Inspection on 22/11/05 for Ellesmere

This inspection was carried out on 22nd November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ellesmere 23/05/06

Ellesmere 09/06/05

Ellesmere 20/01/05

Ellesmere 03/08/04

Ellesmere 16/02/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Ellesmere 43 High Street Wolstanton Newcastle-under-lyme Staffordshire ST5 0ET Lead Inspector Irene Wilkes Unannounced Inspection 22 November 2005 10:00 Ellesmere DS0000004937.V267884.R01.S.doc Version 5.0 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 Ellesmere DS0000004937.V267884.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ellesmere DS0000004937.V267884.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ellesmere Address 43 High Street Wolstanton Newcastle-under-lyme Staffordshire ST5 0ET 01782 620155 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) Choices Housing Association Limited Mrs Jill Millar Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Ellesmere DS0000004937.V267884.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 1 Maybe LD(E) Date of last inspection Brief Description of the Service: Ellesmere is a residential care home that is registered to provide five places for adults with a learning disability. The home is operated by Choices organisation, a local provider with a number of small homes across North Staffordshire. The home is a mature semi detached house located on the busy High Street of Wolstanton, near to Newcastle-under-Lyme, and within easy access of all local amenities and public transport. The property is well maintained and presents a warm and welcoming atmosphere. The design and layout of the premises promotes normal daily living. The home is tastefully furnished and communal space consists of a pleasant lounge and a large kitchen/ diner. There is one ensuite bedroom situated on the ground floor. The other four bedrooms are on the first floor. These are not en-suite, but each has a wash-hand basin. The bedrooms are decorated to reflect each service users interests and personality. The bathroom and toilets are in close proximity to the bedrooms and communal areas. Laundry facilities are available within the home, and service users are supported to undertake their own laundry tasks. There is a patio style garden at the rear of the property with a rockery garden that the service users maintain. The home does not have space to provide car parking for visitors or staff. Cars have to be parked in the surrounding side streets. Ellesmere DS0000004937.V267884.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over five hours by one inspector. Five gentlemen live at the home, whose ages range from 30 to 69 years old. There have been no changes in people living at Ellesmere since the last visit. Four of the five service users were at home during parts of the visit and each was happy to chat about his life at the home. One relative of a service user also visited during the inspection and kindly spared some time to talk about her views of the home. The manager and two staff were on duty at different times of the day. What the service does well: All of the service users said that they were happy at the home. ‘Yes, I like it here. The staff are great, particularly x. I do what I want to do’ was how one person put it. It was clear from listening to the staff talk to the gentlemen that they knew what each person likes and dislikes, and that they do their best to meet their needs. All of the gentleman laughed and joked with the staff on duty and they were very happy. A relative visited and also said that she was happy with the home. ‘I’m always made welcome and they let me know what’s happening with x.’ The staff talk to the gentlemen often about the sort of things that they would like to do, and they keep good records about these chats so that they can see how they can best help. The gentlemen said that they go out alone when they want to, but if they need help to go shopping or to a football match a staff member is always there to go with them. The staff also check that the men are well, but if they need some help because of illness the staff make sure that the doctor is called so that they can have the right treatment. The staff have good training so that they can make sure that the men living at Ellesmere are kept safe and can live the life that they want. Ellesmere DS0000004937.V267884.R01.S.doc Version 5.0 Page 6 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. Ellesmere DS0000004937.V267884.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ellesmere DS0000004937.V267884.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were inspected at this visit. Past inspections have evidenced that prospective service users have their needs fully assessed prior to admission, and the home provides up to date and relevant information in the Statement of Purpose and Service User Guide. This means that anyone considering a move to the home can be reassured that their needs can be met at Ellesmere. EVIDENCE: The service users who live at Ellesmere have lived there for some time now, and there have been no changes since the last announced inspection that was undertaken in June 2005. At that visit Standards 1 and 2 were inspected and were clearly met. Ellesmere DS0000004937.V267884.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9 The goals and aspirations of each service user are continually evaluated, addressed, and clearly recorded so that they and the staff team can see what they want to do with their lives. The risks that arise from their independent lifestyle are thoughtfully considered with each person, and an agreement made with them about the most appropriate way to manage these risks. In this way the service users lead the life that they choose but know that they are well supported by the staff team. EVIDENCE: Four of the service users were at home at the start of the visit. One service user had already left for work via his employment as an Assistant Handyman with Choices, and one gentleman was just getting ready to visit Newcastle and have a walk around the shops. One gentleman had just finished his breakfast and was sitting in the kitchen, and the other two gentlemen appeared later in the morning, having preferred a later time to come downstairs from their bedrooms. All of the service users who were at home were happy to chat and talk about their lives. Ellesmere DS0000004937.V267884.R01.S.doc Version 5.0 Page 10 The personal files of three of the men were looked at and their content was discussed to