Inspection on 19/06/07 for Elm Royd Nursing Home

This inspection was carried out on 19th June 2007.

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 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 Royd Nursing Home 18/06/08

Elm Royd Nursing Home 23/05/06

Elm Royd Nursing Home 13/01/06

Elm Royd Nursing Home 05/07/05

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Hawkhills

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

CARE HOMES FOR OLDER PEOPLE Elm Royd Nursing Home Brighouse Wood Lane Brighouse West Yorkshire HD6 2AL Lead Inspector Liz Cuddington Unannounced Inspection 19th June 2007 11:35 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 Royd Nursing Home DS0000061813.V331486.R03.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 Royd Nursing Home DS0000061813.V331486.R03.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elm Royd Nursing Home Address Brighouse Wood Lane Brighouse West Yorkshire HD6 2AL 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) 01484 714549 01484 711400 elmroydoffice@tiscali.co.uk Philip Bennett (Elmroyd) Ltd Mr Keith Derek Wilson Care Home 45 Category(ies) of Old age, not falling within any other category registration, with number (45) of places Elm Royd Nursing Home DS0000061813.V331486.R03.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Can provide accommodation and care for one service user under 65 years of age category physical disability (PD). Can provide 5 intermediate care for older people over 65 years of age. Date of last inspection 23rd May 2006 Brief Description of the Service: Elm Royd Nursing Home offers nursing care, personal care and accommodation for up to 45 people over 65 years of age. This includes 5 places registered for intermediate care as well as 1 place for an adult with a disability under 65 years of age. There are 31 single bedrooms, 22 of which have en suite facilities, and 7 twin bedrooms. The home is located in a residential area of Brighouse just a short distance from the town centre and near to the bus routes between Brighouse, Elland and Halifax. The current fees range from £339 - £525 per week. Hairdressing, chiropody and personal items are not included. Elm Royd Nursing Home DS0000061813.V331486.R03.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The last key inspection of the home took place on 6 June 2006. I have made two further visits to the home on 1/11/06 and 22/02/07. The visit in November 2006 was to assess the progress made in implementing the requirements and recommendations from the previous inspection. The visit in February 2007 was made to investigate concerns, raised by a visiting nurse, about pressure area care. The inspection reports for these two visits are available on request. The purpose of this inspection was to assess the quality of the care and support received by the people who live at Elm Royd. The methods I used to gather information included a visit to the home, conversations with the people who live there, their relatives, healthcare professionals and the staff, looking in detail at the care and records of four people, examining other records and looking around the home. I spent eight hours at the home. Before visiting I sent out questionnaires for the people who live at the home, their relatives and healthcare professionals to complete. I received twenty-two back from the people who live at Elm Royd, six from their relatives and one from a healthcare professional. Feedback from these surveys is included in this report. The manager also completed the home’s pre-inspection questionnaire. These questionnaires provide valuable information to help me form a judgement about the quality of service offered at Elm Royd. Although there are still areas for development, the home continues to make significant improvements. I would like to thank the people who live at Elm Royd, their relatives and the staff, for their welcome and hospitality and for taking the time to talk to me during my visit and for completing the questionnaires. What the service does well: The people I spoke with said they are happy with the care and support they receive at Elm Royd. One person wrote in her questionnaire ‘I am usually happy with living here’, someone else said they are ‘Happy with (their) care’. Another said that the staff are ‘….cheerful and hard working’. One person told me that the staff support her to retain her independence, while still offering assistance when needed. Elm Royd Nursing Home DS0000061813.V331486.R03.S.doc Version 5.2 Page 6 Relatives of the people who live at Elm Royd commented that the ‘Staff are wonderful’ and ‘They have a lot of patience’. A visiting healthcare professional wrote that the staff ‘Look after patients registered with our practice very well’. The pre-admission assessments are thorough and the majority of people commented on their questionnaires that they had sufficient information about the home and that it ‘…was very helpful and informative’. The house and grounds are well maintained and the home is kept clean and fresh. One person also noted that they are always made welcome when they visit. The people who live at Elm Royd and their relatives confirmed that they know how to raise a concern or make a complaint, if they need to. One person said ‘I feel happy about telling staff if I have a problem’. The staff are aware of their responsibilities if they believe that neglect or poor care practice is taking place. The home takes the appropriate action in such situations and keeps the relevant people informed. There are thorough recruitment and selection procedures in place, to make sure that staff are suitable and safe to work with the people who live at Elm Royd. All the staff receive a range of training to provide them with the skills and knowledge they need to do their work effectively. Half of the care staff have a National Vocational Qualification in care. What has improved since the last inspection? Since the last inspection visit the support and care for people who go to stay at Elm Royd for a period of rehabilitation has improved. Notes about people’s appointments with healthcare professionals, and outcomes, are now being recorded separately, making it much easier to keep track of these events. The care plans are clearer and there are better healthcare assessments in place. Prevention and treatment of pressure areas and other wounds has