Inspection on 11/05/06 for Elm Tree House

This inspection was carried out on 11th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 Tree House 03/11/08

Elm Tree House 30/11/07

Elm Tree House 19/02/07

Elm Tree House 17/11/05

Similar services:

Trevayler Residential Care Home

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

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

CARE HOMES FOR OLDER PEOPLE Elm Tree House 37a Ogle Street Hucknall Nottingham NG15 7FQ Lead Inspector Jayne Hilton Key Unannounced Inspection 11th May 2006 10:00 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 Tree House DS0000064368.V293672.R01.S.doc Version 5.1 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 Tree House DS0000064368.V293672.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Elm Tree House Address 37a Ogle Street Hucknall Nottingham NG15 7FQ 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 963 3573 Carisbrooke Healthcare Ltd Elizabeth Pasik Care Home 17 Category(ies) of Dementia - over 65 years of age (17), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (2), Old age, not falling within any other category (17) Elm Tree House DS0000064368.V293672.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Within the total number of beds, a maximum of 17 may be used for the category OP Within the total number of beds, a maximum of 17 may be used for the category DE (E) Within the total number of beds, a maximum of 2 may be used for the category MD (E) 17th November 2005 Date of last inspection Brief Description of the Service: Elm Tree House is a converted family house providing residential care for up to seventeen (17) older people. The home is situated in a residential area near the heart of Hucknall, within walking distance of shops and local amenities. The home is comfortable and homely and has pleasant gardens to the rear. There is a car park available at the front of the building. The home has recently been registered to provide services for people with Dementia and Mental Health Needs. Fees range between £277-£319 depending on dependency levels. Service users are expected to fund additional costs for newspapers, hairdressing and chiropody. Elm Tree House DS0000064368.V293672.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Jayne Hilton undertook the unannounced key inspection on 11th May 2006 between 10am and 5.20pm. The methodology used included case tracking three service users, observations of staff practice, a part tour of the building, speaking with three service users, relatives, staff and the manager. Some records were inspected but some were not produced, as the manager could not locate them. Unfortunately the manager left the home part way through the inspection to attend a meeting so the inspector was unable to discuss and feedback all of the findings from the day to her personally. An additional visit was made to the home on 15th February in relation to a complaint made to CSCI, which is referenced to in this report. The complaint was found not to be upheld, however seven requirements were set at that visit and two recommendations for improved practice. CSCI have not received an action plan for the requirements made, although the manager stated she had posted this to the Commission. The manager could not locate a copy of the improvement plan on the day of the inspection. The manager was advised to facsimile any information requested. The manager reported that the facsimile had been broken for sometime. The manager was advised that it is a requirement for the home to have a working facsimile machine and a requirement will be set in relation to this. Two immediate requirements were set from the inspection one in relation to staffing levels and one in relation to poor recruitment practices. Both had been set previously as requirements and therefore not met. The dependency levels of the service users at Elm Tree House are changing due to the new registration category and recent vacancies. The methodology at this visit reflects a focus on how the home is meeting the varying needs of service users. What the service does well: Elm Tree House DS0000064368.V293672.R01.S.doc Version 5.1 Page 6 Service users feel that their needs are met by the home and state that they are happy residing in the home and that they have the information to make an appropriate choice about where they live. Staff reported that the home is generally managed well. Service users spoken with were generally happy with the provision of care and were happy that the home is meeting their needs and praised the staff approach. Service users appeared relaxed and well presented and staff were observed treating service users with respect and with patience. One service user told the inspector she had recently visited another home on a trial basis but had decided to stay in the home. On the whole service users needs appear to be assessed but a lack of full evidence means the standard is not met. Further work is required in relation to the full assessment of service users needs and in relation to written documentation for contractual arrangements. The new care plan format is now used for all service users and the three individual care plans examined were observed to reflect on the whole the healthcare and personal needs of service users. Service users felt that on the whole their privacy and dignity was respected. Service users confirm that they have control over their lives and regular visitors are welcomed. Service users feel that they can make complaints confidently. Service users live in an overall clean and comfortable environment and the provider has made some improvement to the bathroom facilities, The manager is registered with the commission and staff stated that they are confident in her abilities to manage the home. Service users and relatives praised the provider, stating he was helpful and approachable. What has improved since the last inspection? What they could do better: Elm Tree House DS0000064368.V293672.R01.S.doc Version 5.1 Page 7 There are some deficits in the care plan process, which must be addressed to ensure all of each individuals needs are fully met. Although there is an activities co-ordinator three afternoons a week during school term times, the dependency needs of the current service users, mean that they require more stimulation and attention to ensure their needs are fully met and therefore the social, leisure and cultural needs of service users need to be more detailed and the current provision reviewed. The systems in place for the management of medicines, requires further improvement. Service users felt that on the whole their privacy and dignity was respected, observations of staff practice did not fully support this and some poor care practices were noted in relation to the dignity of service users. Due to the issues around poor staffing levels the inspector’s professional judgement on the evidence gathered at this inspection is that quality outcomes for service users need to be improved. Further work is required in relation to the full