Care Home: Elmwood Lodge

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What the care home does well Residents were involved in the day-to-day running of the home, they were also encouraged to speak up and to say what they wanted and those interviewed said they did this at the regular service user meetings. The level of activities provided both internally and externally was appropriate to the needs of residents. Both residents, who were case tracked, had received good health care and the management of medication, generally, well organised and managed. The home was comfortable and spacious and service users` bedrooms were personalised with their own possessions. Three residents who were interviewed said that staff treated them well and felt that the manager and staff were doing a good job.The staff team made efforts to make the environment as homely as possible for residents and interaction with residents observed was seen to be both caring and professional. Good attention was given to meeting residents` individual needs. The home had been operational as a registered care home for just over six months at the time of the inspection and it was evident that the manager had given great attention to ensuring that the National Minimum Standards for younger adults had been addressed and complied with as much as could be expected within that short timescale. This was reflected in that only three requirements and five recommendations were made arising from this inspection, a commendable achievement. Three professional comment cards were received from the GP and two Community Psychiatric Nurses who were all very complimentary about the home and the service provided for the residents. What has improved since the last inspection? This was the first inspection of the home since registration on 23/11/07 CARE HOME ADULTS 18-65 Elmwood Lodge 11 Victoria Road Sidcup Kent DA15 7HD Lead Inspector Keith Izzard Unannounced Inspection 16 & 25 May & 11th June 2008 03:30 th th Elmwood Lodge DS0000070969.V364640.R01.S.doc Version 5.2 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 Elmwood Lodge DS0000070969.V364640.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 Adults 18-65. 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. Elmwood Lodge DS0000070969.V364640.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elmwood Lodge Address 11 Victoria Road Sidcup Kent DA15 7HD 020 8309 7905 020 8309 7961 elmwood@quovadis-trust.org.uk 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) Quo Vadis Trust Carol Margaret Richardson Care Home 10 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (10) of places Elmwood Lodge DS0000070969.V364640.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following categories of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Mental Disorder, excluding Learning Disability or Dementia - Code MD The maximum number of service users who can be accommodated is: 10 First inspection Date of last inspection Brief Description of the Service: Elmwood Lodge is a large detached double fronted house, situated in Sidcup very close to the High Street area. It is a registered care home providing specialist and supported residential accommodation for ten adults of either gender with mental health illness. The home provides specialist care for people who may have challenging behaviour but excludes those who may be suspected of committing serious criminal offences, those with dementia or a learning disability. The accommodation comprises individual bedrooms with separate shared bathrooms and shower rooms, a large communal area, dining area, kitchen, quiet room, laundry and a large rear garden with a summer- house and large patio area. The house is well situated for local amenities within the Sidcup area and local transport; both buses and trains readily available within walking distance. The home provides person centred care with in a framework of maximising individual development and encouraging resident participation in the running of the home. Elmwood Lodge DS0000070969.V364640.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 Star. This means the people who use this service experience good quality outcomes. The site visit for this unannounced inspection was completed over a period of three separate days on the 16th and 25th May and the 11th June. The first visit was only for an hour. Overall, three members of staff and both the manager and deputy manager assisted the Inspector in a constructive and helpful manner. Three residents currently accommodated were present and assisted the Inspector by providing information about themselves particularly in respect of the service provided to them by the home, all three stated that the service was of good quality and that they were happy with both the home and the staff who supported them. The inspection included a review of information received about the service, a tour of the premises, examining written records, including care plans, talking to and observing residents’ interaction with members of the staff team. There was a happy and positive atmosphere in the home on the three days of inspection and residents appeared well cared for by staff members who were observed to be both caring and professional in their approach with residents. What the service does well: Residents were involved in the day-to-day running of the home, they were also encouraged to speak up and to say what they wanted and those interviewed said they did this at the regular service user meetings. The level