Inspection on 29/05/08 for Elm House

This inspection was carried out on 29th May 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Elm House 05/06/07

Elm House 03/04/06

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Elm House 22 Elm Avenue Beeston Nottingham NG9 1BU Lead Inspector Karmon Hawley Unannounced Inspection 29th May 2008 09:00 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 Elm House DS0000065843.V365441.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. Elm House DS0000065843.V365441.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elm House Address 22 Elm Avenue Beeston Nottingham NG9 1BU 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) 0115 9225573 0115 9436147 selectelm@ntlworld.com Union Healthcare (Nottingham) Ltd Deborah Redshaw Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Elm House DS0000065843.V365441.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Union Healthcare (Nottingham) Limited is registered to provide accommodation, personal care and nursing at Elm House for up to 25 persons of both sexes whose primary needs fall within the category of Older Persons, not falling into any other category. 5th June 2007 Date of last inspection Brief Description of the Service: Elm House is situated within a quiet residential area of Beeston and provides nursing and residential care for older people. Accommodation is on two floors and a passenger lift is provided. There are four single rooms and ten double rooms. There are several seating areas that service users may access and there is a large well established garden for service users to enjoy. The home is convenient for local amenities and has good car parking facilities. Both the building and grounds are accessible for use by wheelchair users. The current weekly fees range from: £290 - £550 depending upon individual needs. The fee scale and all necessary information to make an informed choice to enter the home is available upon enquiry. Elm House DS0000065843.V365441.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 inspections undertaken by the Commission for Social Care Inspection is upon outcomes for people using the service and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. This inspection involved one inspector; it was unannounced and included the lunchtime period. The main method of inspection used is called ‘case tracking’ which involves selecting four people using the service and looking at the quality of the care they receive by speaking to them, observation, reading their records and asking staff about their needs. Two members of staff were spoken with as part of this inspection and the views of seven people using the service were sought to form an opinion about the quality of the service. Documents were read as part of this visit and medication was inspected to form an opinion about the health and safety of people using the service at the home. A partial tour of the building was undertaken, all communal areas were seen and a sample of bedrooms to make sure that the environment is safe and homely. A review of all the information we have received about the home from the provider and the general public since the last inspection was considered in planning this visit and this helped decide what areas were looked at. What the service does well: A warm and welcoming atmosphere was evident on entering the home. Staff were seen to be chatting freely with people using the service and it was evident that good relationships continue to be maintained. Staff treated people with respect at all times. There are no restraints on visiting and visitors were seen to visit people freely throughout the visit. Elm House DS0000065843.V365441.R01.S.doc Version 5.2 Page 6 Staff training remains at a good standard to ensure that staff are able to meet the needs of the people using the service. Staff spoken with were knowledgeable and able to discuss the individual needs of people using the service. People using the service are given the opportunity to express their views about the service that they receive and any concerns are listened to and acted upon. People using the service expressed the following views about the care home: ‘the staff are very good here, I am comfortable and my needs are met,’ and ‘the staff are generally good, I could do with more opportunity to have more exercise and walks but I have no real concerns.’ ‘There is a comfortable and friendly atmosphere, the staff treat me well,’ the staff are always polite and they knock on my door before they come in,’ and ‘the staff are generally pleasant and respectful.’ ‘My family visit everyday, they are made welcome and there are no restrictions on them coming,’ and ‘I often get visitors, there are no problems with them coming to see me.’ What has improved since the last inspection? What they could do better: Continue to develop plans of care to ensure that these are person centred and reflect the needs of people using the service to ensure that their needs are fully met in the way they prefer. Ensure that risk assessments are in place for all identified risks to ensure that people using the service remain safe at all times. Offer further activities and stimulation to people using the service to ensure that their social and recreational needs are fully met. Elm House DS0000065843.V365441.R01.S.doc Version 5.2 Page 7 Revise the current menu to ensure that people using the service receive adequate choices and a wholesome meal at teatime. Consult with the Fire authority regarding keeping doors open, whilst complying with Fire safety regulations to keep people living at the service safe and implement practice recommended by the Fire authority without delay. 