assessment of service users needs and in relation to written documentation for contractual arrangements. some of the management systems were either not in place or were not available for inspection. Quality monitoring systems require some improvement to ensure the home is operating in the best interests of service users. Staff state they are supervised but no records of this was produced. The inspection found that record keeping was poor overall. The evidence gathered at the additional visit and on the day of this inspection, indicates that complaints are not appropriately documented. The protection and safety of service users may be at risk due to poor recruitment practices and lack of training for staff. The health, welfare and safety of service users may be compromised because of poor standards of practice in the home in relation to infection control, food hygiene and lack of safe supervision of service users. The staffing levels are not satisfactory and the outcomes for service users are compromised. There was a lack of evidence to assess the training provision in the home and service users are being put at risk by poor recruitment policy and practices. Poor management and staff practices around health and safety indicate that the outcomes for service users may be seriously compromised. 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. Elm Tree House DS0000064368.V293672.R01.S.doc Version 5.1 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 Tree House DS0000064368.V293672.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users feel that their needs are met by the home and state that they are happy residing in the home and that they have the information to make an appropriate choice about where they live. On the whole service users needs appear to be assessed but a lack of full evidence means the standard is not met. Further work is required in relation to the full assessment of service users needs and in relation to written documentation for contractual arrangements. Due to the issues around poor staffing levels the inspector’s professional judgement on the evidence gathered at this inspection is that quality outcomes for service users need to be improved. The home does not provide intermediate care. EVIDENCE: A new statement of purpose and Service user guide has been produced regarding the change of ownership and recent change in registration Elm Tree House DS0000064368.V293672.R01.S.doc Version 5.1 Page 10 categories. All service users have been issued with a copy of the service user guide, it is recommended that service users or their relatives sign to say they have received a copy. Terms and conditions are included within the Service user guide. Completed contracts were not seen. As recommended at the Inspection on 11th November 2005 it is recommended that a section be included for the issue of door keys and keys for lockable facilities also with a signature sheet for issue of these. Where service users are not able to manage their own door-key a risk assessment should be in place regarding this. A new care plan format has been introduced. The home was in the process of transferring over to the new documentation at the last key inspection. The format used does not encompass all of the documentation needed and the manager needs to ensure that deficits are included within individuals care plan files. It was reported that all service users are assessed prior to moving in. One service user had recently been admitted as an emergency, staff confirmed that an assessment of the service users needs had been sent by the social worker prior to their admission. Staff at the inspection could, not locate the documentation for this service user, so the inspector could not verify this. The inspector requests that this information be located and a copy sent to the inspector. There was no evidence that the home has written to the service user/relative confirming that the home can meet the service users needs and this is required. Signatures of service users and their relatives were seen in the plans. The assessment documentation does not address all topics as identified in Standard 3.3. Foot care particularly was not covered within the assessment, care planning and there was no indication that a Chiropodist had visited the three service users care plans examined. Another service user reported she had a chiropodist visit three months ago and was desperate for her toenails to be cut. The manager and staff reported that a chiropodist had visited the home the day previous for one service user, however there was no evidence of this in the service users care records or even in the visitor’s book. One service user who was a diabetic had a care plan in place for the management of the condition, however foot care was not included in the care plan. Staff reported that the home is generally managed well. Service users spoken with were generally happy with the provision of care and were happy that the home is meeting their needs and praised the staff approach. Elm Tree House DS0000064368.V293672.R01.S.doc Version 5.1 Page 11 There was an opinion expressed from relatives that the standard of care in the home had deteriorated and they had raised their concerns with the manager to address. Service users appeared relaxed and well presented and staff was observed treating service users with respect and with patience. One service user told the inspector she had recently visited another home on a trial basis but had decided to stay in the home. There are no service users currently at Elm Tree house with any specific cultural or diversity needs. Two service users are assisted to maintain their spiritual/religious needs. The manager recognises she must address equality and diversity within the home and that staff should be trained in its promotion. Care plans need to be expanded to ensure that staff have clear guidance to ensure service users preferences and wishes are fully met. One service user was observed to be wandering and on the whole staff managed this, however on the morning of the inspection only one carer and one cook were on duty. The manager was in then office in a meeting with relatives. The carer was undertaking cleaning duties and therefore service users were left unattended for most of the time. The cook had to observe or attend to service users as required and was observed to be taken from the kitchen several times. [Although the cook is a senior member of the care staffthere are infection control risks with this kind of practice][See Standard 27 re staffing and Standard 38] Information within the assessment and care plan documentation on the social, leisure and cultural needs of service users is minimal and needs to be developed. [See standard 12] Elm Tree House DS0000064368.V293672.