Care Home: The Elms Residential Home

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What the care home does well People living at the home said that staff were friendly and attentive, the food was always tasty and staff welcomed visitors. Staff are now quickly contacting medical services if people have a potentially serious injury. Staff know what to do if abuse occurs or is suspected. Facilities have been upgraded so that the service looks more homely and attractive. The Elms Residential Home DS0000063308.V378232.R01.S.doc Version 5.2 There is signing for people with dementia so it is easier for them to get around the home. Staffing levels have increased and training has taken place to increase staff skills in meeting peoples needs. What has improved since the last inspection? Visitors are asked their opinion on the services that are offered so that management can take forward their suggestions. Staff are now quickly contacting medical services if people have a potentially serious injury. Staff know what to do if abuse occurs or is suspected. Facilities have been upgraded so that the service looks more homely and attractive. There is signing for people with dementia so it is easier for them to get around the home. Staffing levels have increased and training has taken place to increase staff skills in meeting peoples needs. What the care home could do better: Residents welfare could be more effectively met by ensuring that: All aspects of care e.g. detailed moving and handling and hoist procedures, proper toileting programmes, consistent nutrition risk assessments, are set out in Care Plans that are clear and that staff have read, to assist staff to meet all the needs of people who live in the home. Moving and handling practices need to improve.The Elms Residential HomeDS0000063308.V378232.R01.S.docVersion 5.2The Activities Programme is extended by way of more outings and more varied activities to provide more stimulation for people and that training in providing activities for people with dementia takes place to provide appropriate stimulation. The staff training programme needs to become more comprehensive through ensuring all staff receive thorough training on all the conditions that people have to increase staff skills in delivering good quality care. People need to live in a safe environment through management ensuring that all staff who work at the home have full references in place before they commence employment, that all fire risks are fully assessed and prevented, that all deprivation of liberty instances are reported to the relevant Agency, and that infection control is always observed. Key inspection report CARE HOMES FOR OLDER PEOPLE The Elms Residential Home 111 Melbourne Road Ibstock Leicestershire LE67 6NN Lead Inspector Keith Charlton Key Unannounced Inspection 2nd November 2009 09:30 DS0000063308.V378232.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. The Elms Residential Home DS0000063308.V378232.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address The Elms Residential Home DS0000063308.V378232.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Elms Residential Home Address 111 Melbourne Road Ibstock Leicestershire LE67 6NN Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01530 260263 F/P 01530 260263 The Elms Residential Home Limited Manager post vacant Care Home 18 Category(ies) of Dementia (9), Mental disorder, excluding registration, with number learning disability or dementia (6), Old age, not of places falling within any other category (18) The Elms Residential Home DS0000063308.V378232.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. No one falling within category OP may be admitted into The Elms Residential Home where there are 18 persons of category OP already accommodated within the home No one falling within category DE may be admitted into The Elms Residential Home where there are 9 persons of category DE already accommodated within the home No one falling within category MD may be admitted into The Elms Residential Home where there are 6 persons of category MD already accommodated within the home The maximum number of persons accommodated within The Elms Residential Home is 18. 26th May 2009 Date of last inspection Brief Description of the Service: The Elms is situated on Melbourne Road in the village of Ibstock. The home is within walking distance to most amenities and shops within the village. With a bus stop just outside the home, it is easily accessible both by car and public transport alike. The home offers spacious accommodation to 18 older persons and is a large modernised building with half an acre garden, mature trees and shrubs. There is ample car parking space available. The weekly fee is from £341 - £450, which was provided by the Manager on the day of the inspection. There are additional costs for hairdressing, toiletries, transport, chiropody and dry cleaning. The Home’s information - Statement of Purpose, last Inspection Report etc is available on request. The Elms Residential Home DS0000063308.V378232.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 One Star. This means the people who use this service experience adequate quality outcomes. ‘We,’ as it appears throughout the Inspection Report, refers to ‘The Care Quality Commission. The inspection process consisted of pre-planning the inspection, which included reviewing the Improvement Plan that we asked for by the owner to follow up the Requirements from the last key inspection in May 2009. We have sent surveys to people who use the service, their relatives, medical personnel and staff. When we receive these surveys back we will include the results of them if received before the final Report is published. The unannounced site visit commenced on the 2nd November 2009 and was carried out by Keith Charlton. The focus of the inspection is based upon the outcomes for people who use the service. The method of inspection was ‘case tracking’. This involved identifying people with varying levels of care needs and looking at how these are being met by the staff at The Elms. Three residents were selected. Discussions were held with eight residents, the Manager, Mrs. Shivraj Jadeja (the Registered Individual and Owner) and two members of staff. We also spoke with two visiting Occupational Therapists who were assessing moving and handling techniques as an alert has been made stating that practices are not sufficient