Care Home: The Elms [Staunton]

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What the care home does well The home has a system in place to make sure people are assessed prior to admission so they are able to provide confirmation that they can meet peoples assessed needs. People who use the service and relatives that were spoken with during the inspection all praised the staff in the home saying they are hard working and very good. The Registered Manager was also praised by people and relatives and one relative said that she always makes time to speak to people and their visitors to enquiry about them.People spoken with at the inspection all said they enjoy the food provided and they are offered a choice. People can also request snacks during the day and we witnessed this taking place. The home now has 2 activities coordinators who work opposite each other to try to cover as much of the week as possible. People said they are pleased with the provision of activities and they can choose whether they join in or not. What has improved since the last inspection? Care planning has greatly improved since the last inspection. People now have care plans in place for all assessed needs. We saw evidence of ongoing reviews and care plans linked in with risk assessments which is good practice. We also saw that relatives are included in this process if the person is not able to themselves. Following a random inspection last year where one of our pharmacist inspectors visited, the home has addressed the requirements we issued at this inspection. Environmental changes have been made to include fitting of regulators to hot water taps to reduce the risk of scalds. Redecoration has taken place to parts of the home and the front entrance. At the last inspection we observed staff blowing and touching people`s food when they were assisting people. We did not observe this taking place at this inspection. What the care home could do better: To make sure people are not put at unnecessary risk a full employment history is required for all proposed staff with written explanation of any gaps. Prior to this inspection the Registered Provider had identified this and had informed the home, however the member of staff this relates to was appointed prior to this. CARE HOMES FOR OLDER PEOPLE The Elms [Staunton] Staunton Coleford Gloucestershire GL16 8NX Lead Inspector Sharon Hayward-Wright Unannounced Inspection 11th March 2009 08:25 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Elms [Staunton] DS0000062586.V374528.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Elms [Staunton] DS0000062586.V374528.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Elms [Staunton] Address Staunton Coleford Gloucestershire GL16 8NX 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) 08453 455793 01594 837681 Brickjet Ltd Miss Venon Nkosi Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places The Elms [Staunton] DS0000062586.V374528.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To accommodate a named 41yr old female service user. This arrangement must be reviewed by the CSCI after 3 months from the date of agreement should the service user still be living at The Elms. 18th February 2008 Date of last inspection Brief Description of the Service: The Elms is situated alongside the main road between Coleford and Monmouth in the Forest of Dean. The purpose-built building is registered to accommodate 31 older people who require personal and nursing care. The building is constructed on four levels, has a shaft lift, and access to the building is ramped for wheelchair users. The ground floor accommodates the main office, reception, kitchen and laundry room. On the first floor, there is a large lounge dining room and two smaller lounge areas, one being a pleasantly appointed conservatory. The upper floors have bedrooms, bathrooms and additional toilet facilities. All twenty nine rooms offer en suite facilities, with a hand basin and toilet. All rooms offer single accommodation. Spacious gardens surround the home and provide a pleasant area for people to sit when the weather allows. Current fees are £585 to £800.00 per week inclusive of the Funded Nurse Care Contribution Scheme (FNC). Hairdressing, chiropody, escort and personal toiletries are charged extra. The home is able to provide people with a copy of their Statement of Purpose and Service Users Guide. Copies of previous inspection reports are available in the home. The Elms [Staunton] DS0000062586.V374528.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 stars. This means the people who use this service experience good quality outcomes. This inspection was carried out by two inspectors on one day in March 2009. Before we visited the home we sent surveys to the home in order to obtain the views of people who use the service and staff. We received two back from people who use the service. The results of these have been used in the report. We requested an Annual Quality Assurance Assessment (AQAA) prior to this inspection. We received it on time and it contained detailed information about how the home feels they are meeting the needs of people who use the service and any plans for areas they wish to improve over the next 12 months. The AQAA also contains Dataset which is numerical information. This AQAA makes reference to another service that is managed by the Registered Provider therefore we are not sure if this information is specific just to this home. We looked at other information we have received from or about the service from other stakeholders. This includes where the home notifies us of any incidents that affects the well being of people who use the service. We looked at a number of systems the service has in place to include care records, activities, food provision, staff supervision and training, complaints, medication and maintenance records. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. What the service does well: The home has a system in place to make sure people are assessed prior to admission so they are able to provide confirmation that they can meet peoples assessed needs. People who use the service and relatives that were spoken with during the inspection all praised the staff in the home saying they are hard working and very good. The Registered Manager was also praised by people and relatives and one relative said that she always makes time to speak to people and their visitors to enquiry about them. The Elms [Staunton] DS0000062586.V374528.R01.S.doc Version 5.2 Page 6 People spoken with at the inspection all said they enjoy the food provided and they are offered a choice. People can also request snacks during the day and we witnessed this taking place. The home now has 2 activities coordinators who work opposite each other to try to cover as much of the week as possible. People said they are pleased with the provision of activities and they can choose whether they join in or not. What has improved since the last inspection? What they could do better: 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. The Elms [Staunton] DS0000062586.V374528.R01.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 The Elms [Staunton] DS0000062586.V374528.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has systems in place to make sure prospective people are assessed prior to admission to make sure their needs can be met. EVIDENCE: At the last inspection we issued a requirement for the home’s Statement of Purpose to reflect the current situation in the home as it stated they did not have any people with dementia. The home has since added an explanation about how they would manage people with dementia should this condition develop after admission. Prior this inspection the Registered Manager had contacted us regarding a possible admission of a person who was out of their category of registration. The Registered Manager was able to demonstrate how the home could meet their needs and updated their Statement of Purpose to reflect this. This person The Elms [Staunton] DS0000062586.V374528.R01.S.doc Version 5.2 Page 9 was admitted for a period of respite care and had moved back to their home prior to our inspection. We looked at a pre admission assessment of a person who had been admitted to the home within the last few months. The Registered Manager had completed an assessment of their needs prior to admission at the local hospital. Discharge information from the hospital was also available. On the day this person was admitted to the home they completed as part of their care planning format a ‘daily routine’ form that includes night time. This provides staff with a summary of this person’s care needs and their choices, for example what time they like to get up. This is good practice. We did not examine the letter that the home sends to people or their representatives to confirm their needs can be met at this inspection as we have seen them at previous inspections. The Elms does not provide intermediate care. The Elms [Staunton] DS0000062586.V374528.R01.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice by the staff. EVIDENCE: We examined the care of two people in detail. This includes examining care records, speaking to the person if able, speaking to staff and observing any interactions between staff and these people. Both people had detailed care plans in place for all assessed needs and ongoing reviews and evaluations were also in place. Care plans were reviewed monthly or before if the staff felt this was required. Risk assessments were in place for moving and handling, nutrition, challenging behaviour, pressure sores, falls and handwritten risk assessments were in place for any other areas that staff felt people were at risk. Again reviews of these were taking place. The Elms [Staunton] DS0000062586.V374528.R01.S.doc Version 5.2 Page 11 On one person’s moving and handling assessment it mentions that they may not be able to transfer themselves all the time as it is dependant on their condition, but it was not written what equipment staff would need to use if this was to happen. This should be added. We found in one person’s eliminating care plans it mentioned what aids they used and when we checked this the size of continence pad was different in the care plan to what was stored in their room, therefore a slight amendment is needed to this person’s care plan. We looked at another person’s care records in relation to wound care and found that this was in place, however on checking their pressure relieving mattress which is set by the person’s weight it was set to high. We reported this to the Registered Manager and this was rectified during the inspection. We found that one of these care plans had been discussed with the person’s family and they had signed the care records with the Registered Manager. We discussed the care of these two people with staff and they were able to demonstrate a good understanding of these people’s needs and they were aware of what was written in their care plans. We also found that care staff are also writing in the care records. Since the last key inspection the home’s Annual Quality Assurance Assessment (AQAA) mentions that the home has introduced new system to monitor peoples’ nutritional needs. This includes risk assessments for nutrition for each person, weighing people monthly or sooner if required, and a weekly nutritional report that includes information about each person and this is shared with the cook. People are also offered additional snacks and high calorie and protein milkshakes. This is very