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The new care plan format is now used for all service users and the three individual care plans examined were observed to reflect on the whole the healthcare and personal needs of service users. There are some deficits however which must be addressed to ensure all of each individuals needs are fully met. The systems in place for the management of medicines require further improvement. Service users felt that on the whole their privacy and dignity was respected, observations of staff practice did not fully support this and some poor care practices were noted in relation to the dignity of service users. EVIDENCE: The new care plan format is now used for all service users and the three individual care plans examined were observed to reflect on the whole the healthcare and personal needs of service users. There were some deficits noted as specified earlier, such as foot care and chiropody. Behaviour Elm Tree House DS0000064368.V293672.R01.S.doc Version 5.1 Page 13 management was not always formalised into a care plan and one service user who refuses to allow staff in her room, did not have this fully documented, neither had staff been informed of a consistent approach in managing this individual and ensuring the service users health and safety in balance of her rights are upheld within the process. The risk assessments in place were minimal and did not cover specific issues identified such as one service user walking around with a sharp knife that is used for peeling fruit. The same service user has recently lost a close friend who resided in the home and it was not reflected in the care plan or when speaking to staff, that the service user was in the grieving process and required support for these needs. Relatives reported that they had found a number of tablets in the service users purse and again this was not documented as an issue within the service users care plan and risk assessments. Observation of staff practice confirmed that one service user’s nutritional needs were attended to as specified within the care plan. A GP visit record indicated that one service user had seen the GP for depression, but there was no care plan in place for this. Care plans address service users mobility and risk of falls. Staff were observed to move/transfer service users in a safe way. However a problem was observed in relation to a wheelchair being borrowed by relatives to take a service user out and no footplates could be located. A service user had to be encouraged to move so that his wheelchair could be used. Care plans were observed to be reviewed regularly and most, but not all were reviewed on a monthly basis. It is recommended that key workers, service users and relatives are brought together where possible to undertake an evaluation of how the service users care needs have been met each month/two months and a summary recorded about this. Service users reported that they felt their healthcare needs were met. That staff were keen to access the GP where needed. Accident records indicated at least three head injuries where staff had not accessed advice from the GP, or emergency services. One accident did result in one service users being attended at hospital. Continence appeared well managed and service users were clean and well presented. It was reported that there were no service users with pressure areas. Tissue viability is assessed and monitored within the care plan. Two service users were attended by the district nurse for conditions on the day of the inspection. It was observed that any blood tests taken were recorded on the multidisciplinary sheet, however follow-ups to the tests were not. This is an area that the manager needs to address to ensure the service users health needs are fully met and records maintained. Elm Tree House DS0000064368.V293672.R01.S.doc Version 5.1 Page 14 Nutritional assessments are included in the care planning process and the manager has obtained information from the dietician of food and nutritional values for older people. Eye tests were observed to be recorded. Daily notes are recorded but these are still not being written to encompass how the holistic needs of service users have been met that day and tend to focus on eating, sleeping or visits. During the visit on 15th February 2006 a medicine round took place during the inspection. It was observed that a staff member placed medication in a service users mouth with her fingers. Hand washing between was not observed. When spoken with the staff member confirmed her error and stated that she knew the appropriate practice and had indeed used a spoon for this purpose with another service user. At the inspection on 11th May 2006 the following issues were identified. The medication administration record sheets were loose/not secured in a folder and untidy. There were no dividers for each service user and no photograph of the service user. Care is needed in checking the storage instructions for eye drops and for ensuring they are securely put away after use. The key to the CD cupboard needs to be identified should this be needed. Only medicines should be stored in the medicine cupboard [not money or cigarettes. The medicines policies need expanding upon to meet the guidance of the Royal Pharmaceutical Society Guidance. There was no copy of British National Formulary available for staff use in the home. Storage temperatures of the fridge and storage room had not been taken since 2/5/06. A policy for drug errors is in place and clearly accessible for staff should they need it. Medication is stored in a lockable cupboard. The home has recently changed its community pharmacist supplier. A sample of signatures is available of those staff trained in medicines management. The manager reported that she undertakes competency assessments for dispensing medication, but could not provide written evidence for this. Elm Tree House DS0000064368.V293672.R01.S.doc Version 5.1 Page 15 Staff were observed not to wash their hands prior to undertaking medication administration and to clear dirty pots away in between and take them to the kitchen. [See standard 26 and 38-re hand washing issues] One service users self medicates and keeps her medication in a lockable facility. Risk assessments were not examined at this visit but have been observed to be in place and appropriate at previous inspections By speaking with service users and staff and observations made on the day, confirmed that on the whole service users privacy and dignity is maintained. Service users did say that sometimes staff did not knock always before entering their rooms. A pay phone is provided. An electric shaver was observed to be on charge in a communal area of the home and when the inspector made enquiries was informed that two male service users used the shaver. This practice is unsatisfactory and must cease at once. Service users should not share equipment for personal care such as shavers. Service users said that staff answered call alarms promptly. One service users room cannot be locked from the inside, staff could not explain if there was a reason for this. The manager should address this issue at once. Elm Tree House DS0000064368.V293672.