to protect people who live in the home from harm. What the service does well: People living at the home said that staff were friendly and attentive, the food was always tasty and staff welcomed visitors. Staff are now quickly contacting medical services if people have a potentially serious injury. Staff know what to do if abuse occurs or is suspected. Facilities have been upgraded so that the service looks more homely and attractive. The Elms Residential Home DS0000063308.V378232.R01.S.doc Version 5.2 Page 6 There is signing for people with dementia so it is easier for them to get around the home. Staffing levels have increased and training has taken place to increase staff skills in meeting peoples needs. What has improved since the last inspection? What they could do better: Residents welfare could be more effectively met by ensuring that: All aspects of care e.g. detailed moving and handling and hoist procedures, proper toileting programmes, consistent nutrition risk assessments, are set out in Care Plans that are clear and that staff have read, to assist staff to meet all the needs of people who live in the home. Moving and handling practices need to improve. The Elms Residential Home DS0000063308.V378232.R01.S.doc Version 5.2 Page 7 The Activities Programme is extended by way of more outings and more varied activities to provide more stimulation for people and that training in providing activities for people with dementia takes place to provide appropriate stimulation. The staff training programme needs to become more comprehensive through ensuring all staff receive thorough training on all the conditions that people have to increase staff skills in delivering good quality care. People need to live in a safe environment through management ensuring that all staff who work at the home have full references in place before they commence employment, that all fire risks are fully assessed and prevented, that all deprivation of liberty instances are reported to the relevant Agency, and that infection control is always observed. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. The Elms Residential Home DS0000063308.V378232.R01.S.doc Version 5.3 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Elms Residential Home DS0000063308.V378232.R01.S.doc Version 5.3 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3. People using the service experience 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 Elms have their needs assessed before moving into the home, to ensure that their needs can be met. EVIDENCE: A person who lives in the home confirmed that she had been provided with sufficient written information about the home before she came in and that someone from management had come to see her at her home to see what her needs were. We case tracked a person living in the home who had moved into The Elms in the past. We also checked that this person had his needs properly assessed prior to moving in, to ensure that the staff at the home could meet their needs The Elms Residential Home DS0000063308.V378232.R01.S.doc Version 5.3 Page 10 and we found that the assessment system had a good range of information regarding peoples needs. The Elms Residential Home DS0000063308.V378232.R01.S.doc Version 5.3 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People at The Elms do not have all their personal needs fully met. EVIDENCE: People spoken with could not recall having a care plan. No. I wasnt aware that I had one though the care here is good, one person said. The Provider has stated that Plans are available to people/their relatives. This needs to be regularly brought to their attention so that people have an awareness they can see them at any time. We checked the care plans of four people living at the home who were case tracked. We saw evidence that Care Plans had been rewritten since the last inspection to try to bring them up to date and Plans showed information The Elms Residential Home DS0000063308.V378232.R01.S.doc Version 5.3 Page 12 regarding the support required by staff to ensure the physical health of people living at the home, and information to inform staff of the residents personal history, to ensure their social and emotional well being is fully supported. We spoke to two visiting Occupational Therapists who were concerned about the moving and handling practices in the service. They said that current practices were not adequate, and that there was not sufficient detail in Care Plans to ensure that people were safely transferred. They also questioned the training that staff had received and that people should have two slings to enable proper practice, but they only had one. We also found that there was not sufficient detail in Care Plans regarding proper moving and handling practice in terms of the type of sling to be used, the type of hoist needed, what loop should be used etc (as staff were not setting this properly taking into account peoples height and weight). We found confusion between the Care Plan and Risk Assessment for one person in that it stated transfers with transfer belt and two carers in the Care Plan, but in the Risk Assessment it stated, Requires one carer for all transfers’. The Owner said that the Manager is to ensure that all proper steps are taken to rectify this situation. Continence information was recorded though this assessment needed more detail to work out the individual needs of a person so staff can prompt before the person needed to go to the toilet. The Manager said this would be followed up. Weight charts did not have a column showing what action is taken following marked increase or decrease of weight. The Manager would review this idea. There were no turning charts in place for a person that needed to be turned at night or how often this turning should be (it stated ‘regularly’, which is not specifically based on assessed needs). The Manager said this would be followed up. The Provider said that this person had a pressure sore when she was admitted and through good care this was healed within four weeks. Peoples religion was recorded but no action to see if they wanted to go to church or see a religious person from their denomination. The Owner said all people were happy with the Minister who visits monthly. Staff said they had not read all the Care Plans - this is needed so that they can fully understand residents needs. Risk assessments were in place in terms of how to