Care Home: The Elms (Yeovil)

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What the care home does well The Elms is a small care home with a homely atmosphere. It is well furnished and decorated. All bedrooms are for single occupancy and privacy is respected. People living and working at the home said that the manager was open and approachable and that there were always opportunities to make suggestions and share views about the running of the home. There is a complaints procedure and people said that they would be comfortable to raise any concerns with a member of staff or the manager. 89% of people who completed a questionnaire answered ALWAYS to the question ‘Do staff listen and act on what you say?’ The Elms (Yeovil) DS0000016083.V378478.R01.S.doc Version 5.2 The staff spoken with during the inspection, and those who completed questionnaires, were well motivated and positive about their jobs. What has improved since the last inspection? At the last inspection the home received a requirement to review the heating in one part of the home. The home has looked into the problem and taken some actions to address. At this inspection people living in this part of the building said that they were always warm enough. A member of the care staff team has been nominated to take a lead role in the arranging and co-ordination of activities. It is hoped that this will produce a mare varied activity programme that will appeal to a greater number of people. Staff training in the home has become more organised and all staff have now completed training in all statutory health and safety issues and other relevant subjects. What the care home could do better: Care plans would benefit from being more comprehensive to ensure they give clear guidance to staff on peoples’ needs and wishes. This is to make sure that people receive appropriate care in their preferred manner. People should be fully consulted on their care plan and their views should be documented as part of the plan. Medication administration practices and recordings need to be improved to ensure that they are consistent and in line with the homes policy. It is strongly recommended that the homes quality assurance systems incorporate regular audits of care plans and medication practices. It is also recommended that the manager obtains a copy of the local safeguarding vulnerable adults policy and ensures that all staff are familiar with the policy and how to recognise and report any suspicions of abuse. Key inspection report CARE HOMES FOR OLDER PEOPLE The Elms (Yeovil) Yeovil Marsh Yeovil Somerset BA21 3QG Lead Inspector Jane Poole 17th November 2009 DS0000016083.V378478.R01.S.do c Version 5.3 Key 10:00 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 (Yeovil) DS0000016083.V378478.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 (Yeovil) DS0000016083.V378478.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Elms (Yeovil) Address Yeovil Marsh Yeovil Somerset BA21 3QG 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) 01935 425440 01935 471476 osbornetheelms@aol.com Mrs Lee Teresa Osborne Mrs Lee Teresa Osborne Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places The Elms (Yeovil) DS0000016083.V378478.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th November 2008 Brief Description of the Service: The Elms is located at Yeovil Marsh, a small village 2 miles from the town of Yeovil. The village has a church and the facilities offered by Yeovil are a short car ride away. The home is an extended single storey building surrounded by gardens with views of the countryside beyond. The home provides residential care and support for up to 16 older people. The home also offers day care to a small number of non-residents. All bedrooms offer single occupancy with en suite facilities. Current fees at the home range from £402.95 to £462.00 per week. The Elms (Yeovil) DS0000016083.V378478.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 1 star. This means the people who use this service experience adequate quality outcomes. The focus of this inspection visit was to inspect relevant key standards under the Commissions Inspecting for Better Lives 2 framework. This focuses on outcomes for people and measures the quality of the service under four general headings. These are:- excellent, good, adequate and poor. This inspection was carried out over a one day period. During this time We, The Commission, were able to speak with people living and working at the home, tour the building, observe care practices and view records. We were given unrestricted access to all areas of the home and all records requested were made available. Before the inspection questionnaires were sent out to people living at the home and other interested parties. We received 9 completed questionnaires from people living at the home, 7 from staff and 2 from health and social care professionals. Some of the comments from these have been incorporated in this report. The manager completed an Annual Quality Assurance Assessment (AQAA) giving information about the home and their plans for improvements in the coming year. Again some information from this document has been used in this report. The following is a summary and should be read in conjunction with the whole of the report. What the service does well: The Elms is a small care home with a homely atmosphere. It is well furnished and decorated. All bedrooms are for single occupancy and privacy is respected. People living and working at the home said that the manager was open and approachable and that there were always opportunities to make suggestions and share views about the running of the home. There is a complaints procedure and people said that they would be comfortable to raise any concerns with a member of staff or the manager. 89 of people who completed a questionnaire answered ALWAYS to the question ‘Do staff listen and act on what you say?’ The Elms (Yeovil) DS0000016083.V378478.R01.S.doc Version 5.2 Page 6 The staff spoken with during the inspection, and those who completed questionnaires, were well motivated and positive about their jobs. What has improved since the last inspection? What they could do better: 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. The Elms (Yeovil) DS0000016083.V378478.R01.S.doc Version 5.2 Page 7 You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. The Elms (Yeovil) DS0000016083.V378478.