0000061258.V374325.R01.S.doc Version 5.2 Page 22 said that he has undertaken the Servite Houses care planning training and is also up to date with health & safety training topics. In discussion, it was clear that the Manager had already identified various areas in need of improvement and said that he is putting together an action plan to address these. The home has a system in place for quality assurance. The auditing of the medication management in the home over the last year has been very effective and has brought about marked improvements in this area. The home has a Head of Care and a Head of Nursing, both of whom work in a supernumerary capacity. We noted the improvement in the medication management, through robust audit and monitoring. However it was disappointing to note the shortfalls found with the care plan documentation. A robust system of audit and monitoring needs to be implemented in the area of care, to ensure that all residents needs are kept under review and are effectively being met and documented at all times. A requirement has been made under Standard 7. Regulation 26 unannounced visits are carried out on behalf of the Registered Person and reports of these are available in the home. Regular meetings take place for residents and relatives, and staff meetings are also held. The Manager attends handover sessions on the units, plus communication books are in place. The home has a monthly Key Performance Assessment, which is carried out as part of the contract with Ealing Social Services. This is a comprehensive review of all aspects of the home. The AQAA submitted by the home is comprehensive and provides clear information to show the progress being made by the home in each area. The home holds personal monies on behalf of residents, and these are securely stored. An individual envelope is maintained for each person, on which there is a clear list of all income and expenditure. Most entries had been signed by 2 people, as is the company policy, and the need to follow the policy in all cases was discussed. The envelope has receipts for income and expenditure. We sampled the maintenance and servicing records and most of those viewed were up to date. The home does not have a contingency plan in place to ensure maintenance checks continue to be carried out in line with the homes procedures and timescales when the maintenance man is on leave. Some of the documentation was difficult to find and much of the old documentation needs to be archived so that the current information can be easily accessed. This was also discussed at the last inspection. Kitchen records viewed were up to date and the kitchen staff confirmed that the shortfalls identified in the last Environmental Health inspection report had been addressed. Risk assessments were available for all aspects of safety within the home, and had last been completed in November 2008. The fire risk assessment had been reviewed and updated in July 2008, however the new document plus the action plan had not been printed off and placed in the fire log. This was done at the time of inspection. As a result, the action plan, which we were informed had been actioned, had no dates for completion recorded. Staff spoken with confirmed that they have undertaken health & safety training and that there is a good Elm Lodge DS0000061258.V374325.R01.S.doc Version 5.2 Page 23 amount of training provided by the home. The training matrix also evidenced the training undertaken by each member of staff. Elm Lodge DS0000061258.V374325.R01.S.doc Version 5.2 Page 24 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Elm Lodge DS0000061258.V374325.R01.S.doc Version 5.2 Page 25 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 Requirement Service user plan information must be accurate and specific to the individual. There must be evidence that the documentation is being reviewed monthly or whenever a residents’ condition changes. Care plans for residents with dementia must be personalised to reflect each persons individual needs and how these are to be met. A system of auditing must be introduced for all areas of care, to include the service user plans, with action plans formulated to ensure any shortfalls identified are addressed promptly. This is so that all areas of care are monitored and documentation maintained up to date. Where equipment is used as part of the care of a resident, the specific equipment to be used must be recorded to ensure staff use the appropriate equipment for each individual. All assessments must be up to date and accurate, to clearly DS0000061258.V374325.R01.S.doc Timescale for action 01/05/09 2. OP7 15 01/05/09 3. OP7 24 01/05/09 4. OP8 17 01/05/09 5. OP8 17 01/05/09 Elm Lodge Version 5.2 Page 26 6. 7. OP12 16 19 OP29 8. OP38 23(4) reflect the condition of each resident. Activities on all units must be appropriate and meet the needs of the residents. All required staff employment checks and records must be in place before staff work at the home in order to safeguard the residents. The fire risk assessment must be accessible and there must be evidence that any shortfalls identified are addressed without delay. 01/05/09 14/04/09 14/04/09 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. Refer to Standard OP1 OP38 Good Practice Recommendations That the homes pre-admission assessment document be completed in full for each prospective resident, in order to gain an up to date picture of their needs. A contingency plan should be in place to ensure that in the absence of maintenance staff, maintenance checks continue to be carried out in line with the homes procedures and timescales. Out of date maintenance and servicing records should be archived so that the current records and certificates are easily accessible to view. 3. OP38 Elm Lodge DS0000061258.V374325.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Elm Lodge DS0000061258.V374325.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!