of activities provided both internally and externally was appropriate to the needs of residents. Both residents, who were case tracked, had received good health care and the management of medication, generally, well organised and managed. The home was comfortable and spacious and service users’ bedrooms were personalised with their own possessions. Three residents who were interviewed said that staff treated them well and felt that the manager and staff were doing a good job. Elmwood Lodge DS0000070969.V364640.R01.S.doc Version 5.2 Page 6 The staff team made efforts to make the environment as homely as possible for residents and interaction with residents observed was seen to be both caring and professional. Good attention was given to meeting residents’ individual needs. The home had been operational as a registered care home for just over six months at the time of the inspection and it was evident that the manager had given great attention to ensuring that the National Minimum Standards for younger adults had been addressed and complied with as much as could be expected within that short timescale. This was reflected in that only three requirements and five recommendations were made arising from this inspection, a commendable achievement. Three professional comment cards were received from the GP and two Community Psychiatric Nurses who were all very complimentary about the home and the service provided for the residents. What has improved since the last inspection? What they could do better: Three requirements were made: Written contracts must be made available for all residents, the contents must comply with those listed in Standard 5 of “National Minimum Standards, Care Homes for Adults (18-65)”. Handwritten entries on Medicine administration records must be countersigned in order to avoid potential errors. Liquid medications must be dated when opened. The kitchen units were in need of replacement and worn work surfaces that might constitute a health hazard, must be upgraded. Elmwood Lodge DS0000070969.V364640.R01.S.doc Version 5.2 Page 7 Six recommendations were made: The manager was advised to write, individually to placing authorities advising that it is a legal requirement for written contracts to be available within the home produced by the placing authorities. It is recommended that an annual survey of the views of relatives/ regular visitors and visiting professionals be conducted as part of the quality control of the service provided. The manager should continue efforts to appoint a part time cook. Consideration should be given to the replacement of carpeting within the hallway and stairs area of the home. Staff members should sign a document to evidence that they have completed a shift by signing the rota to confirm this. It was recommended night- time care staff members are included in at least two fire drills per year and that this is clearly recorded. 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. Elmwood Lodge DS0000070969.V364640.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR 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) Scoring of Outcomes Statutory Requirements Identified During the Inspection Elmwood Lodge DS0000070969.V364640.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2,4 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Standard 2 The personal care files of both residents who were case tracked were examined. These included detailed referrals comprising assessments completed as part of the care management process and reports from professionals such as psychiatrists, and other therapists. Both the files of the two residents who were case tracked included a comprehensive care plan. For all except one resident it was not possible to assess whether pre admission assessments had been done prior to residents moving in as they were already resident within a Supported living status home prior to the home being registered as a care home. It was noted however, that a full pre admission assessment had been completed that met this Standard in respect of the more recent admission to the home. Both residents case tracked had clearly been involved in the setting up of their care plans and had signed them. Goals for development had been clearly identified and the process by which care staff members would achieve them and reviews of care clearly scheduled with input from both Community Psychiatric Nurses and care management. Elmwood Lodge DS0000070969.V364640.R01.S.doc Version 5.2 Page 10 Standard 4 In respect of the one resident recently admitted it was noted that although prior to admission there was detailed consideration given to a staggered admission, this was assessed as being counter productive the resident’s level of anxiety. This was clearly recorded and agreed within the admission process by the Community Psychiatric Nurse and the Manager of the home. The resident subsequently settled very well and was positively accepted by the other residents of the home, who had been enabled by staff members to express their view on this, an example of good practice. The manager stated that all future admissions would also be assessed on a similar basis and that the intention would always be to offer a staggered admission process unless there were compelling reasons not to. Standard 5 As noted in Standard 2 most residents were already living in the home prior to registration as a care home. This had impacted on the requirements of this Standard, in the sense that contracts had not been fully set up and the manager is still was awaiting responses from the placing authorities to comply with this. The manager was advised that written requests for contracts be sent as soon as possible to the various placing authorities advising that it is a legal requirement. It was noted that this had already been done on a verbal level by the manager and recorded. See Requirement 1 & Recommendation 1 Elmwood Lodge DS0000070969.V364640.