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. Elm House DS0000065843.V365441.R01.S.doc Version 5.2 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 Elm House DS0000065843.V365441.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who may wish to move into the home are assured that their needs will be assessed and that these can be met before they decide to move into the care home. The service does not offer intermediate care. EVIDENCE: Before a decision to move into the home is made, the manager or a registered nurse visits people who may wish to use the service within the community to carry out a preadmission assessment to ensure that the staff are able to meet their needs. Evidence of the assessments taking place was available within the files of those people case tracked. People may also visit the home and spend time there before they make a decision to move into the home. One person spoken with discussed how their family had visited the home before they moved in. staff spoken with stated that they received all the necessary information that they need when someone moves into the home to ensure that they are able to meet their needs. Elm House DS0000065843.V365441.R01.S.doc Version 5.2 Page 10 The service does not offer intermediate care. Elm House DS0000065843.V365441.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care planning and risk assessments have improved but require further development to ensure people’s needs are met in the way they prefer and safely with dignity and respect. People using the service are treated in a respectful manner and their privacy is maintained. EVIDENCE: People using the service undergo various assessments such as manual handling, pressure area care, the activities of daily living and nutritional needs. Information gained forms the plan of care. Assessments were personalised and reflected service users likes, dislikes and preferences, however this information was not used within plans of care, which were task focussed rather than written in a way that would ensure that the needs of the person using the service would be met in their preferred way. Two requirements were set at the previous visit; (1) to ensure that plans of care are in place for all identified needs to ensure that the needs of the people using the service are met and also (2) risk assessments are required to be in Elm House DS0000065843.V365441.R01.S.doc Version 5.2 Page 12 place for all identified risks to ensure that people using the service are protected. Development has taken place in regard to the management of maintaining healthy skin and relevant plans of care were in place as required. The plan of care covered the necessary equipment and the support needed to ensure that people’s needs are met. There was also evidence that the manager was assessing people’s pressure areas and skin integrity on a weekly basis to ensure that any deterioration is noted quickly and therefore acted upon. There was also evidence that the district nurse had been liaised with as required. The number of people with pressure sores within the care home has decreased. Staff spoken with were able to discuss the needs of individual people using the service and they demonstrated a good understanding in regard to pressure area care. Brief plans of care were in place for complex needs, such as challenging behaviour and diabetes, however these did not contain all the required information to ensure that people’s needs were fully highlighted. There were two incidents where a risk had been highlighted within daily records, one in regard to a persons behaviour and the other in regard to maintaining a diabetic diet, however the risks assessments and plans of care were not sufficient to ensure that the person remained safe. People using the service offered the following comments: ‘the staff are very good here, I am comfortable and my needs are met,’ and ‘the staff are generally good, I could do with more opportunity to have more exercise and walks but I have no real concerns.’ There was evidence of people seeing professionals such as the dentist, optician, doctor and district nurse in case files examined. People told us that their health care needs are met as needed; ‘I can see the doctor if I need to, the staff arrange this for me,’ and ‘ the staff are very good, if I need to see someone about my glasses, they arrange this.’ During the brief tour of the home pressure relieving equipment was seen to be available for people using the service. Medication record charts were clear and maintained as required. Handwritten entries were signed by two members of staff to show that these had been checked as correct so that people receive the correct medication. There were no gaps in signing for medication, demonstrating that people using the service are receiving their medication as prescribed. One person spoken with said, ‘the staff look after my medicines for me, I can not do this myself, it is better this way as I get them when I need them.’ To assess whether the privacy and dignity of people using the service is maintained a discussion in regard to staff’s knowledge took place. Staff spoken Elm House DS0000065843.V365441.R01.S.doc Version 5.2 Page 13 with offered the following comments, ‘we ensure that we knock on doors before we enter and keep people covered when we carry out personal care. There is screening available in shared rooms which we always use.’ We saw staff treat people using the service in a respectable manner at all times. As there are a large number of shared rooms within the home, people using the service or their relatives have signed a form stating that they consent to a shared room. We saw that screening is available within the shared rooms as stated. People using the service offered the following comments, ‘there is a comfortable and friendly atmosphere, the staff treat me well,’ the staff are always polite and they knock on my door before they come in,’ and ‘the staff are generally pleasant and respectful.’ Elm House DS0000065843.V365441.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some people using the service would benefit from a more structured activity plan to promote stimulation. Providing further alternatives at teatime would ensure that people using the service have more choice in what they chose to eat. EVIDENCE: As there is no dedicated activities coordinator at present staff facilitate activities, as they are able. Activities such as arts and crafts, carpet skittles, board games and trips out are available should people wish to join in. A ‘music man’ also visits the care home for a sing a long session. There were mixed views received from people using the service about the activities on offer, ‘ there are no activities, I would like to do more, however the joy of living here is being able to sit outside,’ ‘I often go up to town, there is not much else to do but I don’t really want to do anything anyway,’ ‘there needs to be more stimulation of the mind and activities and exercise,’ and ‘I enjoy sitting out in the garden.’ A number of people using the service were observed to sit outside on the day of the visit, whereas the remainder of people sat in the lounges with no real stimulation except the television. Staff spoken with stated that although they try to carry out activities, these were limited due to the amount Elm House DS0000065843.V365441.R01.S.doc Version 5.2 Page 15 of staff on duty; they confirmed that more stimulation is needed for people using the service. People using the service stated that the routines of the care home were flexible and they could spend their time as they wished, staff spoken with confirmed this. There are currently no church services held in house, however staff stated that people using the service are supported to attend the local churches should they wish and people using the service are supported in meeting their religious and cultural needs. There was evidence of support being offered within two plans of care observed. To ensure that people maintain contacts that are important to them, there are no restrictions on visiting and visitors may be received in private. Several visitors were seen to come and go throughout the day and staff were observed to speak with them in a pleasant manner. People using the service spoken with offered the following comments, ‘my family visit everyday, they are made welcome and there are no restrictions on them coming,’ and ‘I often get visitors, there are no problems with them coming to see me.’ To ensure that people are treated as individuals and their rights and choices are maintained a discussion in regard to equality and diversity was held with the staff spoken with. They were able to discuss the individual needs of people using the service and also respected that each person had rights and choices. They stated that, ‘ this is their home, they can do as they please and have their own routines, and we work hard to make sure that people get the care that they need.’ Within plans of care there was reference to specialist needs and how these were to be met for each individual person. One person using the service stated that, ‘I feel that the staff know me, they take me out and we have a good time, I can make my own choices about how I spend my time, there are no restrictions.’ To ensure that people using the service receive a wholesome and appealing diet the menu on offer was examined. This demonstrated that a variety of food is on offer for all main meals, however the choice at teatime is limited. Specialist diets such as diabetic and soft diets are catered for. People using the service expressed the following comments, ‘the food is good, there is plenty of choice and there is enough to eat,’ the food is very nice, there is plenty, however I would like more choice than just sandwiches at tea time, there is a soft option that we can have, but I am fed up of the same things’ and ‘the food is nice, I have plenty to eat.’ Staff spoken with were able to discuss the necessity of ensuring that people using the service receive a wholesome diet and the importance of a diabetic diet. They did however state, ‘there could be more variety at tea time, as the alternative to sandwiches is mainly used for those people who require a soft diet.’ Elm House DS0000065843.V365441.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are assured that they can make a complaint if they need to and that this will be dealt with. People using the service are now protected from abuse. EVIDENCE: To ensure that people using the service and relevant others are aware of how they may make a complaint known, a copy of the complaints policy is on display. There have been no complaints received at the home or by us since the previous visit. Staff spoken with were able to discuss how they would deal with a complaint should one be received. People using the service spoken with offered the following comments; ‘ I am happy and settled here, the staff are very friendly, we are definitely well looked after,’ ‘If I am unhappy about anything I know that I can speak to the manager,’ and ‘ most staff are pleasant with the exception of a few.’ This last comment had also been expressed to the manager within a returned quality assurance questionnaire, she stated that she was currently looking into the issue; this was confirmed by the person using the service. There were previous concerns with regard to pressure area care within the care home, which resulted in a meeting being held with the care home, the Adult Social Care Housing and Health and the Commission for Social Care Inspection. The staff at the care home received additional support and training to assist them in remedying these concerns. The manager continues to work Elm House DS0000065843.V365441.R01.S.doc Version 5.2 Page 17 towards completing an action plan to ensure that these issues are fully resolved and the service is being monitored whilst this is taking place. Staff have completed training in safeguarding adults and when spoken with they were able to discuss what types of abuse may occur and their responsibilities in ensuring that this does not happen and the action that they need to take if they suspect that it is. One person spoken with said, ‘I feel comfortable and safe here, it is good to know that people are here to look after you.’ Elm House DS0000065843.V365441.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People using the service live in a satisfactorily maintained environment, which is homely and comfortable. People using the service may be at risk because of doors being propped open in the event of an outbreak of fire. EVIDENCE: There was evidence of ongoing maintenance taking place within maintenance records kept and the information provided to us within the Annual Quality Assurance Assessment. The general environment remains satisfactorily maintained and rooms continue to be redecorated when they become vacant. New chairs and tables, curtains and lights have been purchased, offering people using the service a comfortable environment. A recent visit by the fire authority highlighted concerns in regard to doors being propped open, the main issue being the dining room door. This door was propped open whilst the room was in use during the visit. This was discussed with the manager who stated that the fire authority had said that it was alright Elm House DS0000065843.V365441.R01.S.doc Version 5.2 Page 19 to have the door propped open whilst the room was in use and staff were present until an alternative solution had been found. The manager stated that the area manager would be looking at a self-closing device for this door to remedy this concern. All areas of the home accessed during the visit were clean and tidy. One person using the service stated that, ‘the staff work very hard, the home is always clean and tidy.’ Elm House DS0000065843.V365441.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is adequate . This judgement has been made using available evidence including a visit to this service. People using the service are supported by staff that are trained, although the numbers of staff available to support them needs to be reviewed to ensure they can meet the care needs of the people accommodated. EVIDENCE: As the current number of people living in the home is reduced, this is reflected in the number of staff available. Staff spoken with felt that although the numbers of people living in the home were reduced, time to meet people’s complex needs was still required and they felt that at times they were rushing people. Only one person using the service spoken with stated that they felt that more staff were needed as they sometimes have to wait for help, all other people spoken with felt that staff were available when needed. To ensure that new staff are aware of their roles and responsibilities they undergo an induction when they first commence employment. There was evidence of this outlined within the Annual Quality Assurance Assessment information received by us. Staff personnel files also showed us that these take place. The Annual Quality Assurance Assessment told us that 33 of the staff have undertaken the National Vocational Qualification level 2 in care (a nationally recognised work and theory based qualification). There was evidence to Elm House DS0000065843.V365441.R01.S.doc Version 5.2 Page 21 confirm this within staff personnel files and staff spoken with confirmed that they had achieved this qualification, which enhanced their knowledge and skill in caring for the people using the service. A requirement was set at the previous visit to ensure that all staff files contained the required documentation by law to ensure that people using the service are protected form unsuitable people being employed. All files did contain the required documentation such as a Criminal Record Bureau check (a police check to see if an individual has received a police caution or has a criminal record) two references and proof of identification. Staff spoken with were able to confirm that they had undertaken the required checks before they started working in the care home. A requirement was set at the previous visit in regard to ensuring that measures are in place to show that registered nurses have the necessary qualifications to carry out their job roles. Evidence was seen in staff personnel files and administration records that regular audits and checks now take place. To ensure that staff have the required knowledge and skill to meet the needs of people living at the home staff continue to undertake compulsory training, such as fire, manual handling and health and safety. There was evidence of this within personnel files examined. Staff spoken with confirmed that this training had taken place and that they felt supported by the management in their development needs. Intense training on pressure area care (to ensure that people’s skin remains healthy and does not break down) has taken place. Staff spoken with were able to discuss in depth the signs that they would look for which would tell them that there was a concern and what action that they would take following this. Elm House DS0000065843.V365441.