good practice. We established from peoples’ care records that they have access to external health professionals to include, GP, Community Nurses, Physiotherapists, Speech and Language therapists, Chiropodists and Psychiatrists. We spoke to a number of people and relatives of people who use the service and they all said the home provides a good standard of care and they are all very pleased. The relatives of a person who had died at the home came in to thank the Registered Manager and the other staff for their care and commitment as they said they could not fault the care. We received 2 surveys back from people who use the service and we asked them do you receive the care and support you need, both people said ‘always’. One person had written “The present staff are very supportive”. Following the last key inspection one of our pharmacist inspectors visited the home to undertake a review of the medication systems used. A report was sent to the registered people. The Elms [Staunton] DS0000062586.V374528.R01.S.doc Version 5.2 Page 12 At this inspection a pharmacist was visiting on behalf of the local Primary Care Trust (PCT) to undertake an audit. Therefore we used the results of their findings. We did observe administration of medications in the main communal room and the nurse used a safe system. Records were in place for the vast majority of medication received into the home and if any changes have been made to the directions on the Medication Administration Records (MAR) these had mostly been signed by the member of staff making the alteration. No gaps were found in the recording of medication administered to people. An error had been identified on a printed MAR but the staff had corrected this. People who are prescribed analgesia tend to have in the majority of cases the times printed onto the MAR by the pharmacy. However it was found that the correct timescale between doses was being followed. Care plan for medications prescribed as ‘prn’ or as required had care plans in place and these provided staff with clear direction on how to use this medication. People we spoke with said the staff respect their privacy and dignity. We observed staff knocking on peoples’ doors prior to entering and when hoisting people in the communal room a blanket was used to cover people, which is good practice. The Elms [Staunton] DS0000062586.V374528.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to make choices about their life style and they can access an activities programme that has been devised based on people needs, choices and abilities. EVIDENCE: Since the key inspection the home now has 2 activities coordinators who work opposite shifts to cover as much of the week as possible. They are able to provide group or one to one activities. A new sensory garden terrace area was opened last summer and people are able to access this in the warmer weather. The home has applied to their local Council for bus tokens for people and this has enabled people to be able to go on outings. Some people who use the service are able to visit the local village hall for events and this enables them to mix with people from the local community. As part of their plans for the next 12 months the home is looking to raise more funds for entertainment. Activities were taking place during the afternoon of the inspection in the communal lounge. We spoke to a number of people and they were satisfied The Elms [Staunton] DS0000062586.V374528.R01.S.doc Version 5.2 Page 14 with the activities provided by the home. Several people said they prefer to make own their own activities and do not join in the ones provided by the home. We asked people in the surveys we received if there are any activities that they can take part in and one person said ‘always’ and one person said ‘usually’. We spoke to a number of visitors to the home who confirmed that visiting is not restricted and they are made to feel welcome by the staff in the home. During the tour of parts of the environment we saw a number of rooms belonging to people and they had their personal belongings on display. Several people had photographs on their walls of their family and friends. We observed staff offering people choices for example in relation to meals preferences and if they wished to join in activities. One person said they would like to have a cooked breakfast and the Registered Manager was informed of this and said she would speak to the person involved and arrange this for them. Information about advocacy is available in the home. Menus are on display in the main entrance of the home for the week. We spoke to the cook who said they are able to make changes to the menus that are devised by the Registered Provider to suit the choices of people who use the service. The cook said they are able to offer alternatives to the menu and can make people snacks during the day as one person asked for some toast mid morning and the cook made it for them. The cook said they are given a copy of the nutritional needs of people and they provide high calorie and protein milkshakes to people who are assessed as requiring this. Health and safety checks are taking place and records were seen of these. More detail is required for their food records as alternatives to the menu are not always documented and the flavour of the soup and sandwich fillings need to be recorded. The kitchen has been awarded 3 stars from the local Environmental Health Department. We observed a mealtime in the main communal room. People are able to sit at tables that have been laid with table clothes and condiments. The cook serves the meal from a hot trolley and the staff take the meal to people. We observed staff assist people in a discreet manner and they were sat down whilst helping people with their meals. People are offered drinks with their meal. We tasted the meal and found it to be very good. People we spoke to said the food was very good and they had enjoyed the meal today. We asked people in the surveys we sent to them if they like the meals in the home and both people had replied ‘usually’. The Elms [Staunton] DS0000062586.V374528.