Inspection on 16/06/05 for Elm Tree House

This inspection was carried out on 16th June 2005.

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

The inspector 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 06/03/07

Elm Tree House 22/03/06

Elm Tree House 16/11/04

Elm Tree House 27/04/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Elm Tree House 8 Chandag Road Keynsham Bristol BS31 1NR Lead Inspector Paula Cordell Unannounced 16 June 2005 09.30 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 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 - Draft Report Version 1.10 Page 3 SERVICE INFORMATION Name of service Elm Tree House Address 8 Chandag Road Keynsham Bristol BS31 1NR 0117 9867791 0117 9867791 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Treehome Ltd Mr Stephen Charles Wilkins PC Care Home 8 Category(ies) of LD Learning Disability (8) registration, with number of places Elm Tree House - Draft Report Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: May accommodate up to 8 persons aged 18-64 years with Learning Disabilities. Date of last inspection 16 November 2004 (Announced) Brief Description of the Service: Elm Tree is a registered care home owned by Treehome Ltd a subsidiary of Craegmoor Healthcare (Parkcare No 2 Ltd). Mr Wilkins manages the home on a day-to-day basis. Elm Tree is registered with the Commission for Social Care Inspection to provide accommodation and personal care to eight people with a learning disability aged between 18-64. Elm Tree House is a two storey property situated in a residential area of Keynsham. Local amenities include a leisure centre, shops and recreational park. Transport to Bristol and Bath and other areas can be accessed by rail or bus. Due to the accessibility of the building the home is unable to provide a service to people with a physical disability or for those people who use a wheelchair. All service users are provided with a single bedroom. Elm Tree House - Draft Report Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection following the visit in November 2004. The purpose of the visit was to review the progress to the requirements and the recommendations from last inspection monitor the quality of the care provided to the residents accommodated at Elm Tree House. There have been no additional visits during this period. The home has been keeping the Commission for Social Care Inspection informed of incidents that affect the wellbeing of the individuals living at Elm Tree House and the provider has sent monthly appraisals of the service in all but two months. The home has one vacancy. The visit was conducted over a period of five hours, which included the lunch time period. The inspector had an opportunity to meet with seven of the residents, four members of staff including the manager and read a random selection of records. The inspector viewed three of the eight bedrooms and the communal areas. The inspector would like to take this opportunity to thank the team and the residents for their welcome and their assistance in the inspection progress. What the service does well: The impression the inspector gained on the day of the inspection was one of a homely relaxed atmosphere where staff were aware of their roles and responsibilities. Residents have personalised packages of care with a high level of involvement in the running of the home. The home has built good relationships with the local community learning disability team in supporting the needs of the individuals living in the home complimenting the skills of the staff. All residents spoken with described a high level of support and satisfaction from living in Elm Tree House. It was evident that they were involved in making decisions about their care and the home does this well. There is a commitment to ensuring that staff are skilled and have the relevant training to be able to fulfil their roles within the home and this is kept under review. Elm Tree House - Draft Report Version 1.10 Page 6 What has improved since the last inspection? What they could do better: There are four requirements and two recommendations rising from this inspection. Three of the four requirements are outstanding from the previous inspection. Further non-compliance could lead to enforcement action being taken. However, on this occasion the timescales have been extended to enable the home to comply. Residents and relatives would benefit from having information available to them on the home in the form of service user guide. The manager stated that whilst this has been written as yet no copies have been sent to relatives and residents. The statement of purpose must meet with the legislation and clearly state the staffing on a daily basis including the reduced staffing at the weekend. The home must be able to demonstrate that the environment is suitable for the individuals living in the home and appropriate aids and adaptations are place. Residents would benefit from a ground floor shower facility. Regulation 26 visits must be monthly and a copy to be sent to the Commission for Social Care Inspection. To ensure the safety of residents and staff the home it is recommended that the home complete an annual check on the electrical appliances. Elm Tree House - Draft Report Version 1.10 Page 7 The fire records would benefit from a review of the content to ensure it is accessible and logical to the reader. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Elm Tree House - Draft Report Version 1.10 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Elm Tree House - Draft Report Version 1.10 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5 Residents and their relatives have information about Elm Tree House, however the home must include more information relating to the staffing in the home. Residents assessed needs are being met and kept under review. EVIDENCE: Information was available for residents and their families. This included a contract a service user guide and a statement of purpose. The manager stated that this has recently been updated and will be sent to all relatives with copies of the complaints procedure. There is an outstanding requirement for the home to clearly describe the staffing structure in the home. Whilst the statement of purpose has been updated the home failed to document the reduced staffing in the home at weekends. This will be further discussed under staffing. The home has one vacancy and the manager was able to articulate the process they were planning to follow to ensure that the new admission was suitable for the home. This included talking with other professionals, relatives and the prospective individual. The psychiatrist confirmed that the home had liaised with him during the process. Policies and procedures were available to describe the process the home should follow when a new resident moves to the home. Elm Tree House - Draft Report Version 1.10 Page 10 This included the assessment process and planning visits to ensure a smooth transition to the home. The home was able to demonstrate that existing residents would be involved in the process to ensure compatibility. Evidence at this inspection was that the home was meeting the changing care needs of the individuals in the home. All residents spoken with described a high satisfaction with their home and the support of staff. Elm Tree House - Draft Report Version 1.10 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,8,9 Residents’ care was person centred and the home was able to demonstrate that this was kept under review. However, the home has failed to demonstrate that the environment has been adapted to meet the changing care needs of one individual. EVIDENCE: Three care files were reviewed on this occasion. Information was person centred and being reviewed at the appropriate intervals. Residents described how they were involved in the process and where appropriate could invite relatives and friends to a meeting to discuss their plans of care. The manager stated that all care files are in the process of being reviewed and updated on a more person centred format. A resident stated the home has facilitated an independent advocate (person centred planning co-ordinator) to assist with writing their plan of care. This is good practice. It was evident that the individual would own the plan. Elm Tree House - Draft Report Version 1.10 Page 12 The home operates a key worker system where each resident is allocated a member of staff to assist them. Residents described the role of the key worker. This had been discussed at a residents’ meeting. Residents stated that they had been involved in the allocation demonstrating that choice had been given. Records seen included care plans on supporting individuals with behaviour and support given to ensure that individual’s emotional wellbeing was being met. Risk assessments were in place. The home has demonstrated compliance to ensure that residents are kept safe and a risk assessment was in place to reduce the risk of falls for one individual. The home had liaised with the occupational therapist and physiotherapist. The professional’s report made reference to aids and adaptations for the individual. These included handrails to the top of the stairs and a ground floor shower facility. Whilst the home was able to provide evidence that the home has requested a budget for the necessary works these had not been undertaken. This is disappointing in that the report was over six months old. The timescale has been extended to enable the home to comply. Further non-compliance could lead to enforcement action. Residents described how they were involved in the running of the home, including attending meetings, completing questionnaires as part of the quality audit tool making decisions about activities and the décor of the home. The inspector was pleased to see that residents meetings were more frequent than on the last inspection. Minutes were seen of relative meetings, which are organised annually to discuss matters relating to the home and the organisation. A resident stated that they attended a conference on service user involvement with Craegmoor Healthcare. Elm Tree House - Draft Report Version 1.10 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,13,14,15,16,17 Residents’ social and personal development needs were being met. EVIDENCE: Residents were keen to share information about their activities they were undertaken during the day. This included college, day centres and activities organised by the home. Residents stated that they were able to choose how to spend their time and were involved in accessing information about college courses, social events and the organising of the annual holiday. All residents have access to an annual holiday. Opportunity plans and daily statements demonstrated that the individuals were supported in their chosen pursuits. A conversation with a visiting professional commended the home on the innovative way that they organise meaningful activities for residents. Elm