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 (Yeovil) DS0000016083.V378478.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): 1, 2 & 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 wishing to move to the home have their needs assessed and receive information about the home before deciding to move in. Intermediate care is not provided. EVIDENCE: The home has a statement of purpose and service user guide which gives details about the home and the facilities offered. The home also has a small colour brochure that can be given to people who are unable to visit the home before moving in. People living at the home said that they had relied on family or friends to view the home on their behalf. The Elms (Yeovil) DS0000016083.V378478.R01.S.doc Version 5.3 Page 10 Anyone wishing to move in has their needs assessed and an opportunity to meet the manager before they decide to make The Elms their home. Copies of assessments carried out by the manager and professionals outside the home were seen. 8 of the 9 people who completed a questionnaire before the inspection said that they had received written information about the home’s terms and conditions. The contract clearly states that the first 4 weeks of a persons stay is a trial period for the person and the home. This gives people time to ensure that the home is able to meet their needs and expectations before taking up permanent residency. The Elms (Yeovil) DS0000016083.V378478.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. Everyone living at the home has a care plan, but these would benefit from being more comprehensive to ensure staff have clear guidance about people’s needs and wishes. Medication practices need to improve to make sure that people receive all prescribed medication and that there is clear recording to enable the effectiveness of medication to be evaluated. EVIDENCE: 8 of the 9 people who completed a questionnaire answered ALWAYS to the question ‘Do you receive the care and support that you need? The other person answered USUALLY. The Elms (Yeovil) DS0000016083.V378478.R01.S.doc Version 5.3 Page 12 Everyone living at the home has a care plan that gives basic details about their needs and how staff will meet these needs. Care plans cover basic physical needs and give some information about likes and dislikes. One person living at the home told us that they had diabetes and that staff tested their blood sugar level twice weekly. There was no care plan in place for this and no indication what the persons’ usual levels were or what to do if the test revealed that the blood sugar levels were outside the usual range. The assessment of need for another person said that they were blind but there was no care plan outlining how staff should assist them to orientate themselves at the home or in new environments, and no guidance about assisting them with appropriate activities. For another person, who had moved into the home 4 days before the inspection, there were no needs identified. The only information available was a basic pre admission assessment. A further full assessment had been obtained but this was not with the care plan and therefore not available to assist staff to care for the person. There was good evidence that the home monitors healthcare needs and contacts appropriate professionals. There were up to date assessments in respect of skin care, nutrition and falls. There was evidence that weights were being monitored and action had been taken to increase the weight of people who the home had concerns about. The person cooking on the day of the inspection was aware of the need to increase the calorie intake for some people and to provide specialist diets for some. There was a good care plan in place for one person who was loosing weight and evidence of appointments with GPs and a dietician. All appointments with healthcare professionals are recorded and records seen showed that people have access to GPs, district nursing staff, opticians, dentists and chiropodists. People asked said that their privacy was respected and it was noted that people were able to spend time in communal areas or in the privacy of their personal rooms. People said that they were able to see professional and personal visitors in their own rooms. Staff were observed knocking on doors before entering bedrooms. The home uses a monitored dosage system for medication. No one currently living at the home administers their own medication. Medication Administration Records (MARs) were viewed. Although all staff have received training in the safe administration of medication there were some inconsistencies in the records maintained giving evidence that not all staff are following the homes policies and procedures. Where a variable dose was prescribed such as ‘take one or two tablets’ some staff were writing the actual dose given but some were not. If the actual dose given is not clearly recorded then it is difficult to evaluate the effectiveness of the medication. Were medication was prescribed on an ‘as required’ basis there was evidence that some staff were offering this at every medication round and signing if refused or given, whilst others were The Elms (Yeovil) DS0000016083.V378478.R01.S.doc Version 5.3 Page 13 leaving the space blank so it was unclear if it had been offered and refused or not offered at all. To minimise the risks of errors all hand written entries on MARs should be signed and witnessed. It was observed that some entries were double signed but the majority were not. One person had not received their prescribed medication for three evenings prior to the inspection and a note was written that the medication had ‘run out.’ This information had obviously not been passed to the management team meaning that no action had been taken and the person had been without medication for three days. A controlled drugs register is maintained and records kept correlated with stocks held. The Elms (Yeovil) DS0000016083.V378478.