varying degrees with the gentlemen. The manager also discussed the individual needs of each of the gentlemen and their written plans. The files showed that each person had a six monthly review of their person centred plan (PCP) and that these plans are evaluated on a monthly basis. Two of the files showed that a review of the British Institute of Learning Disabilities (BILD) assessments had been undertaken, that assesses by a numbered scoring method all aspects of a person’s life. The ‘OK Health Check’ had also recently been reviewed. Each file contained good information about the goals that each person is working towards in terms of greater community presence, meaningful activities to secure a valued lifestyle etc. One gentleman talked about his lifestyle and his choice to be out of the house and meeting people in Newcastle, or at the pub in the village. It was clear that he makes his own choices and his care file showed clearly that the staff supported him in this. The files each contained relevant risk assessment related to the service users chosen lifestyles and the ultimate risks that present. Individual risk assessments were in place relating to every aspect of the person’s life that may present an element of risk, such as accessing the community alone, accessing public transport, going to the pub, violence and aggression. Each of these risk assessments were appropriate and showed the control measures put in place to minimise the risk as far as possible. It was clear that the assessments had been drawn up with the full involvement of the service users. One gentleman has recently experienced some health problems and his file showed good recording of care plans and new risk assessments that had been fully discussed with the young man and explained to him why they were considered necessary. The service user talked openly about his illness during the visit and clearly understood the need for staff to undertake greater observations of him for his own safety, and he said that he had agreed with these restrictions that had been placed on him. The risk assessment had also been discussed fully with his consultant psychiatrist. Ellesmere DS0000004937.V267884.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17 Service users enjoy their individual activities and relationships with their families and friends, and they are clearly accepted as valued citizens both in their own home and in the local community. EVIDENCE: The oldest gentleman living at the home is always happy to chat about his lifestyle and this visit proved no exception to this. He was just preparing to go into Newcastle on the bus at the start of the visit but he stayed and talked for a little while before leaving, and also returned before the end of the visit when he chatted again about how he spends his time. He has a bus pass and takes full advantage of this, travelling into Newcastle to wander around the market and chatting to the many acquaintances that he has made. He attends a luncheon club once a week, and also is employed by Choices organisation for one day a week on their ‘handycare scheme.’ He also enjoys going to car boot sales, and visiting the local pub for a drink. Ellesmere DS0000004937.V267884.R01.S.doc Version 5.0 Page 12 All of the men living at Ellesmere undertake a range of activities linked to their individual interests. Another younger man is also employed by Choices under the ’handycare scheme,’ and another is waiting to hear about some prospective future employment. Individual leisure activities range from going to the gym, football, pub visits, including playing pool, and socialising with friends and/or family. On the day of the visit, in addition to the activities of the older gentleman, one service user was going out shopping with a member of staff, one was going to the football match in the evening, and the mother of another service user visited and was taking her son to the family home for the day. The comings and goings of all of the men were the same as in any household. In discussion with the service users it also became evident that they maintain contact with their families. As highlighted above, a relative arrived during the visit. When asked about her views of the home she said ‘I’m always made welcome and they let me know what’s happening with x.’ One gentleman explained how his family live abroad but he has pictures of them in his bedroom and maintains phone contact. Each also has friends living in the community who either visit the home or they visit them. Note of such family and friends contact was recorded in each individual plan, and the manager also talked about the particular relationships enjoyed by the gentlemen, and the advice and support provided by the home to enable such contacts to be maintained. The manager advised that when one of the service users was ill recently, the owner of the local video shop that he visits came to the house to say that he was concerned about him. This man’s visit demonstrated that the service users are an integral part of the local community and this was pleasing to hear. Service users said that they enjoyed their lives. ‘Yes, I like it here. The staff are great, particularly x. I do what I want to do’ was a typical comment made. On visiting Ellesmere there is always a good atmosphere in the home, and the interactions that take place between service users and staff highlight that the home is run to suit the needs of the service users and what they want, which is pleasing to note. Discreet observation showed again at this visit that it is recognised that Ellesmere is the service user’s home, not the staff’s domain, and clear respect for the service user’s rights was evidenced throughout the visit. Service users privacy was maintained, staff were seen to knock on bedroom doors before entering and service users moved freely about the home. The service users’ responsibility for household tasks is specified in the Service User Guide and in each individual plan. Ellesmere DS0000004937.V267884.R01.S.doc Version 5.0 Page 13 Meals were not discussed with the gentlemen on this occasion but have been in the past when they have all been happy with the food on offer. The men plan the main meal menus together for the coming week, and choose their individual breakfasts and other meal dependent on what they are doing on the day. Nutritional screening forms were in place for individual service users. Menu plans are recorded in a permanent record book. Meals are enjoyed at the large dining table in the spacious dining kitchen. Ellesmere DS0000004937.V267884.