Tree House - Draft Report Version 1.10 Page 14 A resident stated that there are plenty of opportunities to go out and about in the community. However, the individual acknowledged that they often refuse to participate preferring to spend time on their own. Care documentation included information on how the staff were supporting individuals with social, emotional, communication and independent living skills. Records seen indicated that residents had been offered bereavement and relationship counselling where relevant. Many of the staff have attended training in professional relationships and all the team have attended a course in adult protection. This is good practice. The manager and the deputy manager stated that there is a long term plan for the home to potentially build a small home in the grounds of Elm Tree House to enable residents to live more independently with the support of familiar staff. It was evident that the home encouraged residents to live independently making choices on how they want to live. Residents stated that staff in the home support them to maintain contact with relatives including transportation and regular social gatherings in the home. A resident was seen accessing the telephone to make contact with friends during the course of the inspection. The manager stated that many of the residents spend with weekends with relatives hence the reduced staffing. Residents confirmed the regular contact with family. Residents stated that the food available to them was good and that they could choose alternatives and make suggestions to the weekly menu. Members of staff on duty were observed to be socially interactive with the residents clearly understanding their behaviour and individual characteristics. Staff were aware of their roles and the plans of care in place. A member of staff stated that social activities are organised on a daily basis. Elm Tree House - Draft Report Version 1.10 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,20 Residents’ personal and health care needs were being met. EVIDENCE: Care plans included information on how the home was supporting residents with their personal and health care needs. Residents had a distinctive style this was noted with their choice of haircut and clothes. Residents told the inspector that there was no fixed time for getting up and going to bed and this was service user led. This was documented in daily records. Staff and a resident confirmed that residents can chose who they want to be supported by. Two residents prefer to be supported by female staff. Records were maintained of appointments with health professionals and the action taken. On the day of the inspection a meeting was organised with health professionals including a behaviour nurse, speech therapist and a psychiatrist. Comments from the professionals were positive about the care the individuals were receiving. Care records demonstrated that the home liaised with a Elm Tree House - Draft Report Version 1.10 Page 16 number of professionals, complimenting the skills of the staff team in supporting individuals in the home. The home was keeping the Commission for Social Care Inspection informed of incidents that affect the wellbeing of the individuals and where actions had been discussed these had been undertaken by the home. The medication system was inspected and found to be satisfactory. In addition the pharmacist inspects the home every six months. Staff have received training in the safe administration of medication. The home has reviewed the medication system in place, in response to two medication errors. Information was shared with the Commission for Social Care Inspection. Appropriate action was seen to be taken at the time of the error including supervised medication administration and training. Elm Tree House - Draft Report Version 1.10 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22,23 Residents were confident that the home would respond to a complaint and are protected from abuse. EVIDENCE: The home has a robust procedure for residents and their representatives to use in the event of a complaint. The home was able to demonstrate that complaints would be listened to and responded to in an appropriate manner. The home has had one complaint in the last twelve months from a resident. The individual stated that the area manager is investigating the complaint. The manager stated that all staff would be attending updates on abuse to protect the residents living in the home. All staff attended training on abuse in the last two years with the manager and the deputy attending an investigatory course organised by the local Social Services Department. In addition all staff are either in the process or have gained a National Vocational Qualification and a member of staff stated that abuse is discussed as part of the assessment process. It was clear from discussions with staff that they had a good understanding both of what constitutes abuse and the procedure to follow if abuse is suspected. The home has good financial procedures to ensure the protection of resident’s finances. A random selection of finances were checked and corresponded with the records held in the home. The home has reported missing monies and an issue of negligent in the last twelve months under the Protection of Vulnerable Adults Policy. A full investigation was undertaken and the appropriate action Elm Tree House - Draft Report Version 1.10 Page 18 undertaken. The manager stated that the area manager has referred