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments viewed were up to date, comprehensive and reviewed on a regular basis and showed that residents were involved and family or representatives and professionals involved had been invited. Residents were involved in decisions about them, supported to be as independent as possible and records about them were handled appropriately to maintain confidentiality. EVIDENCE: Standard 6. Two care files and individual plans were examined in respect of both the residents who were case tracked. Individual plans were comprehensive and Elmwood Lodge DS0000070969.V364640.R01.S.doc Version 5.2 Page 12 involved both service users and their representatives, including family or advocates and other professionals involved. These plans are reviewed with outcomes clearly stated and agreed by all participants. Records seen were comprehensive and up to date and records included appropriate risk assessments. Where risks were identified procedures and care plans reflected how these were being managed. Standard 7 Residents are encouraged to make decisions wherever possible in respect of activities, food, domestic tasks, the décor and layout of their rooms, their personal appearance and clothes they choose to wear. All residents’ rooms were seen and all were highly personalised and residents chose their preferred colour scheme. Residents are encouraged to take part in the preparation of meals, make drinks and snacks for themselves and to assist in the compilation of the menu and also take part in the weekly shopping. The manager stated that further work is planned by staff members to increase the participation of residents in planning a weekly menu. Standard 9 Independence is promoted where possible. Risk assessments were available in both resident’s care files we examined and are readily accessible by all staff members. Any restrictions placed are minimal these are recorded in the care plan and would be for the safety and welfare of residents, for example only smoking in the designated conservatory area or outside. Evidence was available from the service user’s records examined and from discussion with three residents spoken to that they are enabled to express choice in what they do and did not feel that any restrictions were placed upon them. Elmwood Lodge DS0000070969.V364640.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12-17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Attention was given to meeting the leisure and social needs of the residents. Meals provided were varied and planned to meet the resident’s choice and preferences. EVIDENCE: Standard 12 Evidence was available from the care files that opportunities are being made available for the personal development of residents. Although owing to the degree of mental health disability difficulties none of the service users have been identified as being able to participate in full employment or further education. Two residents currently attend day centre places and one attends a local Mind centre. The other six residents have an activity plan, this is provided Elmwood Lodge DS0000070969.V364640.R01.S.doc Version 5.2 Page 14 on a daily basis, and ensure outings are possible into the community every day. Standards 13 &14 Residents are provided with a good level of community outings and activities and the home was assisted in this provision by having regular access to a mini bus and staff available and qualified to drive the vehicle. Records showed that residents were supported to access leisure activities of their own choice and to integrate with the community. A range of outings was noted, for example, visits to cinemas, places of interest, pub lunches, visiting friends and family. An activity programme also highlighted indoor activities such as Board games, bingo, painting and drawing, reminiscence, news discussions, card games and a regular movies night. The latter takes the form of a cinema visit with drinks, sweets and snacks available and residents choose the film they want to watch. Residents’ comments on how they enjoyed these events are recorded in their daily notes. Standard 15 Staff members actively support and encourage family contact and one resident visits a grandmother for a weekend visit once as month. All residents Two other residents have contact with either relatives or friends. Through the various activities and outings provided residents are provided with some opportunity for meeting with other people. Staff members reported that there are no relationships of emotional or relationship significance for any of the residents other than for those with parental involvement. Standard 16 Residents were enabled to choose their own clothes and hairstyles, when accompanied by staff members on shopping trips and one of the care staff is a qualified hairdresser. Residents were also supported to choose their own decoration and personal items for their own rooms and to participate, or otherwise, in activities of their own choosing. Standard 17 Varied and nutritious meals were provided to meet resident preferences and a rota of