Care Home: Elmhurst

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What the care home does well Elmhurst has a friendly and supportive atmosphere. The manager and staff are committed to providing a very good level of care to all residents. The staff understand the needs of residents and work hard to meet these needs in a way that respects their privacy and dignity. Residents are encouraged to be as independent as they wish. The manager of the home is professional and committed to providing a caring and supportive environment. One resident told us, "I wouldn`t like to live anywhere else". Another resident commented, "I don`t think you could choose anywhere better". What has improved since the last inspection? Three requirements and three good practice recommendations were issued at the last inspection. These have now all been complied with. The manager has now applied to the Commission to be the registered manager of the home. The manager now receives regular supervision. Residents now have more of a say in how the home is run. Residents are more involved in their care plans and risk assessments. Night staff now undertake regular fire drills. The manager is making sure that criminal record checks are being renewed for all staff who have been working at the home for a long time. What the care home could do better: ElmhurstDS0000010671.V376087.R02.S.doc Version 5.2 Five new requirements and one good practice recommendation has been issued as a result of this inspection. The home must make sure that only those residents who fall into the agreed categories of registration are admitted to the home. This means that until the home has a dementia category, no people with dementia should be admitted to the home. The dishwasher must be repaired so that staff can spend more quality time with residents. The manager must check to see if staff are up to date with the training they need to do in order to support people safely and appropriately. Maintaining the proper written records at the home has become patchy. It is vital that no important documentation is taken out of the home. The registered person must make sure that the electrical installation in the home is checked to make sure it is still safe. Every resident should have an individual fire risk assessment so staff know what to do in the event of a fire and how best to support the evacuation of each resident. Key inspection report CARE HOMES FOR OLDER PEOPLE Elmhurst 7 Queens Road Enfield Middlesex EN1 1NE Lead Inspector Mr David Hastings Key Unannounced Inspection 15th June 2009 09:30 DS0000010671.V376087.R02.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. Elmhurst DS0000010671.V376087.R02.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 Elmhurst DS0000010671.V376087.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elmhurst Address 7 Queens Road Enfield Middlesex EN1 1NE 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 8366 3346 F/P 020 8366 3346 Mr Teen Fook Chon Mrs Julie Sooi Yuin Chon Mrs Janet Murphy Care Home 14 Category(ies) of Old age, not falling within any other category registration, with number (14) of places Elmhurst DS0000010671.V376087.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th July 2007 Brief Description of the Service: Elmhurst is a home for 14 older people. It is owned by Mr & Mrs Teen Fook Chon and is located a short distance from Enfield Town. The home provides a service to older people with a wide range of needs. Some of the older people are very mentally alert and able to maintain their own self-help skills. Some of the other older people have high care needs and require staff support in all aspects of their care. The house is on two levels and there is a lift. There are two shared bedrooms and the others are single. All the rooms have en-suite facilities and there is also one assisted bathroom on the ground floor. There is a large lounge/ dining room at the rear of the house overlooking the garden. This room is comfortable and bright with chairs around the edge of the room in a traditional manner. The stated aims of the service are to provide a secure home in which the service user can express their individuality, to seek the maximum development of each service user within their potential and to promote a feeling of self worth for each service user. Fees at the home range between £420 and £450. A copy of this report can be requested directly from the home or accessed via the CSCI website (web address on page 2 of this report) Elmhurst DS0000010671.V376087.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This Key Unannounced inspection took place on Monday 15th June 2009 and was completed on the same day. The inspection lasted five and a half hours. We spoke with three staff on duty during the inspection. We spoke with seven residents of the home. We observed the interactions between staff and residents. We inspected the building and examined various care records as well as a number of policies and procedures. The home also prepared a self–assessment (AQAA) and this was submitted to the Commission. This information was used as part of the inspection. What the service does well: Elmhurst has a friendly and supportive atmosphere. The manager and staff are committed to providing a very good level of care to all residents. The staff understand the needs of residents and work hard to meet these needs in a way that respects their privacy and dignity. Residents are encouraged to be as independent as they wish. The manager of the home is professional and committed to providing a caring and supportive environment. One resident told us, “I wouldn’t like to live anywhere else”. Another resident commented, “I don’t think you could choose anywhere better”. What has improved since the last inspection? What they could do better: Elmhurst DS0000010671.V376087.R02.S.doc Version 5.2 Page 6 Five new requirements and one good practice recommendation has been issued as a result of this inspection. The home must make sure that only those residents who fall into the agreed categories of registration are admitted to the home. This means that until the home has a dementia category, no people with dementia should be admitted to the home. The dishwasher must be repaired so that staff can spend more quality time with residents. The manager must check to see if staff are up to date with the training they need to do in order to support people safely and appropriately. Maintaining the proper written records at the home has become patchy. It is vital that no important documentation is taken out of the home. The registered person must make sure that the electrical installation in the home is checked to make sure it is still safe. Every resident should have an individual fire risk assessment so staff know what to do in the event of a fire and how best to support the evacuation of each resident. 