Inspection on 15/05/07 for Elm View Nursing Home

This inspection was carried out on 15th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Elm View Nursing Home 18/09/06

Elm View Nursing Home 21/03/06

Elm View Nursing Home 30/09/05

Elm View Nursing Home 04/03/05

Elm View Nursing Home 04/11/04

Elm View Nursing Home 02/02/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Elm View Nursing Home Moor Lane Clevedon North Somerset BS21 6EU Lead Inspector Patricia Hellier Unannounced Inspection 15th May 2007 09:30 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 View Nursing Home DS0000020304.V335784.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Elm View Nursing Home DS0000020304.V335784.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elm View Nursing Home Address Moor Lane Clevedon North Somerset BS21 6EU 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) 01275 872088 01275 872088 belmontcare@btconnect.com Belmont Care Limited Susan Ingrid Gready Care Home 45 Category(ies) of Old age, not falling within any other category registration, with number (45) of places Elm View Nursing Home DS0000020304.V335784.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. May accommodate 45 persons aged 65 years or over who require nursing care of which 6 may be aged 50 - 65 years. Manager must be a RN on Part 1 or 12 of the NMC register Date of last inspection Brief Description of the Service: Elm View is a purpose built home providing 45 beds for residents requiring nursing care. It is situated in an urban area and surrounded by wellmaintained gardens. The building and décor is of a high standard providing a comfortable and homely environment. Accommodation is provided over two floors with a passenger lift giving easy access to all floors. There are 41 single rooms, and 2 double rooms, all with ensuite facilities. All rooms have a call bell system. There is a large open dining area and two comfortable lounges. Part of one lounge is designated as a quiet area and can be used for receiving visitors or for family celebrations. Provision is made within the home for a variety of activities and outings, which also enable close links with the local community to be maintained. A minibus is available to take residents to the local shops, or for trips to Weston-SuperMare or the surrounding countryside. The provider makes information available through a company leaflet and service specific booklet about the home. CSCI reports are displayed in the entrance to the home and available for all to read. The fess range from £575 - £635 per week with additional charges being made for hairdressing, chiropody, newspapers, escorts, toiletries and social therapy entrance fees. This information was provided in April 2007. Elm View Nursing Home DS0000020304.V335784.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took place over 6 hours. Gready, was present throughout. The Registered Manager, Mrs Before the inspection the information about the home was received from the pre inspection questionnaire and comment cards received from 6 residents and 2 relatives. The last inspection report was reviewed and all correspondence since the last inspection. The accumulated evidence for this report comes from the above and also fieldwork that included the following: discussions with 8 residents, 3 relatives, and 5 staff; observation of practices, tour of the premises, review of documents relating to care, recruitment and health and safety; review of policies; inspection of medication records and storage. Of the 10 resident surveys sent 6 were returned and all were satisfied with the care they received. All said the home is clean and fresh, and that they would know who to speak to if they were unhappy. Comments from residents were “the staff are very friendly and kind”, “the standards are excellent”, “many word of mouth recommendations about the home locally.” All relatives spoken with felt welcomed at the home and that they were consulted regarding their relatives care and needs. Comments included “the staff are very friendly and welcoming”, “the staff’s kindness and care help my relative to settle in”. Surveys were sent to 5 Health Care Professionals that visit the home and 1 was returned. They felt that the care given is good and that the home works in close partnership with them incorporating specialist advice into the care given to enhance the health and well being of residents. Comments included “there is very little to complain about”; “the staff are very receptive to any concerns raised”; “there is a welcoming and friendly atmosphere”; the staff are kind to residents and there is a high standard of care”. All residents and staff spoken with told the inspector that the home was very good and the staff very kind. Comments received were “it is very homely and comfortable”; “I would recommend it to anyone”, “my relatives care needs are well met”. What the service does well: The staff work well as a team and ensure the well-being and comfort of the residents’ and treat them with great respect and kindness. For example 5 residents spoken with said, “the home is lovely, the staff are kind and caring, Elm View Nursing Home DS0000020304.V335784.R01.S.doc Version 5.2 Page 6 and the food is good.” There is a good rapport between staff and residents and occupancy level are consistently high. Meals are varied, healthy and nicely presented offering choice and variety. Residents’ health and personal care needs are well met by knowledgeable staff in an understanding way. Residents feel that if they had something to complain about they would speak to a member of staff. All residents spoken with said they had nothing to complain about. One relative said ‘the home is excellent, I would recommend it to anyone”.’ What has improved since the last inspection? What they could do better: Currently pre admission assessments are undertaken and a wealth of information gathered to inform the decision that the home can meet the prospective residents needs. This is not fully documented and does not evidence the good practice. It is recommended that clear and full documentation be made to provide information to all staff and ensure the provision of appropriate care. The home currently has a two-part homely remedies policy to be found in two different areas of the home. It is recommended that these be brought together to ensure that all staff have access to the full information to ensure appropriate administration and safeguard residents. Some residents feel that there are not always enough activities of the sort they would like. It is recommended that a review of the activities provided and residents’ preferences be undertaken. The findings of monthly audits are not formally collated and fed back to residents and staff for discussion. It is recommended that this be done for maintenance of good standards and the inclusion of good ideas in the ongoing service provision and development. Elm View Nursing Home DS0000020304.V335784.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Elm View Nursing Home DS0000020304.V335784.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Elm View Nursing Home DS0000020304.V335784.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 1,3,4,5, The Statement of Purpose and Service User Guide is comprehensive and provides prospective residents with information to make an informed choice. The home’s assessment process is satisfactory and ensures that it is able to meet residents’ needs. Prospective residents and relatives are encouraged to visit the home to assess suitability. EVIDENCE: Residents are provided with a comprehensive Residents’ booklet containing the Statement of Purpose and all the information required to ensure they or their relatives have access to the relevant information at all times. Care needs are well met through a full assessment process. The assessment information is not always clearly documented to evidence the good practice. It Elm View Nursing Home DS0000020304.V335784.R01.S.doc Version 5.2 Page 10 is recommended that this be done to provide clear information sharing with all staff for the provision of appropriate care to meet the new residents needs. A plan of care to meet the new residents needs is developed from the assessment information. The assessment includes all the elements listed in the standard. An assessment was seen for a newly admitted resident, which contained the key medical details, but did not evidence the outcome of the assessment. It is recommended that this information be completed. The resident when spoken to said ‘they are very kind; know what I need and look after me well’. Care practices observed showed that staff were fully aware of the residents needs as stated in their assessments. Elm View Nursing Home DS0000020304.V335784.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 7,8,9,10 Residents benefit from care plans that are well formulated and give clear information to enable staff to meet residents’ health and social care needs. Risks to residents are fully assessed and actions to minimise these planned, for the safeguarding of residents. Respect and dignity are well maintained by kind and caring staff. EVIDENCE: Individual records are kept for each of the residents, which include a social history. Six care plans were inspected and all reflected clearly current identified health and social care needs. All of these records showed clear evidence of Interprofessional working with other Health Care Professionals to provide full, holistic, care to residents. Visits by the dentist, chiropodist and optician were recorded in four of the care plans. Wound care plans are clear and contain all necessary details of the wound and its progress. These good practices are to be commended. Elm View Nursing Home DS0000020304.V335784.R01.S.doc Version 5.2 Page 12 Evidence was seen that social and psychological needs are well met. A dedicated carer has been provided to one area of the home to assist with continuity for residents suffering from some confusion. Another care plan showed how the home has facilitated one resident to attend a weekly club. Clear actions to meet identified needs were recorded and regular evaluation noted. All care plans showed resident or relative involvement. All care plans contained Manual Handling, nutrition, falls and pressure sore risk assessments, with the outcomes being used to inform the provision of care. Other personal and environmental risk assessments were present to ensure the safety of the resident while promoting independence as able. Daily records were up to date and written in a respectful manner. All residents were neatly dressed, and attention had been paid to hair and nail care. Detailed conversations with six of the residents confirmed a good standard of nursing and personal care. Comments made were – “”the home is excellent, no improvements needed”, “staff are always kind and approachable – nothing is too much bother”; “I’m very happy here”; “you can have a laugh with the staff they are very good”. One relative praised the home for the way in which their mother is cared for, “it’s like the best of hotels, and they have all the specialist equipment needed to help mum”. Care practices observed showed caring interactions and good communication skills from staff. Choices and preferences were observed being discussed and offered. One resident said ‘they always do things the way I like, and if I want to get up later they let me’. A member of care staff when asked about the care of this resident, informed the inspector they had asked for a lie in and had not been disturbed before 11am. Since the last inspection the management of medicines has been reviewed. There were no gaps on the Medication Administration Records (MAR) and it was possible to audit all medicines that enter and leave the home. Alterations to prescriptions on the MAR sheets were seen and these had not been verified by two members of staff, thus not providing the recommended safeguard for residents. The area where medication is stored is in the centre of the building. Daily temperature checks of the room and medication fridge ensure that medication is safely stored. The home currently has a two-part homely remedies policy to be found in two different areas of the home. It is recommended that these be brought together to ensure that all staff have access to the full information to ensure appropriate administration and safeguard residents. All residents spoken with felt that kind and caring staff respected their dignity and privacy. One resident stating “they always knock on the door”; and another said, “they are always polite and ask what I would like”. Elm View Nursing Home DS0000020304.V335784.R01.S.doc Version 5.2 Page 13 The home has an Equality and Diversity policy that recognises the cultural and social needs and differences that are present in society. In discussion with the manager and staff these issues have not yet arisen within the service provision. Both management and staff demonstrated clear knowledge and desire to meet cultural and diversity needs as and when they should arise. Elm View Nursing Home DS0000020304.V335784.