Care Home: Elm Residential Care Home

What the care home does well This is a very homely care home that runs along person centred lines, and puts the people who live there at the heart of everything that happens. Comments received from people who live at the home in questionnaires included: "It`s beautiful, excellent" "Everything is perfect" "It`s very nice" "Everything is done nice and smoothly" "I am very happy, it`s the best home" "It`s really good." The home is comfortable with good quality fixtures and fittings, and the people who live there say they are busy and have interesting activities. They also say that the food is "excellent." What has improved since the last inspection? At the last key inspection four statutory requirements were made: These related to care plans, homely remedies, keeping a staff rota, and recording hot water temperatures in the bathroom. Evidence was seen during this key inspection that these requirements had been addressed and met. In addition the number of registered beds has increased from four to eight. Staffing levels have been increased, new carpets have been laid throughout the care home, radiator covers have been fitted to improve people`s health and safety, and new gates and fences are in the process ofbeing fitted to improve security. What the care home could do better: Two statutory requirements have been made as a result of this key inspection. These relate to: The Statement of Purpose must include all of the information detailed in schedule 1 of the Care Standards Act (2000) and the Complaint`s procedure must have accurate contact details for the Care Quality Commission, including the correct address and telephone number. In addition five good practice recommendations have been made. These relate to dating the Statement of Purpose and the Service user Guide, looking at providing the Statement of Purpose and the Service user Guide in alternative formats, such as with signs and symbols or pictures, ensuring that health care plans have as much detail as possible to guide the staff, contacting Boots to carry out an inspection of the medication procedures (this is overdue), and provide all staff with a minimum of six formal supervision sessions per year. Key inspection report Care homes for adults (18-65 years) Name: Address: Elm Residential Care Home 7 Elm Close Bolsover Nr Chesterfield Derbyshire S44 6EA The quality rating for this care home is: two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Rob Cooper Date: 1 4 0 4 2 0 1 0 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. The first part of the review gives the overall quality rating for the care home:  3 stars – excellent  2 stars – good  1 star – adequate  0 star – poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area Outcome area (for example: Choice of home) These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement Care Homes for Adults (18-65 years) Page 2 of 30 Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) 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. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) © Care Quality Commission 2010 This publication may be reproduced in whole or in part in any format or medium for non-commercial purposes, provided that it is reproduced accurately and not used in a derogatory manner or in a misleading context. The source should be acknowledged, by showing the publication title and © Care Quality Commission 2010. www.cqc.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 30 Information about the care home Name of care home: Address: Elm Residential Care Home 7 Elm Close Bolsover Nr Chesterfield Derbyshire S44 6EA 01246826230 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): elm-house@msn.com Jaywantee O`Farrell Name of registered manager (if applicable) Type of registration: Number of places registered: Conditions of registration: Category(ies) : care home 8 Number of places (if applicable): Under 65 Over 65 8 0 learning disability Additional conditions: The maximum number of service users who can be accommodated is 8 The registered person may provide the following category of service only Care Home only PC To service users of the following gender Both Whose primary care needs on admission to the home are within the following category Learning Disability Code LD Date of last inspection 0 5 0 5 2 0 0 9 Care Homes for Adults (18-65 years) Page 4 of 30 A bit about the care home Elm House is a small residential home, offering eight places to adults who have a a learning disability. Situated in a residential cul-de-sac, the accommodation is a large detached house. It is spacious and comfortable, with a good sized and private garden and patio area. The home is close to the town centre of Bolsover with its range of facilities, and more locally there are small general stores for immediate needs. Good links have been developed with local care professionals, and residents are encouraged to maintain community links with the social contacts and organisations they had prior to their admission. Fees are £380.45 per week. Extra charges are made for hairdressing, chiropody, magazines and newspapers. Care Homes for Adults (18-65 years) Page 5 of 30 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home Care Homes for Adults (18-65 years) Page 6 of 30 How we did our inspection: This is what the inspector did when they were at the care home The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This was an unannounced visit as part of the key inspection process, so that no one at the Elm care home knew that the inspection visit was going to take place. The