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although there is an activities co-ordinator three afternoons a week during school term times, the dependency needs of the current service users, mean that they require more stimulation and attention to ensure their needs are fully met and therefore the social, leisure and cultural needs of service users need to be more detailed and the current provision reviewed. Service users confirm that they have control over their lives and regular visitors are welcomed. Service users now have more choice about their meals and that they are happy with quantity and quality of the food. EVIDENCE: An activities co-ordinator is employed during school term time only. Activities tend to be bingo and one to one outings and the occasional entertainer visiting the home. Service users are otherwise un-stimulated, as staff does not have the time to undertake activities or spend time with service users. Some service users have regular visitors and are taken out by them. As the dependency levels of service users in the home are changing over time, more attention is Elm Tree House DS0000064368.V293672.R01.S.doc Version 5.1 Page 17 needed on assessing the social, leisure and cultural interests of service users at the assessment and care plan level. There was no activities taking place on the day of the inspection. Staff informed the inspector that residents had recently been out to a show and meal by coach which they enjoyed and that Easter was celebrated, Various visitors were observed to come and go throughout the day, staff did not always remind the visitors to sign in and out, although one visitor did object and complained that the visitors book was placed too low. The visitors book is placed on a low table and staff agreed to move the visitor’s book to a higher table for the comfort of visitors. Rooms are personalised and service users can bring in their own belongings wherever possible. One service user has mostly her own furniture and bedding etc. Service users say they can get up and go to bed when they wish and can please themselves and have a bath when they like. This information is not detailed within the care plan process. The service user has also had a broken hinge on his wardrobe door, which he reports has been like it for three years, which must be repaired. At the visit on 15th February 2006 a member of staff was observed to prepare and serve food without wearing protective clothing. Aprons are supplied for kitchen use. Disposable aprons were not seen as supplied. At the visit on 15th February 2006 a service user reported that she had gained a stone in weight since moving to the home a few months ago. Four staff members and the manager confirmed that staff had not been instructed to reduce the amount of potatoes, however a pan of potatoes ready prepared for by night staff was assessed as not sufficient to feed seventeen people adequately. Advice must be sought from an appropriately qualified dietician/nutritionist as to adequate nutritional value and portions of food to be supplied to meet service users needs. Service users said they enjoyed the food and the menu options were cheese and potato pie, potato waffles, peas, carrots and tinned tomatoes, jelly and ice cream. A second option had been offered but not taken. Service users were observed making choices for tea. The manager has now obtained the above information from the dietician and menu portions were reported to be set by this. Service users reported that they were happy with portions and quality of food. Staff were wearing aprons and tabards for food preparation. Menu choices were evidenced for most days but some gaps in this recording was noted. Menus appeared varied and Elm Tree House DS0000064368.V293672.R01.S.doc Version 5.1 Page 18 nutritious. The inspector observed staff asking service users what they wanted to eat and where a service user had not got his hearing aid in staff wrote the question down for the service user to read. Staff were observed to assist service users as necessary and in a discreet manner. The mealtime observed was unhurried. Food stocks although not plenty, were sufficient to feed the residents for the following few days apart from stocks of cereals and tea bags. The manager and staff reported that she was going shopping later in the day and that supplies of teabags arrive from the sister home on a Friday. There was however no cereals in the home only a small amount of porridge. Although fresh stock rotation is good practice it did appear that stocks were left to get very low before replacement and relied on both the manager and handyman to bring in the supplies. It is recommended that a system of food delivery be organised in amore efficient and safe manner. There was no indication of any risk assessments in place for the manager to undertake this task, or any evidence of HACCP [Hazard analysis and Critical Control Point] in place. Staff spoken with reported that they were up to date with food hygiene training, although a new member of staff who was observed assisting with lunch had no evidence of this qualification in their personal records. See standard 26 and 38 re food safety issues Elm Tree House DS0000064368.V293672.R01.S.doc Version 5.1 Page 19 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The evidence gathered at the additional visit and on the day of this inspection, indicates that complaints are not appropriately documented. Service users feel that they can make complaints confidently. The protection and safety of service users may be at risk due to poor recruitment practices and lack of training for staff. EVIDENCE: At the visit on 15th February 2006 The Complaints records are stored on each individual files and the inspector requested a central copy to be kept for inspection. It was discovered that a recent complaint received by a relative had not been documented which is a breach of regulation. On the 11th May 06 the manager was in a meeting with relatives as the inspector arrived. Both the relatives and the manager confirmed that the relatives had raised issues of concern. The manager could not provide any written evidence of the concerns raised by the relatives and confirmed she had not taken any notes. The manager was reminded about the previous requirement and that records of complaints made must be recorded. Copies of previous complaints were seen in the complaint file and the manager reported that no other complaints had been made since the last inspection until the day of this visit. Elm Tree House DS0000064368.V293672.R01.S.doc Version 5.1 Page 20 Service users and staff confirmed that they knew how to report any complaints and that they felt confident to do so. Service users and relatives reported that the provider was very approachable, kind and eager to be helpful. Policies are in place for abuse awareness and whistle blowing. Some staff were not aware of the whistle blowing policy and were advised to refresh themselves of its use. They confirmed however that they would report any bad practice observed and described how they would deal with a disclosure made by service users. Service users reported that they felt safe. The