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 12,13,14,15 Social activities and meals are both well managed, creative and provide daily variation and interest for people living in the home. Residents right to choice and control over their lives is well respected, and encouraged, helping residents to maintain independence. Friendly staff always welcomes relatives and visitors. EVIDENCE: An excellent range of activities is provided with posters displaying information of forthcoming events throughout the home. Residents spoken with said, “we have plenty of choice and variety”. One resident said, “the activities are marvellous”. Four of the residents spoken with said they would “like more activities that interested them e.g. board games, and speakers”. Three residents spoke of the recent introduction of the exercise class and their enjoyment of it. Two residents who have sensory impairments said they “would like some or more time on a 1:1 basis for activities”. It is recommended that a review of the activities provided and residents’ preferences be undertaken. Elm View Nursing Home DS0000020304.V335784.R01.S.doc Version 5.2 Page 15 A social therapist is employed 3 days a week and works hard to provide a varied programme with activities that will appeal to all. Posters of activities taking place and planned are Sixty six percent of residents surveyed said they feel that there are usually, or always, activities arranged that they could take part in. Spiritual needs are catered for and local clergy visit as requested. Several visitors were seen coming and going during the inspection. Relatives spoken with said they could come any time and felt that their relatives were well looked after by friendly staff. One relative said, “the staff are so patient and residents never look untidy or uncomfortable”. Choice and preference is well respected. There was evidence of a good rapport between residents and staff, with lots of laughter and encouragement. Care records contained clear information about their likes and dislikes and residents’ preferred daily routine. The kitchen is clean, tidy and well organised. The lunch served during the inspection looked appetising and well presented. Good practice was seen in the manner in which care staff were helping residents with their meal. All residents spoken with about the food said ‘it is good’. Many said they “ like the meals, and the choices offered”. Elm View Nursing Home DS0000020304.V335784.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 16,18 Residents are confident that they are listened to and their requests acted upon. Knowledgeable and competent staff protect residents. EVIDENCE: The home has a comprehensive complaints procedure and all residents receive a copy on admission. All relatives and residents spoken with were aware of the complaints policy. There have been three complaints since the last inspection, which have been fully resolved. All residents stated that if they were not happy about anything they would speak to the manager. Staff and residents spoken to, say the manager is very approachable and understanding. Three residents said ‘I’ve nothing to complain about, it’s a lovely home”. A record of complaints received, with actions taken and outcomes is kept to show residents are responded to, and the information used to inform the running of the home for the residents’ benefit. A comprehensive policy and procedure for responding to allegations of abuse is available, together with the Local Adult Protection (No Secrets in North Somerset) guidelines. The home also has a Whislteblowing policy and staff said they would report any concerns to the manager. Staff said they had never seen any signs of abuse in the home and demonstrated a good Elm View Nursing Home DS0000020304.V335784.R01.S.doc Version 5.2 Page 17 understanding of what abuse is. Staff said they have received training in the recognition and handling of abusive situations for the safeguarding of residents. This was verified during inspection of training records. Care plans inspected showed that consent for the use of bedrails had been obtained from residents or relatives thus safeguarding choice. All residents spoken with said ‘the staff are very kind’; ‘they take time to help me’; ‘I can’t fault them’. Elm View Nursing Home DS0000020304.V335784.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. 19,22,26 Residents are provided with homely, safe and comfortable surroundings. . The home has suitable equipment to maximise resident independence. Robust Infection Control practices are followed. EVIDENCE: The home is purpose built, light, airy and furnished to a good quality, arranged over two floors with a passenger lift to enable access. The property is well maintained, with homely and comfortable communal spaces. The living accommodation is well decorated and homely. Residents’ rooms are personalised and comfortable. All rooms are provided with ensuite facilities. The décor, fixtures and fittings are in excellent order. Maintenance and refurbishment plans and records are kept, to ensure the homes’ environment is maintained at a high standard. Elm View Nursing Home DS0000020304.V335784.R01.S.doc Version 5.2 Page 19 The home has grab rails situated at relevant points and a shaft lift that is easily used to assist resident mobility, and aid independence within the home. All resident rooms are provided with a lockable space for securing personal possessions, if desired, and door locks that are accessible to staff in an emergency. The home was clean and free from offensive odours throughout. The laundry facilities were well organised. Staff interviewed and observed demonstrated good understanding of Infection Control procedures and practices and maintained a clean and hygienic environment. The home has good facilities for ensuring that staff can maintain good hand washing practices, between caring for residents. Elm View Nursing Home DS0000020304.V335784.