meals provided was seen over a period of four weeks and a good supply of both fresh and frozen food canned or died foods was seen stored in the home. Two residents receive a diet appropriate for diabetics and one an appropriate Carribean diet, whenever she requires. All residents are encouraged to eat health and nutritional meals, as many would survive on chips and junk given the opportunity. A small dining room is pleasantly laid out enabling residents to enjoy their food in a sociable situation. At present all care staff assist with the preparation of meals but the intention is to employ a part Elmwood Lodge DS0000070969.V364640.R01.S.doc Version 5.2 Page 15 time cook. This would allow more time for care staff with residents and it is therefore recommended that this appointment be made as soon as possible. See Recommendation 2 Elmwood Lodge DS0000070969.V364640.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ needs were being met based on assessment of need and with the involvement of the resident. Medicines were safely managed. EVIDENCE: Standard 18 All bedrooms in the home are single occupancy, which provides privacy for the residents. Residents are able to choose whether they receive same gender care. Care plans that were seen showed how personal care needs were to be met. Three residents who we spoke to commented that their needs were met in a way that suited them as individuals. Most of the residents in the home would be able to give feedback about any aspect of the service and both the daily notes and resident meetings showed that they were satisfied with the care provided fro them. Daily records were kept to show the care provided and activities the residents were involved with. Elmwood Lodge DS0000070969.V364640.R01.S.doc Version 5.2 Page 17 Standard 19 Care plans and daily records showed how personal care was provided. Staff interviewed spoke with knowledge and confidence about resident’s individual needs and preferences. Residents were supported to access health services appropriately and these were provided either in the home or by attendance at local clinics and surgeries. All residents were registered with a local GP and staff supported them to access other medical services such as dental and optical care. Links were well established with the community mental health teams in order to support staff with meeting residents’ needs and evidence available of regular visits by them to facilitate this. A CSCI questionnaire completed by the local GP and comments we received directly from two visiting Community Psychiatric Nurses were very positive about the care and professionalism of staff members within the home. Any nursing care needs would be commissioned via the GP from the local District Nursing Service and all residents had established links with the local mental health services including CPN’s. Standard 20 Both residents case tracked stated that they were happy for staff members to assist them with their medication and did not express any desire to self medicate. The manager stated that should a resident wish to deal with their own medication and this was risk assessed as appropriate, then they would be encouraged to do so, under supervision and appropriate lockable facilities made available. The medication system was examined and was appropriately organised; medication was stored in a locked cabinet and quantities and dosage of medications tallied with the MAR sheets examined. Controlled drugs were appropriately double locked and two signatures obtained when giving to residents as required. The home had a policy and procedure for medication that was comprehensive and only staff members who had received training were allowed to deal with medication. The manager stated that advice was readily available from the supplying Pharmacist. In fact, a training session had recently been provided for all staff members and also an audit of the medication system; the report of which was seen and was positive and one recommendation made had already been implemented. We did note however, that handwritten entries on MAR sheets were not countersigned and some liquid medications had not been dated when opened. See Requirement 2 Elmwood Lodge DS0000070969.V364640.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22-23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Adequate procedures were in place to ensure complaints were managed and to protect residents from abuse. EVIDENCE: Standard 22 The home had policies and procedures in relation to complaint management. A system was in place to record complaints made about the service. No complaints had been made to the provider since the home opened. Nor have any complaints had been received directly by the Commission. All residents have the capacity to raise concerns and when we spoke to three residents they all indicated that they were very happy within the home and had no complaints. A copy of the complaints procedure is clearly displayed in the entrance area along with a “grumbles folder”, a good initiative by staff, that highlighted very minor issues that had been resolved by staff members in conjunction with residents. Elmwood Lodge DS0000070969.V364640.R01.S.doc Version 5.2 Page 19 Standard 23 The home had policies and procedures in relation to Safeguarding Adults protection and a whistle blowing policy. No allegations of abuse had been made to the provider or the Commission since the home opened. The home had a copy of the London Borough of Bexley safeguarding Adults Procedures and