front door is alarmed and the rear garden can be made secure to those who wander. [See environmental standards] A sample of service users finances held on behalf of residents were examined and found to satisfactory. Two staff have undertaken abuse awareness training-all staff must have training in this topic. Recruitment practices are not robust and therefore service users are being put at risk. Elm Tree House DS0000064368.V293672.R01.S.doc Version 5.1 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19-26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users live in an overall clean and comfortable environment and the provider have made some improvement to the bathroom facilities, but poor management and staff practices around health and safety indicates that the outcomes for service users may be seriously compromised. EVIDENCE: At the visit on 15th February 2006 the personal belongings of staff, coats and handbags etc were lying around the small sitting room next to the kitchen. Staff reported that they have an option of storing their personal belongings in the manager’s office, but only when she is there as this is kept locked otherwise. Regulation 23 requires that appropriate storage facilities be provided for staff belongings. Elm Tree House DS0000064368.V293672.R01.S.doc Version 5.1 Page 22 On the 11th May lockers were in place for staff personal belongings but all staff had not used them. Coats are now stored in the office. At the visit on 15th February 2006 Both Staff members and the manager confirmed that storage space was limited at the home and only one spare quilt was stored in the cupboard on the first floor bathroom. Service users beds have under drawer storage and a spare set of sheets pillowcases and quilt cover are kept under each service users bed. It is recommended that at least two further quilts be provided for spare/emergency use and a further supply of spare bedding sets be kept also. The manager confirmed these had been purchased but the inspector did not have time to examine them. At the visit on 15th February 2006. The home was warm on arrival; service users bedroom radiators have thermostatic regulators. One service user prefers her own fan heater. Another prefers to have the radiator in her room turned off. The heating is set on a timer. Staff confirmed they do not turn the heating off, but may turn it up if the weather is colder and it is needed. At the visit on 15th February 2006 Staff members and the manager reported that lights are only turned off to be energy saving where areas of the home are not in use. Lighting is never switched off that may increase the risk to service users health and safety. On the day of the inspection the weather was warm and some service users wished to spend time in the garden. The garden facilities were assessed in detail at this inspection. Although another member of staff arrived on duty it still proved difficult to observe all service users. Staff were observed supporting service users to mobilise onto the patio area with seating, but one table was piled with chairs and cushions from a drying settee were placed around the seating area which could easily have been hazardous, particularly to one service user who is partially sighted and who was wandering around the area for a few minutes. The inspector observed that staff had not made any risk assessment of this situation. Two service users have a smoking area they use which is sheltered. Part of the garden is raised with steps leading to a lawned area and a greenhouse, as the dependency levels of the service user group is changed, this area needs to be risk assessed and made safe for those at risk. Service users rooms were personalised and well furnished, appeared comfortable and clean, most are en-suite. Toilet rolls were sufficient in supply. Service users have a lockable drawer but do not hold keys for these. There was no evidence that service users had been offered a key or any risk assessment where not able. One service user has no thumb turn on the bedroom door lock Elm Tree House DS0000064368.V293672.R01.S.doc Version 5.1 Page 23 so cannot lock it from the inside. This must be attended to promptly. Evidence of key options should be written within care plan documentation. There were no paper towels in the downstairs toilet and cream cleanser and toiletries were left out on the window ledge. An unwrapped continence pad was left on the top of the drawer storage and holes to the wall where the toilet roll holder had been removed. The wallpaper boarder was starting to peel off and there was some soiling on the wall near the call alarm. A manual handling belt is stored in this room and the inspector advised that it would be more hygienic to store the belt in another area. Relatives reported that they had difficulty using a wheelchair on the ramp, this issue has not bee raised previously. The registered provider should seek professional advice from the environmental health department in relation to the safety of the ramp in place and provide the inspector with a copy of the outcome. Care staff was attending to laundry during the inspection, which is outside of the building and which means leaving service users unattended. Staff were observed not wash their hands when dealing with medication, serving at lunch and when clearing away etc. The kitchen has a hand washing facility but pots were noted to be piled in the main sink and a colander placed in the hand washing sink which it appeared to have been used to drain the vegetables as the other sink was in use with dirty pots. There was no evidence of the provision of suitable gloves for staff in the home on the inspector’s arrival. Gloves are provided, but these are not the latex type and are not conducive with infection control. Staff have been buying their own from choice. There were some supplies of appropriate gloves in the office, which the manager took out for use in the home on the day of the inspection. Staff confirmed that the gloves had not been provided as required previous to the day of the inspection. As the person responsible for cooking is being called upon to undertake care duties there is a risk of cross contamination where staff combine both duties. Fabric aprons were seen in use but there was no evidence of disposable aprons in use or displayed around the home. Staff reported that they have not undertaken any training in infection control. No training records were available for this topic either. Paper towels and hand soaps were seen in the kitchen and stocks of these were seen also. The provision of a dishwasher would be advisable. Elm Tree House DS0000064368.V293672.R01.S.doc Version 5.1 Page 24 A new bath with modern chair hoist has been provided in the upstairs bathroom. A service user reported he had a broken hinge on his wardrobe door, which he reports has been like it for three years, which must be repaired. [The current provider has owned the home for a year.] Relatives reported that their relative’s wardrobe had been un-level for some time and that a plank of wood had been