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. Elmhurst DS0000010671.V376087.R02.S.doc Version 5.2 Page 7 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 Elmhurst DS0000010671.V376087.R02.S.doc Version 5.2 Page 8 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. The home carries out an assessment of individual’s needs so that they know that the home is able to meet their needs before they decide to move in on a trial basis. The service is not always keeping to its categories of registration. EVIDENCE: Pre admission assessments were examined for three people who are now living at the home. The information was satisfactory and clearly outlined each person’s individual needs. There was evidence that these identified needs were also being recorded in each person’s individual care plan. People who use the service told us that they were involved in this assessment process and, where possible, had visited the home before moving in on a trial basis. One resident told us, “My daughter visited the home before I moved in”. Elmhurst DS0000010671.V376087.R02.S.doc Version 5.2 Page 9 One person had been admitted to the home with a diagnosis of mild dementia. The home is not registered to admit people with a diagnosis of dementia. We checked the care plan for this person and saw that her needs were being met. We spoke with the resident who was very positive about how the staff were supporting her. The home recently applied to the Commission to be able to take people with a diagnosis of dementia however this change to the home’s registration was refused. Staff at the home are now undertaking a distance learning course in dementia and there are plans to convert the house next door and enlarge the home. The manager told us that the service would be reapplying to be able to admit people with dementia. Until this has been agreed with the Commission no one with a formal diagnosis of dementia can be admitted to the home. A requirement relating to this has been made in the relevant section of this report. Elmhurst DS0000010671.V376087.R02.S.doc Version 5.2 Page 10 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 and 10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans clearly set out residents’ health, personal and social care needs so that staff know how best to support everyone at the home. Residents have good access to health care professionals and they are treated with respect. Residents get the medication they require, at the right times and by appropriately trained staff. EVIDENCE: Six care plans were examined. Each plan had a summary of the person’s care needs including their physical, emotional and social needs. Each plan gave clear instructions to staff about how best to care for each person. Care plans were being reviewed on a regular basis and updated where needed. There was evidence that people were being asked what they thought about their own care plans. It was positive to see that residents were also able to comment on their individual risk assessments as well. Elmhurst DS0000010671.V376087.R02.S.doc Version 5.2 Page 11 Each person’s plan of care included an assessment of the risk of falling and how staff are to reduce this risk, for example, having two staff to help with personal care tasks or by supervising the resident when they walk around the home. There were other risk assessments seen in each person’s file, including manual handling, pressure care and nutrition. All these were being reviewed on a regular basis. The home has made sure that everyone has a yearly review of their placement so they can make sure the home is still meeting their needs. There was evidence from care plans that people have good access to health care professionals such as doctors, chiropodists, district nurses and opticians. People who use the service confirmed that they had good access to health care professionals. One resident told us that the staff would call for a doctor if needed or they would take them to see the doctor. On the day of the inspection people using the service looked well cared for, their clothes were clean and they were appropriately dressed. Satisfactory records were examined in relation to the receipt, storage, administration and disposal of medication. Records indicated that staff have undertaken medication training and only qualified staff administer medication at the home. Each person’s medication chart has a picture of them attached to it so that staff can double check who is receiving the right medication. We saw a number of examples of supportive staff interactions with people and staff were able to describe to us how they ensure the privacy of people they support. We saw staff knocking on resident’s bedroom doors before entering. People we spoke with told us that the staff were respectful and kind towards them. A resident told us, “They never come in without knocking first”. Another resident told us the staff were, “Very kind”. Elmhurst DS0000010671.V376087.R02.S.doc Version 5.2 Page 12 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 and 15 People using the 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 home provides varied activities for people who use the service in order to keep them suitably occupied and engaged. Visitors to the home are encouraged and welcomed. Residents are able to exercise choice and control over their lives. The home provides people with a wholesome appealing balanced diet. EVIDENCE: During the inspection staff were observed carrying out activities with residents such as playing card games and bingo. People told us they were satisfied with activities on offer at the home. A weekly trip out to the local supermarket is organised and some residents go out of the home on a regular basis to see their family and friends. One resident told us, “I can’t say I every get bored”. Residents also told us that they help out around the home such as laying tables for lunch. Elmhurst DS0000010671.V376087.R02.S.doc Version 5.2 Page 13 Residents were spoke with said that visitors are welcomed and encouraged and always offered tea or coffee when they visit. The visitors’ book indicated that family and friends could visit at any reasonable