Inspection on 27/09/07 for Elmhurst

This inspection was carried out on 27th September 2007.

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

The inspector 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

Elmhurst 03/03/08

Elmhurst 17/08/06

Elmhurst 09/03/06

Elmhurst 17/11/05

Elmhurst 10/02/05

Elmhurst 17/08/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Elmhurst Priory Road Ulverston Cumbria LA12 9HU Lead Inspector Ray Mowat Unannounced Inspection 27th September 2007 06:15 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 Elmhurst DS0000036576.V346170.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. Elmhurst DS0000036576.V346170.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elmhurst Address Priory Road Ulverston Cumbria LA12 9HU 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) 01229 894115 www.cumbriacare.org.uk Cumbria Care Mrs Jayne Allonby Care Home 40 Category(ies) of Dementia (3), Dementia - over 65 years of age registration, with number (32), Old age, not falling within any other of places category (40) Elmhurst DS0000036576.V346170.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service must at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. The home is registered for a maximum of 40 service users to include: up to 40 service users in the category of OP (Old age, not falling within any other category) up to 32 service users in the category of DE(E) (Dementia over 65 years of age) 3 named service users in the category DE (Dementia under 65 years of age) may be accommodated within the DE(E) number of registered places Date of last inspection 17th August 2006 Brief Description of the Service: Elmhurst is a purpose built locally authority care home. Cumbria County Council own the home, which is operated by Cumbria Care. Mrs Jayne Allonby is the registered manager. Elmhurst is a single storey building situated 15 minutes walk from the centre of Ulverston town. It is divided into four units of 10 bedrooms. Each unit has its’ own dining lounge, two bathrooms and a toilet. There are four bedrooms with an en-suite bathroom, and two with adjoining doors for married couples or siblings. Three of the units cater for people with dementia, and the other unit is for the physically frail. The three-dementia care units have open access within the home, but no free external access. Elmhurst has a small smoking room, and a pleasant secure garden. The weekly fees ranged from £363.00 to £422.00 according to residents’ dependency needs. The home had information for prospective residents and their families in the form of a statement of purpose and service users guide. A copy of the latest inspection report was also available from the home. Elmhurst DS0000036576.V346170.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection visit took place between 6am and 4pm to enable me to see the early morning routines of the home and talk to night staff. During the visit I met with people living in the home, visitors and relatives and spent time with the manager and supervisors on duty. I also spoke to staff as they went about their duties. I was joined by the Pharmacy Inspector, who spent six hours in the home and has contributed to the relevant sections of this report. Prior to the visit the manager completed a self-assessment questionnaire called an Annual Quality Assurance Assessment. This provided me with information about how the home is run and the manager’s views on what the home does well and where they need to improve. There is also information about people living in the home and the staff. The views of people living in the home, their relatives, staff and other professionals were used to formulate the judgements made in this report. I also examined records relating to the running of the home as required by legislation, including personal care plan files. These provide staff with information about the support people require, what is important to them and how they like to live their lives. I also examined staff files and records relating to the maintenance and safety of the home. What the service does well: Detailed assessments are used to compile personalised care plans that make sure people get a consistent service that meets their individual needs. The staff make sure that they have a good understanding about what needs people have and how they like to live their lives. The manager makes sure the home has staff with the right skills and there are suitable resources to meet these different needs. Records for administration of medicines to people living in the home are accurate and show clearly the treatment received. The service has a policy for administration of non-prescribed medicines so that people are able to have prompt treatment for minor ailments without the need to call a doctor. Information is being put into different formats such as a pictorial menu, to help people make informed choices in their lives, which is good practice. The quality and quantity of the food provided is good and it reflects individual tastes and requirements. Elmhurst DS0000036576.V346170.R01.S.doc Version 5.2 Page 6 A good variety of activities are being provided both in the home and in the local community, which people enjoy. Visitors to the home are made welcome and can meet their relatives in private. There are regular meetings between the staff and the people living in the home, to make sure people’s opinions and preferences are acknowledged and responded to. The manager and senior staff make sure the care staff get regular supervision and are well supported in their role. They have regular meetings to make sure information is passed on and they can contribute to the running of the home. The staff feel valued and work well as a team. What has improved since the last inspection? What they could do better: The safety and welfare of people who use the service must be safeguarded at all times by following multi-disciplinary guidelines and procedures in relation to the Protection of Vulnerable Adults (POVA). An assessment relating to the condition of carpets within the home should be completed, with badly stained or worn carpets replaced. The service should ensure that new medicines are started as soon as possible to prevent delay in treatment and to protect health. The service should also make sure that the medicines fridge is monitored and adjusted so that it runs at the right temperature to protect the quality of medication stored there. The use of signs, photographs and symbols to make the home more accessible to people and to promote their independence, particularly for those with dementia, should be considered in line with good practice guidelines. The cleaning regime should be reviewed to ensure malodours are eliminated in the areas identified and the home is clean and hygienic. Elmhurst DS0000036576.V346170.R01.S.doc Version 5.2 Page 7 All staff should complete training in relation to the policies and guidance for the protection of vulnerable adults to enable them to identify abuse and report incidents. 