placed underneath it for a while, but this had now been repaired. Information had been sent to CSCI indicating that MRSA was present in the home. The manager reported that there were no service users in the home with MRSA. Elm Tree House DS0000064368.V293672.R01.S.doc Version 5.1 Page 25 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28,29, 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The staffing levels are not satisfactory and the outcomes for service users are compromised. There was a lack of evidence to assess the training provision in the home and service users are being put at risk by poor recruitment policy and practices. EVIDENCE: The visit on 15th February 2006 noted that care staff are undertaking cleaning and a calculation of staff working hours is as follows. Care staff 8am –10pm 196 hours. Catering hours are separate and satisfactory. Even by calculating 10 hours of the manager’s hours and the activities worker this leaves a deficit of domestic and laundry provision. The minimum staffing levels for the home must be at least 210 hours for care. 34 hours for Domestic and Laundry and 34 hours for Catering. A staffing review must therefore be undertaken. On the visit on 11th May 2006 only one carer and one cook were on duty, it was reported that one member of staff had gone off sick. Other staff was Elm Tree House DS0000064368.V293672.R01.S.doc Version 5.1 Page 26 attending a service users funeral. The manager called in a member of staff rostered for the afternoon shift to commence her shift early when the inspector advised the manager that suitable cover was to be arranged. The Service users were clearly at risk with the level of staff on duty on the inspector’s arrival. One carer was undertaking cleaning duties and the other on kitchen duty. Service users dependency levels need to be taken into account and staffing levels amended accordingly. Information received at the Commission reported that one carer and one cook were staffing the home. The duty roster was examined for the previous four weeks, two carers and one cook were rostered on duty but the hours calculated for the care provision are still not adequate [196 hours] and the requirement set at the visit on 15th February 2006 clearly not met. Cleaning hours must be provided in addition which equate to 2hrs each resident E.g for 12 service users 24 cleaning hours must be provided for 17, 34 hours should be provided. An immediate requirement is set in relation to this; failure to provide adequate staffing levels may result in enforcement action being taken. The minimum staffing levels for actual care hours are based on the Local Authority staffing guidance for service users numbers between 12 and 19 service users, which equal 210 care hours. The manager reported that some staff had recently left and she had endeavoured to cover the shifts with staff from the sister care home as she did not want the staff team to work excessive hours. There were no recruitment records for these members of staff in the home and they could not be faxed through, as the facsimile machine was broken. The manager reported that she was trying to recruit suitable staff currently. The cook should be located in the kitchen and access to the kitchen limited for health and safety reasons. Staff have to wash pots by hand and clearly this is causing a problem for access to hand washing for staff. The person on cooking duty should not be expected to monitor residents and the kitchen doors kept closed. Service users are being put at risk from hazards in the kitchen should they wander in and there is a hazard of cross contamination also. Appropriate and designated trained staff should provide the catering arrangements. The manager could not provide evidence of staff undertaking NVQ’s and commented that the NVQ training was expensive and that free training was being explored. Staff reported that there were no staff currently working in the home with NVQ’s including senior care staff. Four staff were selected for the assessment of recruitment practices. Two staff were loaned from a sister home this documentation was not accessible; the manager stated she did not realise that copies should be kept in the home also. She was reminded that she has a responsibility to ensure that all staff are Elm Tree House DS0000064368.V293672.R01.S.doc Version 5.1 Page 27 appropriately checked and keep appropriate evidence for all staff working at the home. One new member of staff had only one reference and this was not from the previous employer. The manager stated she had not realised this and this was an indication that the recruitment practices in the home were not thorough, as important information within the application had not been recognised. The manager had also accepted a CRB from the staff member’s previous employer, which is not acceptable. Both the manager and the staff member confirmed that anew CRB application had been applied for, but there was no paper evidence of this. The manager was reminded that she should keep a copy and have the reference number for any contact needed with CRB etc. Another file evidenced that a CRB had been undertaken for a member of staff in January 2006 did not contain a request for a POVA check, which is not satisfactory. A new application must be made at once for this person to access the PoVA list check. The recruitment files of staff were not easy to audit, start dates were not clear, there was no evidence of induction for one staff, no evidence in the application form or re certificates/evidence of training, no evidence of interview records, no photograph or ID checks etc as required by schedule 2 and Schedule 4 of the regulations. There was no indication of skills for work induction but the manger stated this was being accessed. The evidence amounts to very poor recruitment practices and an immediate requirement is set. This a second breach in this area for this current Provider. Failure to comply will result in enforcement action. There was no evidence of any training on any of the staff files examined, neither was there any system for analysing the annual training needs of each individual or as a group of staff. Long serving members of staff have certificates in their files and they confirmed training in fire safety, manual handling, food hygiene, first aid, update medication training and abuse awareness, Dementia training which included dealing with challenging behaviour. Staff also stated that the district nurse has provided continence management and diabetes information training in the past. Staff confirmed they have not undertaken training in infection control. Staff reported that they are not paid to attend training. Staff should be paid to attend at least three days training. Staff provided evidence of the General Social Care Councils code of conduct booklet. Elm Tree House DS0000064368.V293672.R01.S.doc Version 5.1 Page 28 Elm Tree House DS0000064368.V293672.R01.S.doc Version 5.1 Page 29 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36,37,38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The