time. Staff we interviewed were able to give us practical examples of how they offer choice to people living at the home. We saw examples of staff offering choice in relation to meals and activities during the inspection. Peoples’ preferences in relation to getting up in the morning and going to bed of any evening are recorded in their individual care plans. The home holds regular residents’ meetings and residents we spoke with said these meetings were a useful way of having a say about the home. One person said, “We can be honest about what we say”, another resident said, “We can say our likes and dislikes with food”. On the day of the inspection the cook was on her day off and a staff member was cooking the lunch. The kitchen was clean and tidy with fresh fruit and vegetables available. The kitchen has recently been inspected by the local environmental health department and, after a few issues were dealt with, has been given “4 Scores on the doors”. The dishwasher was not working. As staff have to cook on some days it is unacceptable that they are further taken away from being with residents because they have to wash up as well. A requirement has been issued that the dishwasher is repaired so that staff have more time to spend with residents. People told us they were happy with the food provided by the home. One resident said, “I like the food here”. Another resident commented that the food was, “Tip top”. The staff also provide culturally appropriate diets to residents as well as any special diets that people may require. The lunch on the day of the inspection looked and smelt appetising and residents confirmed they were always offered a choice of meals. Elmhurst DS0000010671.V376087.R02.S.doc Version 5.2 Page 14 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 and 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints are taken seriously and responded to in a professional manner. People at the home are protected from abuse by clear policies and procedures and by an appropriately trained staff team. EVIDENCE: The home has satisfactory policies and procedures in relation to complaints and the protection of residents from abuse. No complaints have been received by the home since the last inspection. Previous complaints recorded, had been dealt with appropriately and in line with the home’s complaints procedure. All the residents and visitors we spoke with said they had no complaints about the service but were clear that they would say something if they had a concern. Residents said they would speak to the manager and were confident that she would, “Sort it out”. One resident commented, “I’ve got nothing to grumble about”. Some minor issues have come out of the residents meetings and records were being maintained about how the manager has addressed this issues. Staff were able to describe how vulnerable people could be at risk of abuse in a residential care setting. All staff interviewed were clear of their responsibility to report any suspicions of abuse to the appropriate authorities. Elmhurst DS0000010671.V376087.R02.S.doc Version 5.2 Page 15 Residents that we spoke to said they felt safe and well supported at the home. The manager has completed a “train the trainers” course in safeguarding and carries out in house training for staff. There have not been any safeguarding issues at the home. Elmhurst DS0000010671.V376087.R02.S.doc Version 5.2 Page 16 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 and 26 People using the 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 home is safe, clean, well maintained and furnished and decorated to a good standard. EVIDENCE: We looked around the home with the manager and visited a number of residents’ rooms. The home was well maintained and decorated to a good standard. The maintenance person from another home in the organisation visits the home when needed to carry out minor repairs and redecoration. Records indicated that maintenance contracts were in place for the lift, moving and handling equipment, the nurse call system and clinical waste management. Residents told us they were happy with their rooms and that they were able to bring in their own possessions. One resident described Elmhurst as, “Homely”. Elmhurst DS0000010671.V376087.R02.S.doc Version 5.2 Page 17 One resident said the home was, “Nicely decorated”. On the day of the inspection the home was clean and tidy. The home employs a domestic worker and the residents we spoke with confirmed that the home was always clean. There are satisfactory policies and procedures in place to reduce the risk of cross infection. The laundry area was clean and all toilets and bathrooms had paper towels and anti-bacterial soap. Records indicated that most staff have attended infection control training. However some refresher courses are needed for staff. This issue is addressed in the following section of this report. Elmhurst DS0000010671.V376087.R02.S.doc Version 5.2 Page 18 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 and 30 People using the 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 staff at the home work hard to meet the needs of the residents and are generally provided with good training opportunities to further enhance their knowledge and skills. Recruitment practices are sufficiently detailed in order to protect residents at the home. EVIDENCE: On the day of the inspection there were ten residents at the home. There are two care staff on during the day and at night there is one waking and one sleep in staff on duty. Residents were positive about the staff team. One resident told us, “They do look after us”. Another resident said, “They are very good”. Staff we interviewed had a good knowledge of the residents’ needs and it was clear that staff treated people as individuals. Information we received prior to this inspection indicated that the majority of the staff team have completed their NVQ level 2 training. Staff were positive about the training offered by the home however we noticed that some mandatory training certificates were out of date. It is very important that staff are able to attend refresher courses to make sure they are up to date Elmhurst DS0000010671.V376087.R02.S.doc Version 5.2 Page 19 with current best practice. A requirement has been issued relating to this in the relevant section of this report. Three staff files were examined from staff recently employed by the home. We checked these files to see if the home’s recruitment procedures were being followed so that residents