staff members had read the document and signed to verify that they understood it. The homes policy matches the requirements within the local authority procedures. Those staff interviewed by the Inspector indicated a good understanding of adult protection and how they would manage such a situation. All staff had received POVA training although the manager felt that a couple needed updating and stated this would be scheduled in as soon as possible. Three staff members we interviewed were confident that both the manager and deputy manager would respond appropriately to any such matter arising. The financial records pertaining to two residents case tracked were examined and found to be accountable. Good records of expenditure were kept along with receipts and the cash held in the lockable safe tallied with that recorded in the ledger. Elmwood Lodge DS0000070969.V364640.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a homely and comfortable environment that is safe clean and hygienic. The premises were generally homely in appearance and decorated to a satisfactory standard. Individual and communal accommodation suited residents’ needs and one resident had the specialist equipment he needed to maximise his independence. EVIDENCE: Standard 24 The home was clean, bright and comfortable. Bedrooms were spacious and highly personalised, this is commendable, and there was ample communal Elmwood Lodge DS0000070969.V364640.R01.S.doc Version 5.2 Page 21 space for service users. We noted that there was a patio area to the rear of the building adjacent to the conservatory leading off from the sitting room. This area had the necessary equipment for relaxation in warmer months by the residents and was part of a well looked after and attractive rear garden. In between the days of inspection the manager had already arranged for the replacement of some carpeting in resident’ bedrooms and the office. It is recommended that consideration be given to similar replacement in the hallway and lower stairs area. See Recommendation 3 Standard 30 The Home was very clean and tidy on all three days of the inspection, and liquid soap and towels was available in the bathrooms and toilets. The kitchen work surfaces were clean and tidy with utensils and equipment appropriately stored. All cleaning materials were locked away and subject to COSHH procedures. However, it was noted that the kitchen units were in need of replacement and that worn work surfaces might constitute a health hazard and should therefore be upgraded. See Requirement 3 A laundry is situated on the ground floor and equipped with a washing machine and a tumble dryer that were suitable, for purpose. Elmwood Lodge DS0000070969.V364640.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33, 34 & 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff training was comprehensive and the required level of staff members qualified to Level 2 NVQ was anticipated latter this year. Residents are supported and cared for by competent and qualified staff members who act as a team to meet their needs. Recruitment practice was satisfactory. EVIDENCE: Standard 32 From observations made of care worker practice and the evidence of training provided for staff the Inspector felt that, overall, there was a good level of skills and experience and that those staff observed had the requisite skills, attitudes and characteristics necessary to adequately support service users. Staff members were observed to be respectful and caring in the way they were Elmwood Lodge DS0000070969.V364640.R01.S.doc Version 5.2 Page 23 relating to service users. It was equally evident that service users were content within their environment and responding positively to any staff interventions. The home has almost achieved the required 50 of care staff members qualified to Level 2 NVQ. The remaining staff members were all working toward this qualification therefore there is every reason to anticipate that this Standard will be met soon. The manager agreed to monitor this. Staffing numbers were as stated in the registration report for the home and rotas over a four week period showed this to be consistent. It was recommended that individual shifts be signed by staff to evidence their attendance on shift See Recommendation 4 Standard 33 Two members of staff are on duty at all times including night time however we agreed at this inspection that the current requirement for two waking night staff be amended to one waking night staff and one sleep in member of staff following the completion of an adaptation to the garage to provide a sleep in room and additional space for meetings, both for professionals and residents. Standard 34 Three personnel files were examined for staff members and recruitment practice was found to be in accordance with the requirements of Regulation 19 and Schedule 2 of the National Minimum Standards. Proof of identity and photos were included on the personnel files and also evidence obtained of the physical and mental fitness of workers had been complied with, CRB and POVA checks completed and references appropriately obtained .Two members of care staff were interviewed and both stated that they had received a thorough recruitment and induction programme when they commenced working for the home. Midway through the days of inspection the manager had felt it necessary to dismiss a care worker following an observation we made about Home Office documentation seen on the file. Following the advice given to contact the Home Office, this resulted in the above action. The manager had acted swiftly to deal with the situation. In all other respects the Standard was met. Standard 35 Training records for individual staff members were seen and this showed that a good level of training had been provided and was being planned for the future. Induction training had been provided for new staff and foundation training following this as well as medication, fire prevention, moving and handling, POVA and person centred care. Overall, a comprehensive spread of training had been provided for staff members. A training matrix showed the training Elmwood Lodge DS0000070969.V364640.R01.S.doc Version 5.2 Page 24 scheduled for future provision and assists the manager to identify any gaps existing for the staff team as a whole. Elmwood Lodge DS0000070969.V364640.