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. With support management of the home is improving in regard to working towards meeting the needs of people living there and ensuring that the care home is well run and managed. People live in a home where they are able to express their views and opinions, which are taken into account in regard to the running of the care home. EVIDENCE: The manager is registered with the Commission for Social Care Inspection. She ensures she remains up to date with training and continues to work towards completing the Registered Managers Award (a nationally recognised work and theory based qualification). Staff spoken with said that the manager was approachable and they felt the home was well run. One person using the service said that the manager was approachable and they could talk to them if they needed to. The manager is working with us and the Adult Social Care Elm House DS0000065843.V365441.R01.S.doc Version 5.2 Page 23 Housing and Health in regard to the management of pressure area care to improve the outcomes for people using the service. Various audits take place, such as medication, care planning, accidents and the environment. Results from these are analysed and an action plan is put together to address any negative issues if required. The recent accident audits showed that there had been a number of falls. People using the service also have the opportunity to complete quality assurance questionnaires, enabling them to offer their views about how the service is run. There was evidence of this taking place and several completed surveys had been returned ready for analysis. Views such as, ‘the staff are kind and helpful,’ ‘it is a friendly and homely place,’ and ‘more activities could be introduced’ were received. Relatives of people using the service have also had the opportunity to attend meetings at the home to discuss the service, however these were poorly attended and have therefore ceased. The personal allowances of four people using the service were checked, all of which were correct. Each has an individual accounting sheet, which corresponded with the money available. Receipts were available and all transactions were signed for. The service is not responsible for any money belonging to people using the service. The Annual Quality Assurance Assessment demonstrated that relevant equipment is checked and serviced to ensure that people using the service are protected as required. The hoist and lift certificate were checked on the day of the visit, these confirmed that the relevant checks had taken place. Staff have attended training on health and safety and they were able to discuss relevant issues when spoken with. There were no obvious hazards observed during the brief tour of the building, with the exception of the dinning room door being propped open with was discussed in standard 19. Elm House DS0000065843.V365441.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Elm House DS0000065843.V365441.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1) Requirement Timescale for action 29/07/08 2. OP7 13(4,c) 3. OP12 12(a,b) 4 OP15 16(2,i) Plans of care must continue to develop to ensure that these are person centred and reflect the needs of people using the service to ensure that their needs are fully met in the way they prefer. This requirement was initially set at the previous visit and whilst development has taken place, further is needed to ensure compliance. Risk assessments must be 29/07/08 developed for all identified risks to ensure that people using the service remain safe at all times. This requirement was initially set at the previous visit and whilst development has taken place, further is needed to ensure compliance. Further activities and stimulation 29/08/08 must be offered to people using the service to ensure that their social and recreational needs are fully met. The current menu must be 29/07/08 reconsidered to ensure that people using the service receive adequate choices and a DS0000065843.V365441.R01.S.doc Version 5.2 Elm House Page 26 5 OP19 23(4,a) wholesome meal at teatime. Consult with the Fire authority regarding keeping doors open, whilst complying with Fire safety regulations to keep people living at the service safe. • Implement practice recommended by the Fire authority without delay. Cease practice of propping open doors. Review the staffing levels to ensure that the number of staff on duty is sufficient to meet the care needs of people accommodated. Monitor accidents to establish time patterns, to ensure that additional attention to the needs of people accommodated can be paid during these times to ensure that they are protected. 29/07/08 6 OP27 18(1,a) 29/07/08 7 OP38 13(4,c) 29/07/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Elm House DS0000065843.V365441.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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. 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