transfer people and continence needs etc but whilst they recorded the risk they did not record detailed action needed to ensure protection of peoples health. Care plans and risk assessments were also kept separately so were not readily available to staff to provide care that met peoples needs. The Manager agreed to review this practice. People said that staff contacted the GP if they were not feeling well. The Elms Residential Home DS0000063308.V378232.R01.S.doc Version 5.3 Page 13 Accident records were checked and medical services were contacted when a resident had a potentially serious injury. A monthly audit is recommended to be in place to review why accidents happened so that preventative steps could be put in place, thus protecting peoples health. Medication is generally well managed and appropriate staff are trained in administration of medication. We spent time observing staff interaction with people living at The Elms. We saw staff being friendly and caring to people throughout the day trying to meet the needs of people living at the home. All the people spoken with said that staff were very friendly to them. The Elms Residential Home DS0000063308.V378232.R01.S.doc Version 5.3 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are opportunities for people at The Elms to take part in activities though this needs to be extended. EVIDENCE: Residents said that they liked current activities but there was not enough of them and they would like more outings. A person said: We think the activities are good but we would like more outings and some more things to do. There was comment that there needs to be more one to one sessions with people with dementia and that only one person had a memory box, which helps stimulate people with dementia by reminiscence, and that there should be more arts and crafts sessions and nostalgia talks. Although there was an activities board in the dining area this had not been filled in so people could not check what activities were on offer. The Elms Residential Home DS0000063308.V378232.R01.S.doc Version 5.3 Page 15 People and staff said they had games, bingo, famous faces, picture cards, DVD showings, monthly church services, music and movement and musical sessions every other month. There was TV in the main lounge. People said staff take them out to the garden in good weather. The Owner said that the staff member who begins at 10.00am does the activities. There was no evidence of training for staff on providing specialist activities for people with dementia. The relations between staff and residents were observed to be relaxed. People said there was choice of food, getting up and going to bed times etc and they were not aware of any rules they had to follow. People said visitors are welcomed at The Elms and they were always greeted in a friendly way by staff. People largely said they enjoyed the food: The food cannot be faulted. It is really nice, one person said. Lunch was three courses and was a choice of two hot dinners. Staff said that the food is homemade and there were compliments about the soup and desserts in particular. Food was well presented and looked and tasted appetising. The Elms Residential Home DS0000063308.V378232.R01.S.doc Version 5.3 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. People using the service experience Good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are systems in place to protect people from abuse. EVIDENCE: People said if they had a complaint they would be take it to the Management where they thought it would be sorted out. I am sure something would be done about it, one person said. There has only been one complaint in the last eighteen months, though this had not been recorded. The Owner said this would be followed up. The service is currently subject to a safeguarding investigation due to moving and handling practices, and this was confirmed by the Occupational Therapists we spoke to on the inspection. Staff said they had been trained in protecting people from abuse. We spoke with staff and asked what they would do if it was reported that a member of staff had been seen hitting a person that lived in the home. They were clear that this was unacceptable and needed to be reported to the Manager and then to other outside agencies if it was not properly dealt with. The Elms Residential Home DS0000063308.V378232.R01.S.doc Version 5.3 Page 17 The Complaint procedure now gives the option to go to the Lead Agency, the Adult Care Department, at the initial point of the complaint. Staff were found to have criminal checks though full checks were not completely in place as a written reference was missing before employment commenced for one staff member, which could have been significant in fully protecting people from unsuitable staff. The Elms Residential Home DS0000063308.V378232.R01.S.doc Version 5.3 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19,26. People using the service experience 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 Elms live in a generally homely and well maintained environment. EVIDENCE: All people spoken with said they liked their bedrooms: My bedroom is nice. I was able to bring my own things, one person said. We saw people at The Elms living in a home that had received refurbishment in the past few months and was a generally well maintained environment. There was one cream carpet in a first floor bedroom that was stained and needed replacement. The Elms Residential Home DS0000063308.V378232.R01.S.doc Version 5.3 Page 19 The furnishings in communal areas are homely and there has been new furniture, decor, flooring and curtains installed in the past few months, and people said they can bring their personal possessions into their bedrooms. The service has improved the environment to further help people with dementia, e.g. photos on peoples doors to orientate them to go to their bedrooms, signs on bathroom doors though not all. The Manager recognised this could be improved - e.g. pictures of peoples favourite scenes on bedroom doors etc to make facilities clearer for them to recognise. There were no odours apart from low level odours from lounge easy chairs. The Owner said she would follow this up. Because of the narrow oblong shape of the dining room/lounge areas/conservatory it is difficult to use moving and handling equipment properly. The Owner said she was considering what to do to improve this situation. The Elms Residential Home DS0000063308.V378232.R01.S.doc Version 5.3 Page 20 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): 27,28,28,30. 