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 27,28,29,30 The home’s staffing levels are sufficient to manage the care needs of residents. The procedures for the recruitment of staff are robust and provide the safeguards required for residents’ protection. Staff access external training to ensure training is matched to the residents needs. EVIDENCE: Staff went about their duties in an unhurried manner and were observed spending time talking with residents. Residents reported, “staff make time for a chat when they can.” Staff approached residents with directness, openness and consideration. Each of the resident’s with whom the inspector spoke said, “ the staff are very good”. Copies of two weeks staffing rosters were supplied to the inspector. Staffing levels rostered are in accordance with CSCI requirements. A sufficient team of ancillary workers supports care and nursing staff to ensure the smooth running of the service. Residents spoken with told the inspector “staff are always there when you need them”; “ you only have to ring the bell and they come”. Staff interviewed said that they were kept busy, but still had time to chat with the residents. Call bells were answered promptly during the inspection. The home has a Key Worker system in place for all residents. Relatives were aware of the role and said, “it worked well”. Elm View Nursing Home DS0000020304.V335784.R01.S.doc Version 5.2 Page 21 A few of the staff team employed at the home are from overseas. Residents and staff said, “they fit into the team well”. Recruitment procedures are robust and all three files inspected contained the required documentation. All staff interviewed stated they had contracts of employment and job descriptions. Newly appointed staff confirmed they had completed an induction programme and evidence of this was not seen for ancillary staff. It is recommended that this be kept in personnel files. The home has recently commenced using the Common Induction Standards. The home provides in house mandatory training with clear records of attendance and renewal dates. Evidence of specialist training accessed through the Primary Care Trust and other sources was seen e.g. stroke awareness. The home views training as very important and almost half of the care staff have an NVQ qualification. Five staff are currently undertaking NVQ training. Interviews with staff verified they had undertaken a wide range of training and had good knowledge with which to meet residents’ needs. Elm View Nursing Home DS0000020304.V335784.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 31,32,33,35,38 The manager provides clear leadership and guidance to staff to ensure residents receive consistent care in a safe environment. Quality assurance processes in the home are formal demonstrating that the home consults with residents, families and visiting professionals. The management of resident’s monies in the home are well managed. Health and safety issues are monitored in the home to ensure that issues are identified and addressed where they arise. EVIDENCE: The manager gives clear leadership, guidance and direction to staff. Residents feel she is approachable, available and seeks to ensure all their needs are met. Elm View Nursing Home DS0000020304.V335784.R01.S.doc Version 5.2 Page 23 Staff interviewed stated that they felt well supported by an approachable manager. A formal quality assurance tool was available for inspection in order to demonstrate that the home consults with residents, and that comments from them are acted upon. Regular audits of various aspects of the home are carried out each month. The results of these audits are not formally collated and reported to residents and staff to demonstrate the good practice of the home and provide a forum for ideas for the development of service provision. Feedback to residents and relatives is provided through discussion at residents / relatives meetings. Residents and relatives told the inspector that they were always encouraged to express their view and “to air the grumbles”. One resident said, “the manager is very proactive and helpful in many ways”. Records inspected indicated regular safety and fire checks are carried out. Staff spoken to confirmed that regular fire instruction and drills had taken place. A number of staff have received First Aid training. Records indicating regular maintenance to gas and water systems were seen, together with servicing records for all equipment. Elm View Nursing Home DS0000020304.V335784.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 3 4 X X 3 X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 2 X 3 X X 3 Elm View Nursing Home DS0000020304.V335784.R01.S.doc Version 5.2 Page 25 NO 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. Standard Regulation Requirement Timescale for action 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 Refer to Standard OP3 OP9 OP12 OP33 Good Practice Recommendations The full documentation of all information gathered at pre admission assessment to evidence the decision that the home can meet the needs of the prospective resident. To bring together the two parts of the homely remedies policy into one document accessible to all staff when administering medication. To review the activities offered and current residents’ preferences. The collation of all audit results and feedback to staff and residents for information and participation in the ongoing service provision. Elm View Nursing Home DS0000020304.V335784.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Taunton Local Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Elm View Nursing Home DS0000020304.V335784.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!