an ex member of staff to the POVA register. In conclusion the home was able to demonstrate how they were protecting the individuals living in the home. Elm Tree House - Draft Report Version 1.10 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,26,27,28,29,30 Elm Tree is a homely place to live, however, the home has failed to demonstrate that the environment has been adapted to meet the changing care needs of one individual. EVIDENCE: Elm Tree House is a two-storey property in keeping with the local area. The home is close to services and amenities in Keynsham and there is regular transport to Bristol and Bath. The home has undergone a major refurbishment programme including electrics, new windows, making the garden safe, new kitchen, refurbishment of the laundry facilities and decorating all communal areas and a most of the bedrooms. These changes have positively transformed this home. The home is now homely and comfortable. All areas seen were clean and free from odour. Elm Tree House - Draft Report Version 1.10 Page 20 All service users are provided with a single bedroom. The manager stated that the vacant room was planned for a complete refurbishment in preparation for the new service user and they would be involved in the planning of the colour scheme. It was noted that one bedroom did not have carpeting by the door, as this has recently been extended in the last twelve months giving the individual more space and reducing the space in the hallway. From conversations with the staff and the individual the delay is due to the individual not making a choice on the colour or the carpet type for their personal space and not the lack of opportunity. The manager stated that this would be undertaken and the individual taken shopping to make a choice. This will be followed up at the next inspection. Service users have access to sufficient bathing facilities. However, these are located on the first floor and would make it difficult for someone with mobility issues as the only access is via the stairs. There was a requirement for the home to provide additional handrails and a toilet seat raiser. Whilst the latter was in place the additional handrails were not. This is an outstanding requirement in addition it was strongly recommended that a ground floor shower facility be made available. The manager stated that a budget has been agreed and this will be undertaken within the next few months. However, the initial report was written in September 2004. This delay does not demonstrate that the home is responding to the changing care needs of the individual within a satisfactory timescale. Elm Tree House - Draft Report Version 1.10 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34, 36 Competent staff support residents, however further information must be made available to individuals in the statement of purpose on the staffing arrangements in the home. EVIDENCE: The duty rota was viewed for the last two months. The home was adequately staffed during the week with four staff working in the morning and two staff in the evenings. This was to ensure that residents could attend their day activities. Weekend cover was reduced to two staff. The manager, deputy and a member of staff stated that this was sufficient as many of the residents visited family at the weekends. However this reduced staffing was not documented in the statement of purpose. This is an outstanding requirement from the previous inspection. Consideration must be taken if residents remain in the home at weekends that adequate staffing is made available. A member of staff stated that the cover was adequate as usually there were only four individuals in the home at weekends. Social activities were made available during the handover period when there was both the morning and evening staff working. Residents and care documentation confirmed that activities were made available. Elm Tree House - Draft Report Version 1.10 Page 22 Competent and trained staff support residents. The manager stated that all staff are undertaken a National Vocational Award at either level 2 or 3. Staff confirmed this. The home was able to demonstrate that they were exceeding the National Minimum Standards to ensure that 50 of the workforce has an NVQ in care by 2005. The deputy manager stated that they were undertaken NVQ 4 in management and the NVQ Assessors Award. Presently the home is accessing external assessors to support staff through the process. There was a strong commitment for staff training and the manager was able to demonstrate that staff had undertaken training relevant to their roles and the care needs of the individuals living in the home and further courses were planned throughout the year. The manager stated that the home has accessed training on management of aggression for all staff and this is planned throughout the year. The manager stated that the home has three staff vacancies, which are presently being advertised. From discussions with the manager they were aware of the legislation and their responsibilities to ensure competent staff are employed ensuring the protection of the vulnerable adults living in the home. The home has a comprehensive induction and training package for new staff however this was not followed up during this inspection as no new staff had been recruited since the last inspection when the home was able to demonstrate that they were meeting the standard and the legislation. The manager was able to demonstrate that staff undergo formal supervision