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. Elmhurst DS0000036576.V346170.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 Elmhurst DS0000036576.V346170.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): 1, 2, 3, 4, 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good procedures in place that ensure people’s needs are fully assessed and the home is able to meet them. EVIDENCE: The statement of Purpose and Service User guide should be reviewed to make sure they reflect the service that is provided in relation to the categories of people they can accommodate and all the information is up to date and accurate. These are made available to all new and prospective residents, therefore ensuring they are given appropriate information about how the home operates and the terms and conditions of living there. Elmhurst DS0000036576.V346170.R01.S.doc Version 5.2 Page 10 Visits to the home are encouraged prior to people moving in however due to individual circumstances this is not always possible. Some people I spoke to had used the home for short respite care stays, which had given them an insight to life in the home before making a permanent move, which they had found beneficial. The following quote explains this “Initial entry to the home was difficult, but staff reassured me and their thoughtfulness was greatly appreciated”. Based on my examination of people’s care plan files and discussions with them, their relatives and staff there was evidence that the admission procedure is effective and puts the needs of the person first. One relative I spoke to described the process as “thorough and professional, my relatives needs were assessed and there was a real attention to detail such as likes, dislikes and daily routines that were important. They made sure things were done the way we wanted”. The home has their own admission assessment which records personal and healthcare information. In addition specialist assessments by other professionals are held on file such as Physiotherapy, Community Psychiatric Nurse and Social Workers. These provide suitable information to develop detailed care plans. The manager has been involved in a pilot study on a new “person centred assessment” that will ensure information gathered is not just focussed on personal care and healthcare issues but will reflect a holistic approach including life histories, relationships, what is important to the person and their personal preferences. During the admission procedure a hospital admission sheet is completed to make sure that if the person is admitted to hospital relevant information is passed onto the hospital staff. All the files I examined contained a detailed contract of terms and conditions that was signed by the person or their relative. Elmhurst DS0000036576.V346170.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): 7, 8, 9, 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Detailed assessments and care plans have been developed that ensure that people, including those with complex needs, receive a personalised service that is flexible and consistent and maintains their dignity at all times. Medication was mostly very well managed. However, occasionally new medication was not always started immediately and this could affect residents’ health by delaying treatment. EVIDENCE: Based on the home’s own assessments and specialist assessments previously described a detailed care plan is developed, which includes an informative personal profile. They include strategies to guide staff in meeting personal and healthcare needs in a consistent manner. Daily routines for key times of the day have been developed such as morning routines, eating and drinking, personal care and bathing and evening routines. Pictorial social histories have Elmhurst DS0000036576.V346170.R01.S.doc Version 5.2 Page 12 also been developed for some people using photographs, which give staff an insight to a person and their life experiences. These are invaluable to staff particularly when someone is not able to make their needs known. Family and other professionals also contribute to the care plan strategies if appropriate. Manual Handling and general risk assessments are also completed ensuring the safety of the person and the staff who support them. In addition specific assessments and monitoring charts are implemented when needs are identified such as catheter care, diet and nutrition, fluid charts and pressure care. Another good example was the use of the Liverpool Care pathway that was used when someone was terminally ill. Monthly reviews of the care plan make sure all strategies and assessments are kept up to date and any changes are recorded. At the end of each shift daily diary records are completed by staff that record any significant events, communication with significant others and the care provided. Regular ‘unit meetings’ are also held with the supervisor and care staff to share information and discuss any concerns or changes to care plans. These help to maintain a good continuity of care throughout the home and between the different shifts. The home has regular contact with the District nurse team, GPs and other health professionals such as the Intermediate Care team and Community Psychiatric Nurse to ensure both routine health needs and specialist needs are responded to appropriately. All contact with health professionals is recorded and referenced in the care plans. Medication was mostly very well managed. Staff showed good knowledge of medication policies and individual medicines including special administration requirements so that they are given in the most effective and safe way. Records for receipt and disposal of medicines were kept though these should be more accurate for medicines in the monthly blister trays and medicines that are refused by residents so that they can all be accounted for. Records for administration of medicines to residents were good and showed clearly the treatment they had received. The home had arrangements in place so that non-prescribed medicines for the treatment of minor ailments could be given. This benefits residents as they can receive treatment for conditions such as minor pain without