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 good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There are some organised activities at the home. Visitors are welcome at anytime. EVIDENCE: People living at the home said that there were no strict routines and they were able to choose what time they got up, when they went to bed and how they spent the day. There are some organised activities in the home but the manager said that very few people choose to join in with these. 8 people who completed questionnaires answered ALWAYS to the question ‘Does the home arrange activities that you can take part in?’ There is a large TV in the main lounge and a supply of videos that people can watch. There are also magazines, books and puzzles available to everyone. The Elms (Yeovil) DS0000016083.V378478.R01.S.doc Version 5.3 Page 15 One person said that they enjoyed taking part in the regular exercise class and another said that there was often a quiz. The hairdresser and a representative from the local church visit regularly. The home has recently nominated one member of staff to take the lead role in organising and co-ordinating activities. One relative was visiting the home at the time of the inspection, they said that they were able to visit at anytime and were always made welcome. Other people said that they were able to have visitors and some said that they enjoyed going out with friends and family. One health and social care professional wrote “Always a welcoming feel to the home.” A new 8 week menu has been introduced and everyone asked during the inspection said that they liked the food. People who completed questionnaires answered ALWAYS (67 ) or USUALLY (33 ) to the question ‘Do you like the meals in the home?’ The menu does not give a choice of main meal or sweet but the manager gave assurances that people could ask for an alternative if they did not like what was on the menu. It is recommended that the menu offers at least two choices to enable people to make a choice rather than ask for an alternative. The Elms (Yeovil) DS0000016083.V378478.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 adequate 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 home know who to talk to if they are unhappy with any aspect of their care. The manager and all staff should familiarise themselves with the local policy and procedure for safeguarding vulnerable adults. EVIDENCE: The home has a complaints and whistle blowing policy. Since the last inspection the home has received one complaint that they investigated in line with their policy. People living at the home said that they would be comfortable to raise any worries or concerns with the manager or a member of staff. Everyone who completed a questionnaire said that they knew who to speak to if they were not happy and the majority said that they knew how to make a formal complaint. All staff who completed a questionnaire said that they knew what to do if someone had concerns about the home. All staff have completed training on safeguarding vulnerable adults since the last inspection. The home does not have a policy on recognising and reporting The Elms (Yeovil) DS0000016083.V378478.R01.S.doc Version 5.3 Page 17 abuse and it is strongly recommended that the home obtains a copy of the Somerset ‘Safeguarding vulnerable adults’ policy and makes staff aware of its contents. The Elms (Yeovil) DS0000016083.V378478.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, 20, 23 & 26. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The Elms provides a comfortable, well maintained environment for the people who live there. EVIDENCE: The Elms is a pleasant well maintained home set in a semi rural location. The home is single storey meaning that all areas are accessible to people with all levels of mobility. There is a large communal lounge, quiet room and dining room. There are also small seating areas around the building. There are accessible gardens to the front and rear of the home and an inner secure courtyard area. All bedrooms are for single occupancy and all have en suite toilet and wash basin facilities. The Elms (Yeovil) DS0000016083.V378478.R01.S.doc Version 5.3 Page 19 People moving to the home are able to bring personal possessions, such as pictures and small items of furniture, when they move to the home. This gives bedrooms an individual and homely feel. At the time of the last inspection concerns were raised about the heating in part of the home. The manager gave assurances that this had been addressed. At this inspection one area was noticeably cooler than other areas but not uncomfortably so. People living in this area said that they were always warm enough. There is a laundry which is appropriate to the needs of the home. All areas seen on the day of this inspection were clean and fresh. The Elms (Yeovil) DS0000016083.V378478.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, 29 & 30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff are well motivated and training opportunities are good. The recruitment procedure is safe and minimises the risk of abuse to people at the home, but would be made more robust if full employment histories were obtained for all new staff. EVIDENCE: The home employs 17 permanent staff, 14 (82 ) have a National Vocational Qualification (NVQ) in care at level 2 or above. In the morning there are 5 staff on duty, in the afternoon there are 3 and in the evenings there are 2 staff. Overnight there is one waking night staff and another person sleeping in. The managers’ hours are in addition to care staff hours. Care staff are responsible for cooking, cleaning and laundry in addition to their care role. Care staff spoken to felt that there were generally enough staff. In answer to the question ‘Are there enough staff to meet the individual needs of all those who live at the home?’ 1 person answered ALWAYS and the other 6 said USUALLY. The Elms (Yeovil) DS0000016083.V378478.R01.S.doc Version 5.3 Page 21 People living at the home who completed questionnaires answered ALWAYS (7) or USUALLY (2) to the question ‘Are staff available when you need them?’ It was observed on the day of the inspection that all call bells were answered quickly meaning that people received assistance promptly. We saw evidence that new staff complete an induction programme when they begin work at the home, staff also said that they are able to shadow more experienced members of staff until they are confident to work on their own. Staff spoken with said that they received good ongoing training and everyone who completed a questionnaire said that they received training appropriate to their role. The home uses a certificated, distance learning training programme for staff training. There is a training matrix in place that shows that all staff have received training in statutory health and safety subjects and have undertaken other relevant training such as nutrition, diabetes, equality and diversity, the Mental Capacity Act and care of people who are dying. We viewed the recruitment records of the three most recently employed members of staff. All had been checked against the Protection Of Vulnerable Adults (POVA) register before they commenced work and all had undertaken an enhanced Criminal Records Bureau (CRB) check. Written references had been obtained. Application forms did not give a clear employment history as although previous jobs where listed, there were no dates on some. For one person the dates on the employment history did not match information given in the written reference. The application form and interview questionnaire needs to be reviewed to ensure that it is in line with current legislation as some questions may be viewed as discriminatory. On the day of the inspection staff seen appeared well motivated and happy in their work. Those who completed questionnaires were also positive, comments included; “I love working at The Elms, it has a family atmosphere” and “housekeeping is excellent and we are encouraged to take a pride in our work.” The Elms (Yeovil) DS0000016083.V378478.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, 32, 33, 35 & 38. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager has the skills and experience to manage the home but should ensure that quality assurance systems are expanded to cover all areas. There are opportunities for people living and working at the home to share their ideas and make suggestions about the running of the home. EVIDENCE: The registered provider and manager is Lee Osborne. She is a qualified nurse and has completed a National Vocational Qualification in management at level 4. The Elms (Yeovil) DS0000016083.V378478.R01.S.doc Version 5.3 Page 23 Before this inspection the manager completed an Annual Quality Assurance Assessment (AQAA) giving details about the home, their achievements in the past year and plans for the future. This was completed to an acceptable standard and returned to the Commission within set timescales. People living and working at the home described the manager as very open and approachable. People said that they could always talk to her if they had any queries and staff described her as very supportive. One member of staff wrote on their questionnaire “Our manager at The Elms is great, she is very understanding and helpful if there is any problems.” Another person wrote about the homes management “Open to suggestions and always available to anyone.” There are some quality assurance systems in place. Surveys are sent to people living at the home and their relatives on an annual basis. Returned surveys showed that all responses and comments are analysed and addressed where necessary. There are also regular meeting for people living and working at the home. It is recommended that quality assurance systems include regular recorded medication and care plan audits. The home does not act as a power of attorney or financial appointee for anyone but allows people to deposit small amounts of money for safe keeping. Records are kept of all money deposited and those checked matched the monies held. Health and safety audits are carried out to ensure that the home is maintained to a good standard and all equipment remains safe. All lifting equipment is regularly serviced by outside contractors. A fire risk assessment has been completed and fire detection equipment is regularly tested. All accidents are recorded. Up to date certificates of registration and insurance are displayed. The Elms (Yeovil) DS0000016083.V378478.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 3 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 3 3 x x 3 x x 2 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 x 3 x x 3 The Elms (Yeovil) DS0000016083.V378478.R01.S.doc Version 5.3 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 12 (3) 14 (2) Requirement The registered manager must ensure that care plans cover all aspects of the individuals care needs, wishes and preferences. To ensure that staff have clear guidance to enable them to provide appropriate care, which is personal to the individual. The registered manager must ensure that people always receive medication as prescribed. They must also ensure that recording of medication administration is clear, consistent and in line with the homes policy. This is to ensure that people receive their correct medication and the effectiveness of medication can be evaluated. Timescale for action 31/01/10 2 OP9 13 (2) 15/12/09 The Elms (Yeovil) DS0000016083.V378478.R01.S.doc Version 5.3 Page 26 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 2 3 Refer to Standard OP15 OP18 Good Practice Recommendations The registered manager should ensure that people have a choice of food at each meal. The registered manager should obtain a copy of the local Safeguarding Vulnerable Adults policy and procedure and ensure that all staff are familiar with it. To ensure that the recruitment procedure is fair and robust the home should review the application and interview form and make sure it is in line with current legislation. The application form should request a full employment history and all gaps in employment should be explained. The Quality Assurance system should include regular formal audits of care plans and medication records. OP29 4 OP33 The Elms (Yeovil) DS0000016083.V378478.R01.S.doc Version 5.3 Page 27 Care Quality Commission South West 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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