improved since we visited in February 2007. A part-time activities co-ordinator has been appointed and the evidence from the people who live at the home, and the records, show that progress is being made to provide a range of meaningful and interesting activities for people. The hallway, dining room and some bedrooms have been re-decorated. One person commented that the ‘General décor is getting better…’. One person who lives there said that the ‘Laundry at the home is much better than it used to be’. I noticed that the wheelchairs were all clean and tidily stored and their footplates were attached. Confidential files are securely stored in locked cabinets. Elm Royd Nursing Home DS0000061813.V331486.R03.S.doc Version 5.2 Page 7 One person said that the situation where there had previously been a lack of staff in the lounge has improved. A desk has been put in the ground floor hall and another in the upstairs hallway. This means that staff are visible and accessible when they are writing reports or completing records, rather than using the office or dining room as before. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Elm Royd Nursing Home DS0000061813.V331486.R03.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 Royd Nursing Home DS0000061813.V331486.R03.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&6 People who use 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. A comprehensive pre-admission assessment is carried out before offering someone a place at the home, to make sure that their needs can be met. An intermediate care service is provided. The home’s staff work with the healthcare professionals to support people to regain sufficient independence to return home after illness. EVIDENCE: The care plans I looked at showed that comprehensive pre-admission assessments had been carried out before offering someone a place. This is to make sure that the home can meet the person’s needs. A senior member of staff visits the person at home or in hospital to discuss their care needs. Social Services assessments are also used to determine the care needs of the individual. People are welcome to visit the home before reaching a decision. Elm Royd Nursing Home DS0000061813.V331486.R03.S.doc Version 5.2 Page 10 The home provides intermediate nursing care for up to five people who need a period of rehabilitation in order to regain their independence before returning home, usually after an illness. During my visit I spoke with a member of the healthcare team that arranges and provides the rehabilitation. She said that Elm Royd is making progress and that the support her clients receive from the home’s staff has improved. Members of the team visit the home every day and the home’s staff follow up on their work during the rest of the day and evening. Some of the home’s staff are employed to work mainly with this group of people. People who go to Elm Royd for rehabilitation make progress towards their goal of achieving sufficient independence to return home, wherever this is possible. The home has a second lounge upstairs which was meant for this group of people to use. I was told that most of them prefer to spend time in the downstairs lounge with the other people who live at the home. Elm Royd Nursing Home DS0000061813.V331486.R03.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 & 10 People who use 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. To maintain their health and well-being, peoples’ personal and healthcare needs are met. People are not fully protected by the home’s medication systems. Medications are stored safely but their administration is not always accurate. To maintain their dignity, the staff treat people with respect and care at all times. EVIDENCE: I looked at four care plans in detail, to make sure that people’s health and personal care needs are being met in the way the person prefers and to help them maintain their health and well-being. Elm Royd Nursing Home DS0000061813.V331486.R03.S.doc Version 5.2 Page 12 The plans cover each area of the individual’s health and care needs in detail. There are risk assessments in place, where needed, and these show how potential risks can be minimised. Each person has a moving and handling plan and details of visits by GPs and other healthcare professionals are kept on separate record sheets. The plans showed that people are being weighed each month. Three relatives commented about the care relating to continence and personal hygiene. One person wrote that a member of staff was unwilling to make someone dry and comfortable before their teatime meal, saying they would ‘Put her to bed early & wash and change her then…..’. Another person’s relative expressed concern that a night catheter was left on during the day. The manager is to look at continence care, to make sure that all staff are aware of and follow good care and hygiene practice. The last inspection in February 2007 was to follow up concerns raised by a visiting nurse about the treatment of pressure area wounds. The management responded promptly to the report of this visit and the evidence I saw confirms that significant improvements have been made. One care plan showed that specialist advice had been sought on the best measures for preventing a vulnerable person developing pressure wounds. The staff have implemented this advice. Another person’s plan showed that specialist advice had been sought and put into practice, to promote healing and make the person as comfortable as possible. I saw evidence that this was being done. A healthcare professional commented on the questionnaire that the home’s staff ‘Look after patients registered with our practice very well’. The nursing staff review the care plans every month. The majority of the care plans have been signed by the individual, or a member of their family, to show they agree with and understand how their care and support is to be provided. During my visit I noticed that staff treat people with respect and maintain people’s dignity. Chiropodists visited the people who live at Elm Royd on the day I was there. A vacant bedroom was being used as a treatment room and people were being seen privately. The people I spoke with during my visit said that they receive the care they need and are supported to maintain their independence for as long as they are able. Eighteen of the twenty-two people who completed the surveys