delay and without the need to see the doctor. Records for communication with doctors were mostly good and most changes to medication could be tracked. Sometimes new medications were not started as soon as they could be and this could delay treatment and affect health. For example a resident with a urinary infection was prescribed an antibiotic but this was not started until the day after the home received it although it was possible to give at least one and possibly two doses on the day it was received. This could result in a worsening of the infection. Storage was good but the fridge was too cold for the storage of medicines and this should be addressed to protect the quality of medication stored there. Elmhurst DS0000036576.V346170.R01.S.doc Version 5.2 Page 13 Based on my own observations and feedback from people living in the home, their relatives and other professionals, on the whole people are receiving a good quality of care that respects them as an individual and maintains their dignity and respect. This was confirmed by a residents and relatives survey conducted by the home that recorded that 89 of people felt their privacy and dignity were respected. Elmhurst DS0000036576.V346170.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): 12, 13, 14, 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People receive appropriate support to make choices in their lives and lead a fulfilling lifestyle. They are supported and encouraged to pursue their interests and staff promote their independence at all times. EVIDENCE: I arrived early in the morning to enable me to see the breakfast routines and meet the night staff. At 6.15 there was only one person who was out of bed. They explained to me that they “liked to get up early and watch the birds”. There was a relaxed atmosphere as staff supported people to get up in their own time. Call bells were answered promptly and it was evident people were able to get up at a time of their choosing. As people moved into the kitchen/dining area they were seated at the table or in a lounge chair where staff served them breakfast. Based on my discussions with people as they had their breakfast they were given suitable choices about what to eat and drink and where they ate their meal. When I asked one person about the breakfast they said, “It’s a very nice place the food is lovely”. Elmhurst DS0000036576.V346170.R01.S.doc Version 5.2 Page 15 The home has appointed an activities coordinator who takes a lead role in developing a suitable programme of activities for the home. The programme was displayed in each unit and included activities suitable for people of different abilities. The programme includes a weekly bus trip to local places of interest, which has proved very popular, armchair aerobics, tabletop games, hand massage, hairdresser, film nights and reminiscence sessions. Periodically and on special occasions entertainment is planned including professional singers and musicians and a Karaoke. Meals are served in the kitchen/dining room or in the person’s own room as they choose. I joined a group of people for lunch in one of the dining areas. This was served from a hot trolley. A freshly prepared roast dinner was served with fresh vegetables. The quality and presentation of the meal was excellent with people confirming, “We always get good meals”. A visiting relative also confirmed the good quality of the food when they explained how sometimes when they visit they are able to have a meal provided in private with their partner. This was something they really valued and appreciated. The cook has recently completed a healthy eating course that they found very useful and is working toward their NVQ qualification. They showed me a pictorial menu they were developing to help people make informed choices about what to eat, which is good practice. Elmhurst DS0000036576.V346170.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): 16, 18. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Although the manager has dealt with adult protection concerns effectively the organisations response has potentially put vulnerable people at risk by not following agreed multi-agency policies and procedures. EVIDENCE: The home has an appropriate complaints procedure in place, which is displayed in the home and included in information provided for people living there. There has been one complaint since the last inspection, which is currently under investigation and relates to an adult protection incident, which was appropriately dealt with by the home’s manager and referred to Adult Social Care services. The home’s policy is in line with the County Council multiagency guidelines and procedures with regard to safeguarding vulnerable adults. Subsequently actions were agreed at the multi-disciplinary strategy meeting relating to this case to safeguard all the people concerned. However the organisations senior management over ruled this decision, which has potentially put vulnerable people at risk. It also could have had an adverse affect on any investigation and is contrary to the agreed multi-disciplinary policy and procedures. Elmhurst DS0000036576.V346170.R01.S.doc Version 5.2 Page 17 Based on discussions with staff and after examining the training records it is recommended all staff who have not already done so, complete adult protection training to ensure they are aware of the new policies and procedures and their responsibilities in identifying and reporting abuse or suspected abuse. Elmhurst DS0000036576.V346170.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): 19, 20, 25, 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some areas of the home were in need of attention to improve the home environment for the people living there. EVIDENCE: An annual condition survey has been produced, which identified the following work to be completed in the next twelve months: replacement of nine double glazed units, decoration of two bedrooms, the staff room and a lounge, replacement flooring in two bedrooms. During a tour of the building malodours were noted in two lounges Birkrigg and Meadow View, the smell was evident on arrival in the building and was present during the day. It was not clear if it was from the furniture or carpet. The cleaning regimes for these areas and the need to review them were discussed Elmhurst DS0000036576.V346170.R01.S.doc Version 5.2 Page 19 with the manager, also highlighted was the need to replace badly stained or worn carpets. Bathrooms and toilets were clean and hygienic as were all other areas of the home. Suitable aids and adaptations were also in place. The laundry was well ordered and had a colour coding system to sort clothes. Elmhurst DS0000036576.V346170.