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns and have access to a complaints procedure. Systems are in place to help protect people from possible harm or abuse. EVIDENCE: Copies of the home’s complaint procedure are included in their Statement of Purpose and Service Users Guide and these are displayed on the notice board in the entrance. We have not received any complaints about this service since the last key inspection. The home has received one complaint and the records provided evidence that they responded to this within the required timescales. The home has also put actions in place to address this issue. We asked people if they knew how to make a complaint and they all said they were very happy here, but said they would speak to a member of staff. We spoke to several visitors and they said if they had any concerns or complaints they would speak to the Registered Manager as she is very approachable. We asked people in the surveys we sent to them if they know who to speak to if they were not happy, one person said ‘usually’ and the other person said ‘sometimes’. However they had made a comment that they sometimes get confused and forget. We also asked them if they knew how to make a The Elms [Staunton] DS0000062586.V374528.R01.S.doc Version 5.2 Page 16 complaint and one person said ‘yes’ and one person said ‘no’ but had added they have forgotten. We did not read any of the policies and procedures the home for the protection of vulnerable adults as the only change that has been made since the last inspection is that the whistle blowing policy has been reviewed and updated. The home provides in house training for staff in abuse and managing challenging behaviour and 3 staff need to have this training. The Registered Manager has completed a one day course called ‘Enhanced adult protection training’ provided by the local County Council. The Registered Manager said she is looking to arrange training for staff in the ‘Alerters’ guide training which is also provided by the local County Council. A copy of the ‘Alerters’ guide leaflet is displayed in the home. No referrals have been made to the local County Council’s adult protection unit. The home’s AQAA states that in the next 12 months the home plans to introduce a happy hour where a member of care staff will sit with a person for an hour each month so the person is then able to discuss any concerns they might have with them. The Elms [Staunton] DS0000062586.V374528.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a clean, comfortable and pleasant environment. EVIDENCE: The Elms is situated in Staunton on the edge of the Forest of Dean. The home is purpose built and has 29 rooms all of which have en-suite facilities. It is set over four floors and a shaft lift provides access to all floors. People are able to have their personal belongings on display in their rooms. Since the last inspection a new terraced garden area has been developed so people can go outside and enjoy the views. We toured parts of the environment to follow up on the requirements issued at the last key inspection. All of these have now been addressed. Redecoration of the entrance and some communal rooms has taken place. We found that in some places the paintwork was looking tired, however the Registered Manager The Elms [Staunton] DS0000062586.V374528.R01.S.doc Version 5.2 Page 18 said that any issues are identified during the audits of the environment and then an action plan is put in place to address this. People we spoke with said they were happy with their rooms and several people said they like to spend their time in their rooms rather than the communal areas. The cleanliness of the home was good and we did not find any unpleasant odours, which is excellent. The laundry area was inspected and the laundry assistant was able to discuss the procedure they have in place for managing soiled linen. Protective clothing is available for staff and we observed them using it when required and alcohol gel dispensers are in places around the home including the entrance. The Elms [Staunton] DS0000062586.V374528.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is confident that their staff are trained, skilled and in sufficient numbers to meet the needs of their residents. EVIDENCE: The duty records were examined with the Registered Manager who is confident that the numbers and skill mix of staff on duty meet the needs of people who use the service. Ancillary staff are available to support the care staff. The home is using agency staff to cover some care and qualified nurse shifts but for continuity for people they use the same agency and staff where possible. Staff spoken with said it is a nice place to work as they are supported by the management of the home. They also said they have access to training and regular supervision sessions with the Registered Manager. People who use the service who were spoken with and visitors to the home all compliment the staff saying they are very good and helpful. We asked people in the surveys if the staff are available when you need then and both people said ‘always’. The home is nearly at the recommended 50 of care staff with an NVQ 2 or above in Health and Social Care. The Registered Manager said 2 staff are planning to start NVQ training. The Elms [Staunton] DS0000062586.V374528.R01.S.doc Version 5.2 Page 20 The recruitment records of two staff who had been employed since the last key inspection were examined