said that they always receive the care they need. One person wrote that they are ‘….being well cared for and looked after’. My own observations confirmed that this is the case. One visitor said they felt that it would be beneficial if their relative was encouraged to walk at least for short distances, rather than always use a wheelchair. Elm Royd Nursing Home DS0000061813.V331486.R03.S.doc Version 5.2 Page 13 Everyone I saw looked well dressed and comfortable. Some people’s families prefer to take all or some of their relative’s clothes home to launder. One person told me that the clothes are not always left for the family, but get sent to the laundry. One person said that the ‘Laundry at the home is much better than it used to be’. There is now a desk in the ground floor and upstairs hallways, so that when staff are writing reports and records they can still see what is happening and are more easily available. The Medicines Administration Record (MAR) charts are securely stored and kept up to date. Medicines are kept safe and secure. I looked at the MAR charts, which must be signed by the member of staff each time they administer a dose of medicine. There were some signatures missing and some charts did not show the quantities received for each medicine. One person’s course of liquid medicine did not appear to have been administered as prescribed. Instead of receiving 28 doses over 7 days, the charts showed that the medicine was finished after 17 doses had been given over 5 days. For the health of the people who live at the home, medicines must be administered as prescribed. Elm Royd Nursing Home DS0000061813.V331486.R03.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 & 15 People who use 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 are supported to maintain contact with family and friends. Leisure activities are provided to try and make sure each person’s recreational needs and expectations are being met. People are offered a choice of meals, however some people felt their dietary needs were not being met. EVIDENCE: The families and friends of the people who live at Elm Royd are always welcome to visit. One person commented that the home ‘Makes relatives welcome, and friends’. An activities co-ordinator has recently been appointed and currently works eighteen hours each week. The co-ordinator keeps a diary of the activities and who has taken part. Many people are unable to take part in group activities and would benefit more from individual attention, such as going for a walk, having the newspaper read to them, looking at photos or a gentle hand massage. Elm Royd Nursing Home DS0000061813.V331486.R03.S.doc Version 5.2 Page 15 The co-ordinator has a limited amount of time each week to provide meaningful and stimulating activities for everyone in such a large and diverse group of people. The diary shows that the co-ordinator is trying hard to engage people’s attention and provide activities that they will enjoy. One person commented in their questionnaire that ‘I can choose if I want to take part’. As a general point one person said that the television is left on too much and that people may prefer music instead. The menus show a good choice at each meal, with two main courses offered at lunch and tea times. On the day I visited the choice at teatime was pasties with mashed potato and gravy, sandwiches and scones. Alternatives to the planned menu are available. Most people who commented during my visit said they enjoy their food. One person wrote on their questionnaire ‘Sometimes I don’t have a wide enough choice’. Another commented that whether they enjoy their meals or not ‘Depends who cooks’. Another person wrote that they are ‘….enjoying meals and eating well’. One relative commented that ‘The food seems to be quite good and a good variation’. Special diets are catered for and the kitchen staff are aware of people’s needs. Assistance is offered to people who are not able to manage independently. Elm Royd Nursing Home DS0000061813.V331486.R03.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 & 18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People living at the home, and their relatives, are aware of how to raise a concern or make a complaint if they are dissatisfied with the service. Staff have received suitable training and understand the adult protection policies and procedures, which makes sure that people living at the home are safe. EVIDENCE: The surveys and the people who live at the home confirmed that people are aware of how to raise a concern or make a complaint, should they need to do so. One person wrote in their questionnaire that ‘My relatives can approach staff and most problems are sorted out’. The complaints procedure is clear and easily available. There is a complaints log to record any complaints or concerns, which are raised. In February 2007 two inspectors visited the home to follow up concerns raised by a visiting nurse. The home’s management and staff addressed the concerns straightaway and made the necessary improvements. Since the last key inspection on 23/05/06 four complaints have been made. These have been investigated and the home has responded satisfactorily. Elm Royd Nursing Home DS0000061813.V331486.R03.S.doc Version 5.2 Page 17 The staff are aware of the need to report any concerns they have about care practice. The home deals with any concerns effectively and without delay and follows the guidelines for reporting such incidents. Some staff have already had Adult Protection training, others were due to attend training soon after the inspection visit. Elm Royd Nursing Home DS0000061813.V331486.R03.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, 20, 21, 23 & 26 People who use 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 live in a safe, comfortable, well maintained and homely environment. EVIDENCE: All the bedrooms that I saw reflect the person’s individual preferences and taste. There is a programme of re-decoration for the bedrooms, as well as for the rest of the house. Several bedrooms and the main reception area have recently been re-decorated and look fresh and attractive. One of the bathrooms has had a special hairdressing sink fitted, to make hair-washing more comfortable. The bedroom doors all have locks, and there is a lockable storage space in the rooms, which means that people can keep their belongings private and secure. Elm Royd Nursing Home DS0000061813.V331486.R03.S.doc Version 5.2 Page 19 The home is fresh, clean, comfortable and well looked after. Everyone who commented agreed that the home is always, or usually, well kept. One person wrote in the questionnaire that they have ‘….always found the home to be clean and tidy….’, although another said ‘Sometimes the room is not up to standard…’. There are sufficient bathrooms for the people who live at the home. One person commented that ‘….a shower would be nice’. The wheelchairs were all clean and their footplates were in place, so that people’s feet are kept safe when the chair is moving. Elm Royd Nursing Home DS0000061813.V331486.R03.