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20 The home pays good attention to the physical and mental health needs of each service user and staff are quick to address any periods of ill health. Medication practices are satisfactory. This means that service users and their families can be confident that should any health problems arise they will be well supported by the home. EVIDENCE: The three individual plans examined and discussion with staff and service users showed that each person is independent in personal care and only prompting is required on occasions. Each person had a 24 hour plan of care in place with appropriate information available for areas of health need such as nutrition screening, epilepsy, diabetes management. Two of the plans showed that the ‘OK Health Check,’ a comprehensive document that looks at all areas of both physical and mental health, have recently had an annual update, with a Health Action Plan developed from this, with the involvement of the practice nurse. The Heath Action Plan had a full list of physical and mental well being areas for action throughout the year, with dates in place for appointments, follow-up action etc. Ellesmere DS0000004937.V267884.R01.S.doc Version 5.0 Page 15 One service user is subject to a Guardianship Order and therefore is entitled to the Care Programme Approach involving other professionals in reviews and action plans for his mental well being. The consultant psychiatrist was recently promptly involved when the service user was unwell. The service user’s file contained comprehensive information linked to his mental health and well being. The young man talked to the inspector about his illness and the support that he was receiving, and how he was beginning to feel better following the support that he was receiving. The home uses the Boots Monitored Dosage System for medication. Procedures for the safe handling of medication, including storage and records were seen and were satisfactory. The manager of the home and her deputy are qualified nurses and there was good information available for staff about all of the medication taken by service users in the home. There were PRN (as and when) and homely remedy policies in place and medication for either of these being taken was separately recorded. In the absence of a qualified member of staff being on duty and such medication being required there is a sound procedure in place where the home must contact a qualified member of staff at another home for advice, or the qualified member of staff on call. None of the gentlemen choose to self medicate. The procedure in place for the medication for one service user when he is visiting his family at the weekend was discussed, and this evidenced that a separate dosette box containing the appropriate medication is supplied by the pharmacist to cover these periods. This was considered good practice. Ellesmere DS0000004937.V267884.R01.S.doc Version 5.0 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected at this visit. These standards were not inspected at this visit. EVIDENCE: These standards were thoroughly addressed at the last inspection visit and were found met. The service users said that they had no issues about their life in the home and that all of the staff treated them well. Ellesmere DS0000004937.V267884.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30 Ellesmere provides a spacious, safe, and comfortable home and the service users play their part in ensuring a high standard of cleanliness in their home. This means that all of the gentlemen appreciate their surroundings. EVIDENCE: A tour of the accommodation was made. The home continues to maintain a high standard of decoration and fitments. There is an attractive and spacious lounge, a large and well fitted dining kitchen, a downstairs toilet, two bathrooms and single bedrooms for each of the gentlemen that are pleasant and well personalised. One bedroom is downstairs and has an en-suite bathroom with shower. This is the bedroom of the oldest gentleman. There is a small but sufficient laundry, and the office is on the third floor. Since the last inspection the home has had a staff call system installed in the bathrooms and the downstairs en suite shower room to ensure the added protection of the service users. Outside the home has a small garden to the front with the rear garden being laid with slabs. There is external seating for the service users to enjoy. Ellesmere DS0000004937.V267884.R01.S.doc Version 5.0 Page 18 Ellesmere provides a spacious and comfortable home for the service users. All of the gentlemen have agreed to do jobs around the home, such as hoovering, as well as maintaining their own bedrooms and assisting with their laundry. The home is very clean and hygienic, including liquid soap and paper towel dispensers being provided to all sinks. This was an unannounced inspection and it was pleasing to note that the standard of cleanliness equalled that of the announced inspection. Ellesmere DS0000004937.V267884.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 33, 34, 35 and 36 The organisation’s recruitment, training and supervision procedures result in a competent and well qualified staff team which means that service users benefit from staff who are well equipped to carry out their support role. The home would benefit from the availability of a “cluster worker” for periods of staff shortage, as happens in some other Choices homes. There were insufficient numbers of staff on duty during the morning which meant that an activity for 1 service user had to be cancelled. EVIDENCE: Ellesmere has a stable staff team led by an experienced and knowledgeable manager and deputy who are both qualified nurses. Choices organisation ensures that all of the staff undertake at least NVQ 2 in care within 12 months of taking up post. Service users were asked about the staff and their approach to them and all of the comments received were positive. Interactions between staff and service users throughout the visit were positive, and it was clear that staff had a good understanding of the needs of each individual. A service user, the inspector and the manager had a long discussion about his recent illness and it was clear that the service user felt comfortable with the manager and could talk to her about his feelings. Ellesmere DS0000004937.V267884.R01.S.doc Version 5.0 Page 20 The manager was the only member of staff on duty during the morning of the inspection, with three staff planned to