on the home’s computer system. Both had the required recruitment checks in place except one member of staff did not have a full employment history as years were used rather than specific dates. To make sure people who use the service are not put at risk more specific dates are required. Prior to this inspection the Registered Provider had a meeting with Managers from all their services and they discussed with them that they need to have a detailed employment history. We saw evidence that both members of staff had a POVAfirst check (Protection of Vulnerable Adults list) and Criminal Records Bureau Disclosures (CRB) in place. We saw evidence of induction training for two members of staff. They keep their induction booklets and these are signed off by other members of staff and the Registered Manager. The Registered Provider has plans to review their induction training and to look at meeting the Skills for Care common induction standards in full. The Registered Manager was able to show a training matrix that has dates when staff have undertaken training and when they require an update. We saw that training sessions for staff include in-house sessions and external courses. The Care Home Support Team has provided training in a number of different areas to include dementia and falls. Training for just qualified staff has also taken place and this included the use of syringe drivers and first aid. Staff confirmed that training is available. The Elms [Staunton] DS0000062586.V374528.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A competent person supervises the management and administration of the home, and a quality assurance system is in place to help make sure the home is run in the best interests of the people who use the service. EVIDENCE: There have been no changes to the management of the home since the last key inspection. The Registered Manager confirmed she undertakes training to keep herself up to date and to develop new skills. People who use the service, staff and visitors to the home all said that the Registered Manager is approachable and they would be able to speak to her if The Elms [Staunton] DS0000062586.V374528.R01.S.doc Version 5.2 Page 22 they had any concerns or complaints. One relative said the Registered Manager really takes an interest in people and their visitors and always makes time to speak with them. The Registered Manager was able to provide evidence of the audits she has undertaken since the beginning of this year and they include, care plans, medication, infection control and selected environmental checks. Regulation 26 visits (where the Registered Provider or a representative on their behalf undertakes an unannounced visit and completes a report) are taking place and now the rating of this service has improved the records of these visits now only need to be available for us to examine at the next inspection and not sent in to us. The Registered Provider each year sends out questionnaires to people and their relatives/representatives and the results of these are displayed on the notice board in the entrance to the home. The AQAA states that the home is incorporating some of the principles of the Mental Capacity Act into their care planning and we would recommend that training is provided for all staff in this area. We received the home’s AQAA on time and it was very detailed providing us with information about what the service feels it does well and their plans to improve over the next 12 months. However the AQAA does refer to another service that the Registered Providers runs and therefore we are not sure if this AQAA is specific to The Elms. We examined the system the home has in place for managing peoples’ monies and we randomly selected two to check and all was correct. We spoke to a number of staff who confirmed they have supervision sessions with the Registered Manager. For this year all but one new member of staff has had a supervision session. We randomly selected staff supervision records for 2008 and we found that staff had at least 6 sessions with several staff having more. Ancillary staff are also receiving supervision sessions. We examined a number of ongoing maintenance checks for equipment and these included fire equipment and water temperatures. We did not examine the home’s fire risk assessment or evacuation procedure. The fire training records that we were shown related to the beginning of 2008. The AQAA also contained information about maintenance of equipment to include electrical systems and heating systems. We examined the bedrail maintenance records. The AQAA also states that the home has a number of policies and procedures in place to make sure people who use the service are safe. The Elms [Staunton] DS0000062586.V374528.R01.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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 2 3 X X X X X 3 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 2 The Elms [Staunton] DS0000062586.V374528.R01.S.doc Version 5.2 Page 24 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 OP29 Regulation 19 Requirement The registered person must obtain a full employment history on all proposed staff with written explanation of any gaps in employment to ensure people who use the service are not put at risk. This requirement remains outstanding. Timescale for action 30/07/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP15 Good Practice Recommendations The home needs to improve their recording of alternatives to the menu, the flavour of the soup and sandwich fillings. The Elms [Staunton] DS0000062586.V374528.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 The Elms [Staunton] DS0000062586.V374528.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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