are protected from unsuitable staff working at the home. The files examined contained all the information needed to protect residents including two written references, proof of identity and criminal record checks. A number of staff have worked at the home for a long time so we issued a good practice recommendation at the last inspection that staff CRB disclosures should be updated. The manager told us that she was dealing with this matter. Elmhurst DS0000010671.V376087.R02.S.doc Version 5.2 Page 20 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, 37 and 38 People using the 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 manager of the home knows the residents very well and understands their needs. Residents do have opportunities to have a say in how the home is run. Residents’ financial interests are being safeguarded. The health and safety of residents and staff are promoted and protected. EVIDENCE: The manager of the home has been in post for some time and has now applied to the Commission to become the home’s registered manager. Residents we spoke with were very positive about the manager. Residents described the manager as, “Very good” and “Very nice”. One person commented that the Elmhurst DS0000010671.V376087.R02.S.doc Version 5.2 Page 21 manager “Has helped me out a lot”. The manager has completed the required training to carry out her role affectively. There was also evidence that the manager attends training courses on a regular basis. We made a requirement at the last inspection that the manager is provided with regular supervision. We could not find any written record of this during the inspection. The registered provider later phoned us to confirm that this takes place on a regular basis and records are maintained however she had mistakenly taken these records out of the home. The registered provider also told us that she had mistakenly taken the monthly regulation 26 reports as well. We reminded the provider that these records must be available for inspection at all times. Residents we spoke with confirmed that the registered provider visits the home on a regular basis and always asks them how things are going and if they need anything. The service carries out regular quality monitoring exercises and surveys are sent to residents and other stakeholders on a regular basis. The results of these surveys have been collated, published and are available to interested parties. As mentioned elsewhere in this report there are regular residents meetings so that people who use the service can have a say in how the home is run. Most of the residents handle their own financial affairs or they are helped to do this by their family or representatives. They are provided with a lockable cupboard in their room. The home holds money on behalf of two residents. These monies were checked and found to be accurate, with receipts and a clear audit trail. These monies are also being audited by the local authority. We saw records that indicated the fire alarm was being checked weekly and both day and night staff were undertaking regular fire drills. Residents confirmed that they were involved in these fire drills. The manager told us that the fire officer recently inspected the home in September 2008. The manager discussed the fire risk assessment with him as well as the emergency fire evacuation plan. These documents did not appear to have been reviewed recently. The manager later told us that these documents had been reviewed but had been put in the wrong file. It is important that all documents are easily accessible for all staff and available for inspection at all times. A requirement relating to this and other documentation has been issued in the relevant section of this report. It would also be prudent to complete individual fire risk assessments for all residents at the home so that staff know how to support and evacuate each resident in the event of a fire. A good practice recommendation has been issued. We saw satisfactory certificates in relation to the fire alarm, Legionella, gas safety and portable appliance testing. Elmhurst DS0000010671.V376087.R02.S.doc Version 5.2 Page 22 The electrical installation certificate was out of date. The registered provider contacted us after the inspection and told us this would be booked as a matter of urgency. A requirement relating to this has been issued. As mentioned elsewhere in this report staff are undertaking health and safety training but some refresher courses are needed so staff are up to date with current best practice. Residents we spoke to said that the service took health and safety matters seriously and that they felt reassured by this. One resident said, “There is no stress about our safety, they are very concerned about safety”. Elmhurst DS0000010671.V376087.R02.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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X 2 2 Elmhurst DS0000010671.V376087.R02.S.doc Version 5.2 Page 24 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 OP3 Regulation 14 Requirement The registered person must ensure that no resident is admitted to the home who has needs that are outside the allowed categories of admission. This includes people with dementia. The registered person must ensure that the dishwasher in the kitchen is either repaired or replaced. The registered person must carry out a training audit for all staff and provide refresher courses where identified. This should ensure that staff are up to date with current best practice. The registered person must ensure that all records that are required to be maintained and stored at the home are available for inspection at all times The registered person must ensure that the electrical installation certificate is updated. Timescale for action 01/07/09 2. OP19 23(2) c 01/08/09 3. OP30 18(1) c 01/09/09 4. OP37 17 01/09/09 5. OP38 23(2) 01/09/09 Elmhurst DS0000010671.V376087.R02.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP38 Good Practice Recommendations The registered person should carry out risk assessments for all residents relating to fire risk and individual fire evacuation plans. This should ensure that all staff are aware of how to support and evacuate all residents in the event of a fire. Elmhurst DS0000010671.V376087.R02.S.doc Version 5.2 Page 26 Care Quality Commission 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. Elmhurst DS0000010671.V376087.R02.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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