visit took approximately six hours and involved three visits to the home, by one inspector. In preparing for this inspection, the information that the Commission holds about this care home was reviewed, this included looking at the last inspection report, the inspection record, considering any complaints or concerns that have been made about the service, and reviewing any notifications made relating to incidents that affect the well being of people living at the Elm. The methods used during this key inspection and visit were to visit the care home, where a method called case tracking was used; this involved identifying four people who live there and looking at their individual files and making a judgement about the quality of care they are receiving, and if their needs are being met. This was followed by a partial tour of the building, looking at the Care Homes for Adults (18-65 years) Page 7 of 30 activities on offer, and talking to four people who live there, and three members of staff about the quality of the service, and their experiences of living and working at the home. We also sent out an Annual Quality Assurance Assessment (known as an AQAA), which allowed the care home to carry out a self-assessment; and provide a range of information relating to their service. Information provided by them helped to form the judgements in this report. We also sent out several surveys asking for views and information to people who live at the home, and the staff. Of these we received seven surveys from people living at the home, and one from a member of staff, which also helped with the judgements that we made. The manager Taywantee OFarrell provided much of the information during this key inspection visit. On the day of this inspection there were 8 people living at the Elm care home. People who might want to live at the care home can obtain information about it direct from them, and this would include seeing previous inspection reports prepared by the Care Quality Commission. Care Homes for Adults (18-65 years) Page 8 of 30 What the care home does well What has got better from the last inspection At the last key inspection four statutory requirements were made: These related to care plans, homely remedies, keeping a staff rota, and recording hot water temperatures in the bathroom. Evidence was seen during this key inspection that these requirements had been addressed and met. In addition the number of registered beds has increased from four to eight. Staffing levels have been increased, new carpets have been laid throughout the care home, radiator covers have been fitted to improve peoples health and safety, and new gates and fences are in the process of Care Homes for Adults (18-65 years) Page 9 of 30 being fitted to improve security. What the care home could do better Two statutory requirements have been made as a result of this key inspection. These relate to: The Statement of Purpose must include all of the information detailed in schedule 1 of the Care Standards Act (2000) and the Complaints procedure must have accurate contact details for the Care Quality Commission, including the correct address and telephone number. In addition five good practice recommendations have been made. These relate to dating the Statement of Purpose and the Service user Guide, looking at providing the Statement of Purpose and the Service user Guide in alternative formats, such as with signs and symbols or pictures, ensuring that health care plans have as much detail as possible to guide the staff, contacting Boots to carry out an inspection of the medication procedures (this is overdue), and provide all staff with a minimum of six formal supervision sessions per year. Care Homes for Adults (18-65 years) Page 10 of 30 If you want to read the full report of our inspection please ask the person in charge of the care home If you want to speak to the inspector please contact: Rob Cooper Care Quality Commission Citygate Gallowgate Newcastle-upon-Tyne NE1 4PA 03000 616161 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 set out 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. Care Homes for Adults (18-65 years) Page 11 of 30 Details of our findings Contents Choice of home (standards 1 - 5) Individual needs and choices (standards 6-10) Lifestyle (standards 11 - 17) Personal and healthcare support (standards 18 - 21) Concerns, complaints and protection (standards 22 - 23) Environment (standards 24 - 30) Staffing (standards 31 - 36) Conduct and management of the home (standards 37 - 43) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 12 of 30 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who would want to live at the care home would have the information they would need to make an informed choice about where to live, they would have their individual aspirations and needs assessed before they moved in. Evidence: The Statement of Purpose and Service User Guide for the Elm residential care home were both seen. The Statement of Purpose has the basic information that Care Homes Regulations say that it should, with the exception of the qualifications and experience of the staff, which is missing from the document. The Service user Guide contain useful information about the service being offered at the home, although there is not currently a signs and symbols version or a version using photographs available for people who have difficulty with written English. Neither document was dated to tell the reader how up-todate the information is. Four peoples care files were seen as part of the case tracking process. Each file contained assessments