Inspection on 05/11/04 for Elm Tree House

Care Home For Older PeopleElm Tree House32 Crow Lane West Newton-le-Willows Merseyside WA12 9YGUnannounced Inspection5th November 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Elm Tree House Address 32 Crow Lane West, Newton-le-Willows, Merseyside, WA12 9YG Email address Name of registered provider(s)/company (if applicable) Living Developments Ltd Name of registered manager (if applicable) Type of registration Care Home No. of places registered (if applicable) 20 Tel No: 01925 291492 Fax No: 01925 228727Category(ies) of registration, with (number of places) Old age, not falling within any other category (20) Registration number F530002105 Date first registered 22/09/2004 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificateIf Yes refer to Part CElm Tree HousePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 35th November 2004 1:00 pm Mrs Lynn PatersonID Code073532Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionMrs Beverley SteeleElm Tree HousePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementElm Tree HousePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Elm Tree House. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Elm Tree HousePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Elm Tree House was first established as a care home in 1985 and is registered to provide accommodation to twenty older people who are in need of social care and support. The accommodation is provided in a large detached Edwardian House which stands in its own grounds set back form the main road situated on the Newton le Willows, Warrington, St. Helens Road. There is a large car parking area to the front of the premises and a side garden and patio area with a raised fish- pond to the side. The rear garden overlooks a modern housing development although it retains an element of privacy. The home provides 18 single and 1 double bedroom which are located on the ground and first floor level. A passenger lift and chair lift facility are provided for ease of access. The home offers two separate lounges and two lounge dinning areas, including a conservatory. Elm Tree House provides aids and adaptations to ensure that all needs are met and operates a no smoking policy within the home.Elm Tree HousePage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) The unannounced inspection of Elm Tree House took place on 5th November 2004 and the inspector noted a transfer of ownership had been completed since the previous inspection. The inspector observed that the new owner had addressed all the requirements recorded on the last inspection report and had commenced a rigorous refurbishment programme of which the benefits were already apparent within the home. The inspector noted that the transfer of ownership had taken place on 22nd September 2004 and the new owner had been proactive in his pursuits to effect positive change, a summary of which is recorded below:CHOICE. Standards 1-6. All met The inspector noted that revised statement of purpose, terms and conditions of residence and contracts had been created and a full appraisal of the homes capacity to meet assessed need had been carried out by an occupational therapist. All documentation seen was clear, relevant and held full information to enable service users to make informed choices about their future care.Elm Tree HousePage 6 HEALTH AND PERSONAL CARE. Standards 7-11. 3 standards assessed.3 met. The inspector persued care plans and noted that new documentation was in place which offered a clear and logic approach to care planning. Senior staff had been given more autonomy regarding input into care plans, which enhanced information sharing and care practices within the home. DAILY LIFE AND SOCIAL ACTIVITIES. Standards 12-15.1 standard assessed 1 met. Service users advised that they felt that the daily routines in the home were flexible and that food provision was of a good quality with choices being afforded at all times. COMPLAINTS AND PROTECTION. Standards 16-18.1 standard assessed 1 met. The inspector noted that a revised complaints procedure was in place and was included in the service users information pack. ENVIRONMENT. Standards 19-26. 5 standards assessed 5 met. The inspector toured the premises and noted that the home had benefited from a refurbishment programme that was ongoing at the time of the visit. Business plans and maintenance records showed that the owner and manager had identified areas of concern within the environmental aspects of the home and had ensured that mechanisms had been sought to ensure that these areas were addressed and dealt with as a matter of urgency. STAFFING. Standards 27-30. 4 standards assessed 4 met. The inspector noted that staff had responded well to the change of ownership and staff interviewed stated that staff morale was very high. Records showed that staff had either achieved or were working towards NVQ 2 qualification. Recruitment procedures inspected showed that the home had a fair and equal recruitment and selection policy in place and records indicated that the manager had developed the staff training in the home very positively. MANAGEMENT AND ADMINISTRTAION. Standards 31-38. 4 standards assessed .4 met. Staff interviewed stated that the registered manager and her deputy were highly respected by staff and service users. Documentation showed that staff meetings were arranged with agendas in place to ensure that staff could input any issues they may have for discussion and debate. Service users advised that the manager had completed much work in developing a positive culture in the home in which they said both the staff and service users felt valued and involved in the running of the home.Elm Tree HousePage 7 Requirements from last Inspection visit fully actioned? If No please list belowNASTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for actionAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Met (Yes / No)Elm Tree HousePage 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for actionRECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard ** Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.Elm Tree HousePage 9 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES NO YES YES NO NO NO YES YES YES YES YES YES NO NO NO YES YES YES 15 0 0 YES YES YES YES X X 5/11/04 1PM 4Elm Tree HousePage 10 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Elm Tree HousePage 11 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide. Range of fees charged From (£) 317 To (£) 317Any charges for extrasYESIf yes, please state what the extras are: 3 Key findings/Evidence Standard met? The statement of purpose and service user guide had been amended since the last inspection to reflect the change of ownership and further development of the home. The inspector noted that copies of these documents were readily available throughout the home and held clear relevant need to know information about the service provision of Elm Tree House.Elm Tree HousePage 12 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 3 Key findings/Evidence Standard met? The inspector viewed 3 service users files and noted that clear contracts were contained therein.Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 3 Key findings/Evidence Standard met? The inspector noted that the home manager had developed a new assessment tool that enabled staff to address all issues relating to need and care planning to include history of falls and medication compliance. The assessment documentation appeared easy to follow and held clear and relevant details of all assessed need.Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? The staff of Elm Tree House identified through discussion that they were trained and experienced in the care of the elderly. Care files viewed showed that service users had received that appropriate level of care as per assessed need.Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 3 Key findings/Evidence Standard met? The statement of purpose and service user guide held details of the opportunity for prospective service users to visit the home prior to admission and record showed that this was an option which had been taken up on a number of occasions.Elm Tree HousePage 13 Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable service users to return home. 0 Key findings/Evidence Standard met? This service was not provided at this time.Elm Tree HousePage 14 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 3 Key findings/Evidence Standard met? The inspector viewed care plans in general and examined 3 in detail to gain evidence for this standard. Care plans seen were well-written, clear and relevant to assessed need. Service users stated they were well cared for, they were consulted in all aspects of health and personal care and that all their needs were met.Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) 2 03 Key findings/Evidence Standard met? Care plans viewed held full detail of the level of support needed in respect of personal care, pressure care, continence promotion, medical appointments and nutritional screening. District nursing notes and records of GP visits were also available.Elm Tree HousePage 15 Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 3 Key findings/Evidence Standard Met? The inspector noted that all medication within the home was stored appropriately at the time of the inspection. The manager advised that senior care staff have the responsibility for the administration of medication and training records indicated that ongoing training is provided in all aspects of medication management to include input via the PCT pharmacy department.Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 0 Key findings/Evidence Standard met? This standard was not assessed at this time.Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 0 Key findings/Evidence Standard met? This standard was not assessed at this time.Elm Tree HousePage 16 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 0 Key findings/Evidence Standard met? Not assessed on this occasionStandard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences. 0 Key findings/Evidence Standard met? Not assessed on this occasionStandard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 0 Key findings/Evidence Standard met? Not assessed on this occasionElm Tree HousePage 17 Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? Daily menus showed that choice was afforded at all mealtimes and service users advised that the food was always wholesome, plentiful and appetising. Care plans held details of service users dietary requirements and these details were held by the cook, who was able to provide individual menus accordingly as and when required. Care plans held detail also of any support and assistance required by service users when eating and staff were observed giving discreet assistance when necessary.Elm Tree HousePage 18 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 2 0 0 0 0 0 100 3 Key findings/Evidence Standard met? The inspector noted that the complaints procedure was included in the service user information pack and held clear details of actions required in the event of a complaint.Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 0 Key findings/Evidence Standard met? Not assessed at this timeElm Tree HousePage 19 Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists Key findings/Evidence Not assessed at this time. Standard met? YES 0 0Elm Tree HousePage 20 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? The inspector toured the premises and viewed business plans to gain evidence for this standard. Records showed that the home had commissioned a company to carry out a full assessment of the premises to ensure that it was suitable for its stated purpose. Observation and documentation identified that the home had introduced a maintenance programme to include repair, redecoration and refurbishment of the building and surrounding grounds. Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 0 Key findings/Evidence Standard met? Not assessed at this time.Elm Tree HousePage 21 Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 3 Key findings/Evidence Standard met? Records indicted that the home had commissioned an external audit to take place to ensure that toilet, washing and bathing facilities were in place to meet assessed need. The facilities seen at the time of the inspection appeared adequate to meet all existing need.Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 3 Key findings/Evidence Standard met? Documentation seen during the inspection evidenced that the home had recently benefited from a full assessment carried out by a qualified and experienced occupational therapist who had knowledge and understanding of the needs of older persons. It was noted that all recommendations made as a result of this assessment had been addressed.Elm Tree HousePage 22 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite NO YES NO 18 6 1 0 3 X XX X X XKey findings/Evidence Standard met? The inspector noted no changes from the previous inspection.Elm Tree HousePage 23 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 3 Key findings/Evidence Standard met? Service users advised that they were most comfortable in their rooms in which they felt safe and secure. The inspector noted that the rooms were benefiting form an ongoing refurbishment programme.Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 3 Key findings/Evidence Standard met? The inspector noted that the home had introduced an essential maintenance programme to address shortfalls with the water supply and the replacement of defective smoke alarms and fire sensors in the building. Record showed that the heating, lighting water supply and ventilation met the required standards.Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 3 Key findings/Evidence Standard met? The home was clean and hygienic and free from malodorous smells at the time of the inspection. The home had a policy on infection control and staff interviewed displayed sound knowledge of the mechanisms involved.Elm Tree HousePage 24 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours X X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff X X X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X XX X X3 Key findings/Evidence Standard met? Staff evidenced that they were knowledgeable and experienced in the care of the elderly and that they were highly motivated to carry out their remit. The staff rota showed that the home employed sufficient staff both in numbers and skill mix to meet the assessed need of the current service users of the home.Elm Tree HousePage 25 Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 Key findings/Evidence Not assessed at this time X X Standard met? 0Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 3 Key findings/Evidence Standard met? 2 staff files were examined and both had the necessary police checks and references. The recruitment and selection policy appeared to meet all the requirements of equality and protection issues.Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? Not assessed at this time.Elm Tree HousePage 26 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 3 Key findings/Evidence Standard met? Beverly Steele was the newly appointed registered manager of Elm Tree House. Beverly had worked in the home for several years previous to her current role in both a senior and deputising role. The inspector noted that the home was also in the hands of a new owner (registered provider) and the inspector was pleased to see the most positive developments which had taken place within the home since the takeover. Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 4 Key findings/Evidence Standard met? Staff and service users advised that the management approach of the home was one of inclusion and positively, one in which all were encouraged to be a part of the decision making and consultative process. Staff advised that they had a high morale and felt that this was mainly due to the way the changes had been managed by Beverly, her deputy Margery Waring and the new registered provider of the home. Staff advised that the management team provide support and guidance at all times and were readily available when needed. Staff also advised that night staff were previously treated as a breed apart who were considered as not being able to relate to the daytime demands of the home but are now regularly supported by the home manager who will work differing hours to ensure that all staff received support. The inspector felt that this action was most commendable.Elm Tree HousePage 27 Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 3 Key findings/Evidence Standard met? The home had completed a quality audit and were awaiting feedback at the time of the inspection. The manager had developed a system to ensure that service users representatives could hold meetings within the home with a view to gaining insight into their perceptions of the success in meeting the aims and objectives of the home.Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 0 Key findings/Evidence Standard met? Not assessed at this time.Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders Key findings/Evidence Not assessed at this time. Standard met? 0 X X XElm Tree HousePage 28 Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 0 Key findings/Evidence Standard met? Not assessed at this timeStandard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 0 Key findings/Evidence Standard met? Not assessed at this timeStandard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? Records showed that all staff had received training in moving and handling, first aid, fire safety and infection control. The manager identified that she had ensured that both mandatory health and safety training and care delivery were in place as were general health and safety risk assessments. Records indicated that the home employed a maintenance person who was available during normal working hours and who was also on standby to deal with emergencies relating to the health and safety of staff and service users of the home.Elm Tree HousePage 29 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceRegulation Inspector Second Inspector Regulation Manager DateLynn PatersonSignature SignatureLorraine MaguireSignaturePublic reports It should be noted that all CSCI inspection reports are public documents.Elm Tree HousePage 30 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 5/11/04 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleElm Tree HousePage 31 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary YESComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESYESNote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. Please provide the Commission with a written Action Plan which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required NO D.2Action plan was received at the point of publicationAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planOther: enter details here Elm Tree HousePage 32 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I Mr Vijay Daswani of Elm Tree House, (Living Developments Ltd) confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Mr Vijay Daswani Mr Vijay Daswani Responsible Individual 21/12/04Elm Tree HousePage 33 Elm Tree House / 5th November 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000061681.V196941.R03© This report may only be used in its entirety. Extracts may not be used or reproduced without the express permission of the Commission for Social Care Inspection The paper used in this document is supplied from a sustainable source - 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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