manager is registered with the commission and staff states that they are confident in her abilities to manage the home. However some of the management systems were either not in place or were not available for inspection. Quality monitoring systems require some improvement to ensure the home is operating in the best interests of service users. Staff state they are supervised but no records of this was produced. Service users financial interests are safeguarded. The inspection found that record keeping was poor overall. The health, welfare and safety of service users may be compromised because of poor standards of practice in the home in relation to infection control, food hygiene and lack of safe supervision of service users. EVIDENCE: Elm Tree House DS0000064368.V293672.R01.S.doc Version 5.1 Page 30 There was evidence that the manager needed to organise files and improve on the systems needed not only under the requirements of the Care Home Regulations and National minimum standards but also to be able to manage the home effectively. Staff reported that on the whole they were confident in the manager’s abilities to lead the team. Information was sent to CSCI indicating that the manager is not always present in the home. The manager left the inspection half way through announcing that she had to attend a meeting, which had not been informed to the inspector earlier in the day. The inspector managed to access some files prior to the manager leaving but some follow up work later could not be accessed for example a new service users care plan. Service users and relatives praised the provider, stating he was helpful and approachable. The use of management time to undertake food shopping should be reviewed. The manager needs to prioritise her responsibilities under the Care Home Regulations 2001. Failure to provide the relevant documentation and meet compliance with the requirements set may mean the Registered Provider and Registered Managers Fitness being questioned. Service users and staff were aware of a recent service user survey and a sample of questionnaires was examined. It was recommended at the previous key inspection, that another survey be carried out in relation to the issues of concerns raised by the inspection and the recent complaints and the outcome notified to all service users and relatives. The manager reported that resident/relative meetings are held but no evidence of these were provided. Staff spoke of a recent staff meeting but was not aware of any minutes being kept. The manager stated that the provider visits regularly but she could not provided evidence of the provider undertaking regulation 26 visits and this is required. This is an outstanding Requirement. There was no evidence of any other quality audits in the home. The home hold small amounts of cash for three service users and the records of these were examined. The system of recording is noted to be improved. It is recommended that the registered provider periodically audit the accounts to support the manager in this process. The manager and staff spoken with confirmed that supervisions had taken place, but the manager could not locate the records for these to be assessed. There is a visitor’s book for use but this was not always used, this is a requirement by regulation. Lack of evidence in records available to be inspected has resulted in standard 37 being scored as 1. Elm Tree House DS0000064368.V293672.R01.S.doc Version 5.1 Page 31 Health and safety practices continue to cause concern in the home. At the visit on 15th February 2006 There was evidence of plastic disposable gloves available in the home, but staff found these difficult to use for care and cleaning tasks. This type of glove is therefore not practicable for all uses and a supply of latex gloves should be provided. Gloves have been provided, although not in great quantities they were available. Staff have chosen to buy their own gloves, it is not a requirement of the home they do, but this is indicative that the ones supplied are not fit for purpose. At the visit on 15th February 2006 the home was clean throughout. Cleaning products were available, however the cleaning cupboard was left unlocked and disinfectant had been decanted to another container without the appropriate labelling. Disinfectant is concentrated and needs to be diluted for safe use. Bleach is diluted in buckets of water as prescribed. COSHH Data was in place for the selection of products seen in the home. Toilet cleaner is also provided but staff reported that they use the disinfectant for general cleaning use and it is recommended that another suitable product be supplied such as a crème all purpose cleaner. On the 11th May 06 issues highlighted in standard 9, 15, 19, 26,27 28, 29, 30 in relation to food safety, infection control, staffing numbers, lack of supervision of service users, service users safety/security, poor recruitment practices/ protection of service users, lack of personal protective clothing, COSHH issues, poor care practices and the following issues leave major shortfalls in meeting the standard. Staff could not access the current fire safety records for examination and assessment. Therefore there is no evidence of a fire safety risk assessment. Evidence was not accessible for generic risk assessments and manual handling operations regulations. There was no evidence of maintenance records for wheelchairs. The annual gas safety certificate is due. There was evidence of the following, lift servicing, electrical safety certificate, portable appliance testing, legionella checks and water outlet tests. Replace the kitchen waste bin with one with a lid Clean the tops of the chest freezers. Elm Tree House DS0000064368.V293672.R01.S.doc Version 5.1 Page 32 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 2 2 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 1 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 1 17 X 18 2 2 2 2 2 X 2 3 1 STAFFING Standard No Score 27 1 28 1 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 2 1 1 Elm Tree House DS0000064368.V293672.R01.S.doc Version 5.1 Page 33 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 OP3 Regulation 14,15,16 (1) The registered person shall not provide accommodation to a service user at the care home unless, so far as it shall have been practicable to do so— (a) needs of the service user have been assessed by a suitably qualified or suitably trained person; (b) the registered person has obtained a copy of the assessment; (c) there has been appropriate consultation regarding the assessment with the service user or a representative of the service user; (d) the registered person has confirmed in writing to the service Elm Tree House DS0000064368.V293672.R01.S.doc Version 5.1 Page 34 Requirement Timescale for action 11/08/06 user that having regard to the assessment the care home is suitable for the purpose of meeting the service user’s needs in respect of his health and welfare. (2) The registered person shall ensure that the assessment of the service user’s needs is— (a) kept under review; and (b) revised at any time when it is necessary to do so having regard to any change of circumstances. Ensure care plans are implemented for specific individual needs and preferences. Timescale 17/12/05 Not Met In relation to: Service user’s social and leisure needs, behaviour, depression, and bereavement experiences needs, foot care and chiropody treatments and to ensure that in conjunction individual risks are fully assessed and documented. The Registered Person must 11/07/06 ensure that staff handle medicines in a safe way that does not put service users at risk of cross infection. Timescale set 15/04/06 not met Ensure that systems for Elm Tree House DS0000064368.V293672.R01.S.doc Version 5.1 Page 35 2 OP9 12,13 medication management is safe and address the issues identified within the report. 