by a range of professionals, covering areas such as communication, mobility, and social skills. Two people had FACE assessments completed by a Social worker, and two more had long term needs assessments, which had also been Care Homes for Adults (18-65 years) Page 13 of 30 Evidence: completed before they moved in. In addition all four files had a number of other assessment tools covering a range of areas and needs, such as moving and handling and risk assessments. Each of the four files contained information relating to the terms and conditions of residence, and the funding arrangements. The terms and conditions had been signed by the person concerned, although the manager explained that the Social Worker for one individual was difficult to contact, and the necessary documentation was not up-to-date as a result. Care Homes for Adults (18-65 years) Page 14 of 30 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good 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 care home know their assessed and changing needs and personal goals are reflected in their individual plan of care. People are also supported to make decisions about their lives with assistance if needed. Evidence: Each of the care files contained a plan of care, based on the individuals needs assessment. The care plans were person centred, and identified what the individual was doing, and how they were doing it. Documentation within the files was clear, and identified peoples needs and how they would be met. Evidence that care plans are being reviewed regularly was seen. However one person was identified as having a specific medical condition and the care plan did not contain clear information or a recording tool to ensure that their needs would be met in a consistent and informed manner by the staff. All of the care plans that were seen contained documents entitled: All about me and What is important to me together with documentation to aid decision making. Discussions with several people, who live at the care home, identified that they are very Care Homes for Adults (18-65 years) Page 15 of 30 Evidence: involved in decision making within the home. This included making decisions for themselves as individuals around, activities, hobbies and going out, as well as group decisions about group activities, meals and outings. Each of the care files contained risk assessments. These related to both individual risks and general everyday living risks. Discussions with four people, who live at the care home, identified that they felt they had ordinary lives, and that there were few restrictions on them, although the staff were there to offer advice and guidance. Care Homes for Adults (18-65 years) Page 16 of 30 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who live at this care home are able to take part in appropriate activities, and are part of the local community, with their rights and responsibilities being respected by the staff. Evidence: Discussions with four people identified that there were plenty of activities arranged, these ranged from activities in the home such as watching DVDs, and playing on the Wii (an interactive computer game), two people were using the Wii, and were bowling during the discussions, while a third watched and commented on their performance. There is a small allotment attached to the home, and one person said they particularly enjoy growing vegetables, which are in turn used in the kitchen. Discussions also showed that there were regular trips out to the cinema, with the people who live at the home deciding on activities, and exercising their choice and control over the activities. During the daytime everyone attends some form of organised day care activity, either at a college, day centre or working in the local community. Care Homes for Adults (18-65 years) Page 17 of 30 Evidence: The home is situated in a cul-de-sac on a housing estate, and the local community surrounds it. Discussions with people who live at the home and members of staff showed that local shops and facilities are used, and trips to local pub/ restaurants are particularly popular. Discussions showed that people have good family links, with family members visiting people at the home, as well as people going to visit their relatives elsewhere. Social events such as birthdays and Christmas are often marked with parties, and two people spoke enthusiastically about these events. Discussions with the manager of the home and several people who live there, showed that people take responsibility for various chores around the home on a rota basis, and everyone takes responsibility for cleaning their own bedrooms, with staff support if needed or required. Cooking is overseen by the staff, although some people like to help with preparing vegetables for example, and get involved if they want to. There is however a washing up rota. There is a well equipped domestic kitchen, and food choice tends to be sorted the day before, based completely on peoples choice. People talked about having special communal meals, for example a curry night was very popular, and the manager talked about making these type of meals a social event, with some other activity taking place, for example watching a DVD. Each of the people spoken with said they thought that the food was: very good, super, lovely and Fantastic. With two people particularly praising the ability of the manager as a cook. A recent Environmental Heath visit to the home, was complimentary, and a copy of the report was seen. Care Homes for Adults (18-65 years) Page 18 of 30 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good 