at the appropriate intervals and regular staff meetings were occurring. Elm Tree House - Draft Report Version 1.10 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, 41, 42, 43 Overall Elm Tree House is a well-managed and safe place to live and work. However, this would be enhanced with the installation of the aids and adaptations and the provision of a ground floor shower facility, which has already been discussed in this report. EVIDENCE: Mr Wilkins is the registered manager and has been in post since November 2003. Prior to November he was the deputy manager and in total has worked in the home for the last five years. Mr Wilkins stated he has successfully completed the Registered Managers Award. However, this could not be verified at the time of the inspection. The deputy stated that they were in the process of completing their NVQ4 in management. Elm Tree House - Draft Report Version 1.10 Page 24 A member of staff stated that the home was managed well and the manager and the deputy have an open door policy. Since the last inspection the home has introduced fortnightly staff meetings and this was seen as positive giving staff further opportunities to air their views and ensure a consistent approach to the delivery of care. Quality Assurance audits were seen involving the residents and their relatives in the form of questionnaires. Comments were positive. However, all returned relative questionnaires made reference to the difficulties in parking. In addition the manager completes audits on the environment, staff training and care audits. These were seen on a previous inspection. The manager stated that these and the policies are being reviewed to ensure that they are relevant to the care of individuals with a learning disability, as presently they tend to focus on the care of the older person. This has been discussed on previous inspections, the manager showed the inspector a memo stating that these were under review and requesting assistance from staff working in the home to join a working party. This is good practice and demonstrated an open approach and encouraged involvement. The inspector focused on the fire records and checks on the electrical appliances in relation to health and safety. Fire records were found to be satisfactory. Demonstrating that the staff were receiving appropriate fire training and the equipment was being checked routinely as per the fire officer’s recommendations. However, it is strongly recommended that the home review the content and the organisation of the file to ensure that information is accessible and logical. The annual electrical appliance check was due in May 2005. The manager stated that a member of staff had attended training on PAT checks but had been unsuccessful. The home must ensure that a competent person checks these and alternative arrangements are made. A certificate was seen that a competent electrician had checked the electrical wiring in the last five years and a Gas certificate was available. The manager stated that they receive regular supervision from an area manager and budgets are discussed during the regulation 26 visits. The Commission for Social Care Inspection are receiving copies of the monthly visits. However, there was no visit during the month of January and April 2005. This is an outstanding requirement the organisation must ensure that regulation 26 visits are completed on a monthly basis and copies of the report are sent to the Commission for Social Care Inspection. Overall Elm Tree House is a well-managed and safe place to live and work. However, this would be enhanced with the installation of the aids and adaptations and the provision of a ground floor shower facility, which has already been discussed in this report. Elm Tree House - Draft Report Version 1.10 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 2 3 Standard No Elm Tree House - Draft Report Standard No 31 32 Version 1.10 Score 3 3 Page 26 11 12 13 14 15 16 17 3 3 3 3 3 3 3 33 34 35 36 2 x 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 x 3 2 2 Elm Tree House - Draft Report Version 1.10 Page 27 yes Are there any outstanding requirements from the last inspection? 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 1 Regulation 5 Requirement For each service user and where relevant relatives to have a copy of the service user guide. (Outstnading requirement 16/1/05). For the statement of purpose to include the staffing arrangements at the weekend.(Outstanding requirement16/12/04). For the home to provide aids and adaptations as identified in the individuals assessment completed by the occupational therapist. (Outstanding requirement 16/12/04). To provide a ground floor shower facility To ensure that regulation 26 visits are completed on a monthly basis. (Outstanding requirement 16/11/04). Timescale for action 16/6/05 2. 1,33 18 (1) (a) 4 (1) (c) Schedule 1 23 (2) (a) 16/6/05 3. 6,29,42 16/6/05 4. 5. 6,29,42 43 23 (2) (a) 26 16/8/05 16/6/05 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 Good Practice Recommendations Version 1.10 Page 28 Elm Tree House - Draft Report 1. 2. Standard 43 43 To ensure that the electrical appliances in the home are checked at least annually To review the fire records to ensure accessible and logical Elm Tree House - Draft Report Version 1.10 Page 29 Commission for Social Care Inspection 300 Aztec West Almondsbury South Glos BS32 4RG 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. 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