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 & 30 People who use 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. Sufficient staff are employed to meet people’s needs. The people who live at Elm Royd are protected by thorough recruitment procedures which ensure that staff are suitable to work with older people. Suitable training is provided, to make sure staff have the skills and knowledge they require to meet people’s needs. EVIDENCE: The rotas and staff numbers suggest that there are enough staff on duty at all times to meet the needs of the people who live at the home. However the six people who wrote comments said that staff response to requests for assistance needs to be quicker and that there may not always be sufficient staff available. One person who lives at Elm Royd wrote ‘Sometimes it takes time to find someone to assist’. It may be beneficial for the management to look at what has caused people to make these comments. The home does not use agency staff and any additional shift cover needed is provided from within the staff group. I looked at a selection of staff files. They all included completed application forms and two written references. The files showed that satisfactory Criminal Elm Royd Nursing Home DS0000061813.V331486.R03.S.doc Version 5.2 Page 21 Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) register checks have been obtained. I was assured that no new staff start work until a POVA register check had been completed. Then, if the CRB check had not been received, they would work only under the supervision of an experienced staff member. Staff recruited from overseas have the appropriate work permits. The manager makes sure that staff have the necessary training to help them do their work as well as possible. There is a wide range of courses available and the records confirmed that the staff are allowed the time to attend. The nursing staff have taken, or are taking, specialist training courses in subjects which include dementia care and all staff are taking infection control training. The nurses are currently taking refresher training in wound care, to keep their knowledge and skills up to date. Fifteen of the thirty care staff have a relevant National Vocational Qualification (NVQ). Two of the nurses are taking a medication administration training course, to update their knowledge; the other nurses have already taken this training. Three of the nurses have completed, or are currently taking, staff supervision training. When we visited in November 2006 we found that all staff had received Care of Substances Hazardous to Health (COSHH) training since the last inspection. Staff had also had training on understanding Parkinson’s disease, which they said was very helpful. Senior staff members and kitchen staff were due to undertake the second stage of the food hygiene qualification. Emergency first aid training for staff was being provided during the November inspection visit. Elm Royd Nursing Home DS0000061813.V331486.R03.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, 37 & 38 Standard 35 does not apply People who use 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 home is safe and well managed and people who live and work at the home can contribute to the decision-making processes. EVIDENCE: The manager has the qualifications and the skills to manage the home effectively. Residents and relatives meetings are held, although I was told they are not very well attended. The home sends out questionnaires to relatives, in order to gain information about how people view the service and what improvements they would like to see. Elm Royd Nursing Home DS0000061813.V331486.R03.S.doc Version 5.2 Page 23 When we visited in November two members of staff said they felt the home was improving. One believed “the home was going in the right direction” and another commented that it was a much better working environment than before. The home does not handle people’s money. This is dealt with by their families, or by other appointees. Confidential information is stored securely. The policies and procedures are kept up to date; to make sure they provide relevant information to guide staff on how to act in every situation. All the regular health and safety checks for the home are carried out in a timely manner. Staff have basic health and safety training. All these measures make sure that the health, safety and welfare of the people who live at the home is promoted and safeguarded. Since the last key inspection the dining room has been re-decorated and new curtains hung. There is still some new furniture, which the home is waiting for, to complete the dining room improvements. As part of the refurbishment a serving hatch has been installed between the dining room and kitchen and the kitchen flooring was replaced. No further improvements to the kitchen have been made since then. Elm Royd Nursing Home DS0000061813.V331486.R03.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 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X 3 X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Elm Royd Nursing Home DS0000061813.V331486.R03.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 OP9 Regulation 13(2) Requirement For the health and protection of everyone at the home, all medication must be administered and recorded accurately. Timescale for action 31/07/07 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 Royd Nursing Home DS0000061813.V331486.R03.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Elm Royd Nursing Home DS0000061813.V331486.R03.S.doc Version 5.2 Page 27 - 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. 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