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 care home receive personal support in the way that they prefer, and they are protected by the policies and procedures in place for dealing with medication. Evidence: The people who live at the care home are in most cases able to make clear choices about their personal care, they can choose whether to have a shower or a bath, and decide when to have it. The people who were spoken with during the inspection are largely independent in the area of person hygiene, and therefore make their own choices. Within the care files personal preferences were identified and recorded in the All about me documentation. Each of the care files had a My health action plan, which contained details dentist, GP, chiropodist and any other health care professional involved, as well as a short health quiz/ questionnaire in each of the files. Discussions with the people who live at the home, showed that they had no issues around their health, with one person saying: If I need to see the doctor, the staff will sort it out for me. Another person said: The doctor is in Bolsover, I sometimes go to see them there. The medication is supplied by Boots (the chemist.) The records relating to ordering, dispensing, and where appropriate destroying or returning medication to the pharmacy Care Homes for Adults (18-65 years) Page 19 of 30 Evidence: were seen, and all found to be complete and correct, with no obvious errors or omissions. Medication was also seen to be stored securely. No one currently self-medicates. The records show that the last inspection of the medication by Boots was in March 2008, so this is well overdue, and should be taken up with the Chemist. Staff training records show that staff administering medication have been appropriately trained. Care Homes for Adults (18-65 years) Page 20 of 30 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good 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 care home feel their complaints are listened to and acted upon. The policies and procedures in place ensure people are protected from abuse, neglect and self harm. Evidence: The Elm has not received any complaints since the last key inspection in May 2009. The homes complaints procedure, is on display in the foyer, and forms part of the service user guide. The address for the Commission within the complaints procedure was out of date, and needs to be changed to the correct contact details (the Newcastle address) Discussions with four people who live at the home indicated that they would speak to the manager if they were not happy, although none of them had ever needed to. In their AQAA the Elm said: We have: good staff observation and reporting skills, raised awareness of issues of safeguarding through training. Robust policies and procedures to cover key areas. A review of the staff training records in relation to safeguarding adults showed that care staff had undertaken this training in the last twelve months. The training is aimed at raising staff awareness of abuse, and issues around abuse and through raising those issues, offering people greater protection against abusive practice, while also making sure that the staff understand the correct policy and procedure to follow if abusive practice is found. Two members of staff were asked about safeguarding adults training and both said they were aware of the issues, and had undertaken this training. The Elm have not had made any safeguarding adults referrals since the last key inspection. Care Homes for Adults (18-65 years) Page 21 of 30 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a safe, homely and comfortable environment. Peoples bedrooms suit their needs and lifestyle, and promote their independence. The care home provides sufficient privacy to meet individual needs, and is clean and hygienic. Evidence: The Elm residential care home is situated in a corner plot of a quiet cul-de-sac. A partial tour of the building showed that the fixtures and fittings are to a high standard, and the design of the building has taken into account the needs of the people who live there, with an open plan design, and some ground floor bedrooms. All of the bedrooms that were seen, showed a good level of personalisation. The building is well equipped, and tastefully decorated. There is a range of bathing options available with either a bath, or a shower available depending on personal preference. Outside there is a large enclosed garden with sitting areas, and a small allotment area to the side. During the course of this inspection visit, staff were seen cleaning in various parts of the home. The care home looked and smelt fresh. All of the people spoken to said they liked the care home, and thought it was clean, with one person saying: The staff work very hard to keep it that way. Care Homes for Adults (18-65 years) Page 22 of 30 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good 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 care home have their care needs met by appropriately trained staff. Evidence: The staffing rota was seen, and this showed a good skill mix through the staff team. However staff numbers are quite low and the manager admitted that staff (including her and her husband) do work a lot of hours. To improve this situation a recent staff recruitment drive has seen two new staff members appointed, although they are currently awaiting clearance of their Criminal Records Bureau (CRB) check before starting work at the care home. The files of three current members of staff were seen, to check that they contained all of