be on duty later in the day. It is understood that this was due to an unforeseen circumstance as one staff member had to be absent due to family illness, and the other member of staff on the rota was attending staff training. The manager reported that she had tried to find a replacement member of staff but that it was too short notice to be successful. The inspector was satisfied that the safety of the service users was maintained, but one gentleman had planned to attend a luncheon club to which he was usually accompanied by a member of staff and this had to be cancelled. The gentleman said that he would have liked to attend. While it is appreciated, the organisation should consider the provision of a “cluster worker” to cover Ellesmere as happens at other Choices homes, to ensure that staff training and any unforeseen emergency does not result in a reduction in the service to the gentleman. This is a recommendation of this report. While it is appreciated that sickness absence cannot be controlled, staff training should be planned for and a replacement member of staff should be available to cover any planned training events. The availability of sufficient members of staff at all times is a requirement of this report. Two staff files were inspected and these evidenced that a CRB had been obtained for each person, there was evidence of identity, two appropriate references and a training record. The Commission is in discussion with Choices organisation regarding other recruitment information that it is known is held about each worker but where the records are maintained at Choices head office. The organisation continues to evidence that it pays considerable attention to the training needs of staff and this visit also confirmed this. The two staff files inspected evidenced that all mandatory training was up to date, and the home’s training file was seen and a number of staffs’ training records were sampled. These again showed that all mandatory training was up to date, and there is a range of other courses provided by the organisation to meet the individual needs of the service users. The manager and her deputy are both qualified trainers in moving and handling and MAPA (Management of Actual and Potential Aggression). The staff files evidenced that staff have regular and recorded supervision meetings in excess of the standard of at least six times per year. These are undertaken on a six weekly basis by the deputy manager when support issues relating to the service users are discussed, and then at quarterly intervals by the home manager to discuss wider job roles and issues. Staff also have an annual appraisal. Ellesmere DS0000004937.V267884.R01.S.doc Version 5.0 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 and 42 Ellesmere continues to be a well run home led by an experienced and competent manager who fulfils her role conscientiously, ensuring that the service users views and needs are at the heart of the service. This ensures that the health, safety and welfare of service users are promoted and protected. EVIDENCE: The home benefits from an experienced manager who is a qualified nurse (RNMH). She has recently completed her NVQ 4 and Registered Managers Award, and is also a trainer in moving and handling and the management of violence and aggression. She is also a member of various development groups that the organisation has formed to consider the quality of its performance in specific areas. In discussion the manager was very knowledgeable about the individual needs of each service user. Ellesmere DS0000004937.V267884.R01.S.doc Version 5.0 Page 22 The home addresses quality assurance and monitoring of its services in various ways. The service users each have an individual review meeting twice a year when their individual needs are discussed and progress against their goals are assessed. Regular house meetings are held on a quarterly basis when the way that the home is run and their satisfaction with the staff is discussed with the service users. The record of these meetings was not inspected at this visit, although it had been seen at the last inspection, and it was confirmed that these meetings are still held. For some time now Choices organisation has been undertaking a review of all of its policies and procedures. Representation of service users from a number of homes across the organisation is included. The review is wide ranging and looking at alternative communication methods for the dissemination of the information in the policies and procedures as widely as possible to all of the users of Choices services. At the last inspection of this home a recommendation was made that a briefing be provided as to the stage that this review was at. This recommendation has not been addressed, and while it is not mandatory the recommendation is made again at this visit, as progress on the outcome would be helpful. A sample check was made of fire records, COSHH storage, fridge and freezer temperatures and food probing checks and all of these had been maintained appropriately and showed no obvious problems. All mandatory training for staff was up to date. Risk assessments both for the environment and on an individual basis were in place. The maintenance file was seen and this showed that annual checks of fire systems, gas, water checks and PAT (Portable Appliance Testing) were all up to date. There were no outstanding maintenance issues. Ellesmere DS0000004937.V267884.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x x x Standard No 22 23 Score x x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 4 3 x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 4 LIFESTYLES Standard No Score 11 x 12 4 13 4 14 x 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score x 3 2 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Ellesmere Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 x 3 x x 3 x DS0000004937.V267884.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 Refer to Standard YA39 YA33 Good Practice Recommendations Provide the Commission with an update as to progress with the review of policies and procedures, and the input that has been afforded the representative service users. Consider the introduction of a cluster worker for the home. Ellesmere DS0000004937.V267884.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 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 Ellesmere DS0000004937.V267884.R01.S.doc Version 5.0 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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