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): 27, 28, 29, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are sufficient numbers of suitably trained and knowledgeable staff to meet the needs of the people living in the home. EVIDENCE: On arrival at the home at 6.15am there were three night staff on duty as required. There was a relaxed atmosphere as they went about their work assisting people to get up as they awoke. After a handover at the end of their shift they were replaced by a supervisor, eight care staff, three domestic staff and a cook. There were two care staff based on each unit that appeared adequate to meet the needs of the current group of people living in the home. On speaking to staff they had a good awareness of their role and responsibilities and were suitably skilled and experienced. They had a good knowledge of the people they were supporting and their individual needs and circumstances. They said they were receiving good levels of training including core subjects and some specialist areas. Each person living in the home has a link worker identified who takes a lead role in liaison with the supervisory team in ensuring people’s needs are recorded and responded to. Elmhurst DS0000036576.V346170.R01.S.doc Version 5.2 Page 21 Feedback from people living in the home and their relatives was very positive. One person said, “We are very lucky we have very caring staff, we’ve no complaints”. Another said how reassuring it was to be able to leave their relative with “caring and professional staff who have a great understanding about people’s needs”. I examined a selection of staff files, which were well ordered and contained all relevant information as required by the National Minimum Standards. All relevant safety checks and references were in place, however Criminal Record Bureau disclosures should now be destroyed in line with Data protection guidelines. Each member of staff has a Continuous Professional Development file in place that records all of their training and development needs and activity. This includes copies of certificates and qualifications and an up to date training record. Regular bi-monthly staff meetings are held in addition to monthly unit meetings, which ensure all staff, are kept up to date and any practice issues or changes cam be discussed or implemented. Elmhurst DS0000036576.V346170.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): 31, 32, 33, 35, 36, 37, 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager and staff ensure the safety and welfare of people living in the home. They are involved in all aspects of home life with their views and rights respected at all times. EVIDENCE: The manager is suitably trained and experienced and provides clear leadership to the staff team. She works closely with a team of supervisors to ensure the home is operating efficiently and effectively and in the best interests of the people living there. Regular meetings are held with people living in the home Elmhurst DS0000036576.V346170.R01.S.doc Version 5.2 Page 23 and staff, which enables them to contribute to all aspects of the running of the home and decision-making. A formal quality assurance questionnaire is issued annually to all the people living in the home and their relatives. Feedback regarding the outcome of the consultation is given to people through a newsletter, which is issued four times a year. It is also included in the Statement of Purpose. Results from the most recent survey confirmed that 84 of people felt well cared for. Other comments made by relatives in thank you cards and surveys included the following, “Kind and thoughtful carers” and “wonderful care by a thoughtful and professional team”. Residents meetings are also held on a regular basis with minutes recorded. I examined the minutes of the previous meeting where discussions had taken place regarding, menus, activities and events, the gardens, the use of agency staff and plans for a strawberry tea. The home only has one day of administrative support each week for 55 staff and the 40 people living in the home. This puts additional pressure on the manager and supervisory team to complete administrative tasks that can detract from their role. The manager monitors the income and expenditure related to the operation of the home using monthly budget returns issued by a central finance department. The home has sound systems in place to maintain a safe and comfortable living environment. Routine health and safety checks and servicing and maintenance of equipment are completed. A recent internal audit by the Health and Safety officer for the organisation commended the home on their “good practice and record keeping”. Elmhurst DS0000036576.V346170.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 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 2 3 X X X X 3 2 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 3 3 X 3 3 3 3 Elmhurst DS0000036576.V346170.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13 (2) Requirement Timescale for action 22/10/07 2 OP18 12 New medicines must be started as soon as possible to prevent delay in treatment and to protect residents’ health. The safety and welfare of people 22/10/07 who use the service must be safeguarded at all times. 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 Elmhurst Refer to Standard OP9 OP9 OP19 OP22 Good Practice Recommendations The records for receipt of medicines should include all monthly blistered medication, and disposal The temperature of the medicines fridge should be adjusted to protect the quality of the medicines stored there. An assessment relating to the condition of carpets within the home should be completed, with badly stained or worn carpets replaced. The use of signs, photographs and symbols to make the DS0000036576.V346170.R01.S.doc Version 5.2 Page 26 5 6 OP26 OP30 home more accessible to people with dementia and to promote their independence should be considered in line with good practice guidelines. The cleaning regime should be reviewed to ensure malodours are eliminated in the areas identified. All staff should complete training in relation to the policies and guidance for the protection of vulnerable adults. Elmhurst DS0000036576.V346170.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP 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 Elmhurst DS0000036576.V346170.R01.S.doc Version 5.2 Page 28 - 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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