3 OP10 12,13 The registered person shall make 11/07/06 suitable arrangements to ensure that the care home is conducted— (a) in a manner which respects the privacy and dignity of service users; 4 OP15 16 Ensure service users privacy and dignity is respected at all times. In relation to the identified areas in the report. Adequate portions of food per person must be provided. The Registered person must obtain appropriate guidance from a dietician/ nutritionist in relation to ensuring staff are knowledgeable about sufficient portion and nutritional values of food. Timescale 15/04/06 Met [Please note the date indicated in the right hand column is the date of this inspection and when reassessed The target timescale set as above is therefore met] The premises to be used as the care home are of sound construction and kept in a good state of repair externally and internally; Repair the broken wardrobe door hinges. Fit a thumb turn to the door lock 11/05/06 5 OP19 23 11/06/06 Elm Tree House DS0000064368.V293672.R01.S.doc Version 5.1 Page 36 6 OP27 18 in the same room. The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of service users— Sufficient staff must be provided as follows; At least 210 care hours 8am – 10pm 34 Domestic and Laundry and 34 Catering. [17 residents] Timescale: 15/04/06 Not Met An immediate requirement is set at this inspection. 11/05/06 7 OP29 19 CSA Staff must not be employed without evidence of a satisfactory PoVA check, CRB check and two written satisfactory references. An immediate requirement was set in relation to this. [This was a previous issue on 17/11/05.] Ensure staff personal files meet the requirements of schedule 2 Timescale set 16/12/05 Not met The Registered Manager must undertake her responsibilities as a Registered Manager and keep necessary records and provide suitable records for inspection as required by regulation. Schedules 2, 3, and 4 The registered provider must provide evidence and keep satisfactory records of staff 11/05/06 8 OP16 17,18 11/06/06 Elm Tree House DS0000064368.V293672.R01.S.doc Version 5.1 Page 37 training and supervision. Ensure all visitors to the home complete the visitor’s book. Ensure fire safety records are available for inspection at all times. A record must be kept of all complaints referred to the home Timescale set 15/04/06 Not Met Copies of incident records must be kept. [see also standards OP 30,31] 9 OP33 26 The registered provider must provide evidence of his obligations under Regulation 26 Timescale set 17/12/05 Not Met A Copy must be sent to CSCI on a monthly basis. 10 OP38 13 The registered person shall make suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home. The registered person shall ensure that— (a) all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety; (b) any activities in which Elm Tree House DS0000064368.V293672.R01.S.doc Version 5.1 Page 38 11/06/06 11/07/06 service users participate are so far as reasonably practicable free from avoidable risks; and (c) unnecessary risks to the health or safety of service users are identified and so far as possible eliminated, and shall make suitable for the training of staff in first aid. The registered person shall make suitable arrangements to provide a safe system for moving and handling service users. The registered person shall make arrangements, by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. In relation to: Seek advice from the Environmental Health Officer in relation to appropriate risk assessments in relation to the Manual handling operations Regulations. Seek advice from the Environmental Health officer into the comments made about the ramp access to the home. Seek advice from the Environmental Health Officer in relation to HACCP [Hazard Analysis and critical control Elm Tree House DS0000064368.V293672.R01.S.doc Version 5.1 Page 39 point] and food preparation areas. The garden area must be kept safe and free from hazards at all times. Particularly in relation to the patio and seating area. Provide evidence of a fire safety risk assessment. Ensure cleaning items and toiletries are locked stored as required by COSHH regulations [Control of Substances hazardous to Health] Ensure all food handlers are trained in food hygiene. All staff must undertake infection control training and training in abuse awareness Ensure practice in the home promote infection control in relation to hand washing, cleaning of the premises, catering arrangements and storage of continence aids. Ensure there is always an adequate supply of personal protective clothing for staff to use. Timescale set 17/12/06 Not Met Timescale 15/4/06 Not Met 12 *RQN 16 [See also standard OP38] (2) The registered person shall having regard to the size of the care home and the number and needs of service users— (a) provide, so far as is necessary for the Elm Tree House DS0000064368.V293672.R01.S.doc Version 5.1 Page 40 11 OP26 13,16 11/06/06 11/07/06 purpose of managing the care home— (i) appropriate telephone facilities; appropriate facilities for communicatio n by facsimile transmission; (ii) A working facsimile machine must be available in the home. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 Refer to Standard OP7OP OP8 OP8 OP28 OP30 OP8OP Good Practice Recommendations Ensure there is evidence that service users have the opportunity to have a door key and this is written in their care plan.[See also standard OP14] Ensure where service users receive a head injury as a result of a fall that medical advice is sought. Keep a separate and running record of each type of healthcare check including follow- ups for blood tests. Provide evidence of NVQ training and induction in skills for work standards. Staff should be paid for at least three days to attend training. Training should be provided in equality and diversity. Provide evidence that the wheelchairs are maintained and suitable for the individual’s use. [see also Standard 38] Elm Tree House DS0000064368.V293672.R01.S.doc Version 5.1 Page 41 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Elm Tree House DS0000064368.V293672.R01.S.doc Version 5.1 Page 42 - 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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