the information that would show that staff at the Elm had been recruited in a safe manner, namely that applicants had filled out an application form, provided two written references and had had a Criminal Records Bureau check. The documentation showed that the homes recruitment policy and procedure had worked to protect the people living there. In their AQAA they said: We provide: Robust recruitment with the required checks, and induction and training. The staff training file was seen, and this showed that the mandatory training in areas such as food hygiene, moving and handling and fire safety had been covered, and this was evidenced by the certificates in the files. The home also encourages its staff to Care Homes for Adults (18-65 years) Page 23 of 30 Evidence: complete National Vocational Qualifications (NVQs.) NVQ level II in care is the basic qualification for staff in the care industry. In their AQAA they said: We have a good understanding of competence and NVQ, National training strategies and co-ordination that translates to individual home requirements. The staff files contained information relating to formal supervision, and showed that staff have formal supervision sessions with a senior member of staff. However the records showed that the National Minimum Standard of six supervisions per year was not being met. Discussions with one member of staff confirmed that there is staff supervision, and the staff member said they felt very well supported. Formal supervision offers staff support and guidance in carrying out their work, and is seen as an essential management tool in residential care. Care Homes for Adults (18-65 years) Page 24 of 30 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good 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 Elm benefit from a well run home, and they are confident that their views underpin all self-monitoring, review and development by the home. The health, safety and welfare of everyone at the care home are promoted and protected. Evidence: Taywantee OFarrell is the registered manager of the Elm. The Commission considers her to be suitably qualified and experienced to be running the home, and she has been through the Commissions own screening process. Taywantee successfully completed her registered managers award in August 2009. The Elms quality assurance system relies on questionnaires being filled in by service users, relatives and visitors. Copies of these questionnaires were seen dated May 2009, however they were only completed by people living at the home, as none were returned by relatives. In addition monthly meetings are held for the people who live there, although the most recent minutes were not seen. A range of different health & safety records were seen, including the fire safety records, water temperature checks and the Control of Substances Hazardous to Health (COSHH) Care Homes for Adults (18-65 years) Page 25 of 30 Evidence: records, all were found to be correct and up-to-date. Evidence was seen that routine health & safety checks are being carried out, and the staff training records showed that staff were receiving relevant training in health & safety related issues. Care Homes for Adults (18-65 years) Page 26 of 30 Are there any outstanding requirements from the last inspection? Yes  No  Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 27 of 30 Requirements and recommendations from this inspection Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No Standard Regulation Description Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set No Standard Regulation Description Timescale for action 1 1 4 the Statement of purpose must contain all of the information detailed in schedule 1 of the Care Homes Regulations. Specifically it must contain details of the qualifications and experience of staff working at the care home. 31/08/2010 This will ensure that people living at the home and those who may wish to in the future know that the staff have the necessary skills and experience to meet their needs. 2 22 22 The complaints procedure must contain correct and accurate contact details for the Commission. 30/06/2010 Accurate contact information for the Commission will Care Homes for Adults (18-65 years) Page 28 of 30 Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set No Standard Regulation Description Timescale for action ensure people can make contact quickly, should they wish to do so. Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 1 Both the Statement of Purpose and the Service User Guide should be dated to allow the reader to judge how up-todate the information is. Consideration should be given to producing the Service User guide in alternative formats, for example using signs and symbols and/or photographs to make them easier to understand for people who have difficulty with written English. Where an individual has a specific health condition, the care plan should carry sufficient information to inform staff about that condition, and where the health condition is being monitored; there should be a recording tool in place. Boots the Chemist should be contacted to arrange an annual inspection of the medication. This will add to the safety of people living at the home, and offer the opportunity to discuss systems that are in place relating to medication. All staff should receive a minimum of six formal supervision sessions per year. 2 1 3 6 4 20 5 36 Care Homes for Adults (18-65 years) Page 29 of 30 Helpline: Telephone: 03000 616161 or Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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