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. Peoples needs are met as staffing levels are sufficient though training needs to be further extended and all recruitment checks fully in place. EVIDENCE: There were some comments received that there were not enough staff to spend one to one time with people but they also said that peoples needs regarding personal care were met. The Improvement Plan we received from the Owner stated that staffing has been increased and we found this to be the case. There are now four care staff on duty in the morning with three staff in the afternoon and evening, with two awake staff at night. There is also a domestic staff for three hours a day, seven days a week to ensure the home is kept clean. A staff member said that she had been encouraged by management to do recent training courses and there were more planned. The Elms Residential Home DS0000063308.V378232.R01.S.doc Version 5.3 Page 21 We found that staff have been on a number of training events to help update their practice on areas such as protecting people from abuse, Food Hygiene, Health and Safety, Moving and Handling, Fire Safety, Infection Control, Dementia, Challenging Behavior for some staff, and the Provider has supplied evidence that staff have been trained on issues regarding peoples health conditions and that the further training arranged for moving and handling and hoist practice has followed best practice, as this was seen as an issue by the visiting Occupational Therapists. Staff records showed that proper criminal records checks had been carried out to protect residents but one reference was missing for one staff member which could put people at risk from an unsuitable staff member. The Elms Residential Home DS0000063308.V378232.R01.S.doc Version 5.3 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are management systems in place to protect the health and safety of people though these need to be strengthened. EVIDENCE: There is an Acting Manager in post and the Provider confirmed she will be applying for registration for this post in the near future after the probation period, if this is satisfactory. The Acting Manager has years of experience in the care sector and has completed the NVQ Award in management skills. The Elms Residential Home DS0000063308.V378232.R01.S.doc Version 5.3 Page 23 Staff informed us that they were able to tell management of the problems they were facing however there are no regular meetings and supervision to support them and to check that their practice meets peoples needs. Management has an awareness of deprivation of liberty referrals that are needed to refer to the relevant body so that people are not to be deprived of their liberty unless it is approved to be in their best interests. Management was asked to contact the Agency for advice as to the fitted stair guard that is used on the first floor at night, which restricts peoples access on this floor. The Owner has since confirmed that all proper referrals have taken place. Satisfaction questionnaires were supplied to people last year, and there is now a form to consult any other relevant parties to see if improvements in the service are needed. Written records regarding finances for people are properly in place. There was evidence of residents meetings discussing relevant issues activities, food etc, which shows peoples involvement in the running of the home. Safe working practice Risk assessments were in place. There was evidence that the Owner has tried to solve the problem of the security of the premises being breached by children climbing the back garden wall, by trying to get action from the District Council. The safety of the stair guard to the top of the stairs on the first floor needs to be risk assessed. Fire records were in place with regular fire drills, fire bell testing and emergency lighting testing. We saw that there was a risk assessment for irregular shaped stairs at the top of the staircase though this did not cover whether they are safe if they are used in a fire and the Owner was asked to consult the Fire Service regarding this and complete a full fire assessment for this issue. The Owner has commissioned a fire risk assessment to cover this issue and sent us this document since the inspection visit. Staff understood the fire drill procedure. Infection control in terms of providing soap and towels in bathrooms and toilets was in place. The Elms Residential Home DS0000063308.V378232.R01.S.doc Version 5.3 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 The Elms Residential Home DS0000063308.V378232.R01.S.doc Version 5.3 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement Care plans must include all relevant care details - e.g. detailed moving and handling information, detailed individual toileting programmes, turning information, religious practice etc so that people have a care plan which supports their individual requirements, and that staff read clear and consistent Plans to ensure peoples conditions are managed effectively. The Registered Provider must ensure that people receive proper moving and handling practice so that their health is protected and they are not harmed. Staff must have two references before they commence employment to fully ensure the protection of people from unsuitable staff. Staff training on all relevant issues needs to be supplied and DS0000063308.V378232.R01.S.doc Timescale for action 02/01/10 2. OP8 13 02/12/09 3. OP18 19 02/12/09 4. OP30 18 02/01/10 The Elms Residential Home Version 5.3 Page 26 must train staff effectively, e.g. in moving and handling practice. 5. OP38 13 Proper Health and Safety systems must always be in place, e.g. full fire safety assessments in the home must always be in place to protect people from harm, and deprivation of liberty referrals must always be made for all relevant issues. 02/01/10 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 OP12 Good Practice Recommendations Activities need to be extended and that a staff member has training on providing proper activities to people with dementia. Facilities need to be kept odour free. 2. OP26 The Elms Residential Home DS0000063308.V378232.R01.S.doc Version 5.3 Page 27 Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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