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was well run. Quality assurance mechanisms were being developed and surveys of service users and others involved with the home were about to be developed. The health and safety of service users was promoted. EVIDENCE: Standard 37 Elmwood Lodge DS0000070969.V364640.R01.S.doc Version 5.2 Page 26 The manager is a very experienced and competent mental health professional having a comprehensive background in various areas of supported living and residential mental health provision. Two staff members and the two service users interviewed were all very positive about the way the home was managed and the support and advice available to them offered by the manager. All commented that they would not have any hesitation in approaching her about any concerns either in respect of the welfare of service users or the running of the home. The manager was aware of the need to update her own training and was already included within the overall training matrix. Standard 39 Feedback was evidently received from both service users in respect of the running of the home via weekly and recorded residents’ meetings. The manager had undertaken an annual survey of residents’ views and the results were seen to be positive. We recommended that a similar survey of the views of visiting professionals and other visitors such as relatives also be implemented as soon as practicable. See Recommendation 5 In any event opportunities are readily available for professionals to communicate their views given the regularity of contact with residents. Nevertheless, the manager stated that she intends to introduce appropriate annual surveys as recommended. The home had received regular monthly monitoring visits as required under Regulation 26 and the reports were available for inspection within the home. Standard 42 Records indicated that all gas, fire and electrical systems and equipment in the home are serviced and inspected appropriately and that all internal checks are conducted at appropriate intervals. Environmental health and fire inspections had also been conducted in the recent past and no concerns were identified. A test for Legionella had been conducted and was satisfactory, this was a requirement from the registration report. A number of areas were picked at random and checked against the pre inspection questionnaire (AQAA), the information provided, was found to have been accurately recorded. It was recommended that fire drills clearly indicated that night- time care staff members were recorded as having taken part at least two times per annum. See Recommendation 6 Elmwood Lodge DS0000070969.V364640.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 3 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Elmwood Lodge DS0000070969.V364640.R01.S.doc Version 5.2 Page 28 N/A Are there any outstanding requirements from the last inspection? 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 YA5 Regulation 5 (3) Requirement Timescale for action 01/09/08 2 YA20 13 3 YA30 23 (2) b Written contracts must be made available for all residents, the contents must comply with those listed in Standard 5. Handwritten entries on MAR 01/08/08 sheets must be countersigned in order to avoid errors. Liquid medications must be dated when opened. The kitchen units were in need of 01/09/08 replacement and worn work surfaces that might constitute a health hazard, must be upgraded. Elmwood Lodge DS0000070969.V364640.R01.S.doc Version 5.2 Page 29 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 YA5 Good Practice Recommendations The manager was advised to write, individually to placing authorities advising that it is a legal requirement for written contracts to be available within the home produced by the placing authorities. The manager should continue efforts to appoint a part time cook. Consideration should be given to the replacement of carpeting within the hallway and stairs area of the home. Staff members should sign a document to evidence that they have completed a shift by signing the rota to confirm this. It is recommended that an annual survey of the views of relatives/ regular visitors and visiting professionals be conducted as part of the quality control of the service provided. It was recommended night- time care staff are included in at least two fire drills per year and that this is clearly recorded. 2 3 4 5 YA17 YA24 YA32 YA39 6 YA42 Elmwood Lodge DS0000070969.V364640.R01.S.doc Version 5.2 Page 30 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 Elmwood Lodge DS0000070969.V364640.R01.S.doc Version 5.2 Page 31 - 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. 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