Inspection on 27/06/07 for Elmhurst Residential Home

This inspection was carried out on 27th June 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Elmhurst Residential Home 21/09/06

Elmhurst Residential Home 27/09/05

Elmhurst Residential Home 24/05/05

Elmhurst Residential Home 21/10/04

Elmhurst Residential Home 15/06/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Elmhurst Residential Home 81-83 Holden Road North Finchley London N12 7DP Lead Inspector Tom McKervey Key Unannounced Inspection 09:30 27th June 2007 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 Residential Home DS0000010404.V333454.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 Residential Home DS0000010404.V333454.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elmhurst Residential Home Address 81-83 Holden Road North Finchley London N12 7DP 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) 020 8445 6501 020 8446 5319 Mrs Bernadette Tisdall Miss Elaine Margaret Tisdall Care Home 30 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (30) of places Elmhurst Residential Home DS0000010404.V333454.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st September 2006 Brief Description of the Service: Elmhurst is a privately run care home, first registered in 1967 for 30 older people, male and female, some of whom may have dementia. The stated aim of the home is to promote the dignity and privacy of service users who are frail and have dementia, thus ensuring their maximum quality of life. The home is a large two storey, detached building. The bedrooms, which are located on both floors, comprise twelve single and nine double rooms. All bedrooms have a washbasin, and three bedrooms have en-suite facilities. A passenger lift provides access to the first floor. The communal lounge and dining areas are on the ground floor, and the kitchen, laundry, office and staff room are all in the basement of the building. At the front of the building there is a large car park, and there is an attractive garden at the rear of the building, which is partly paved, with a ramp for and access by wheelchair users. The home is located in an attractive residential area of North Finchley and close to Woodside Park tube station. It is well served by a variety of shops, restaurants, transport and other community facilities located along Ballards Lane and High Road , North Finchley. The fees for the service range from £432 to £600 per week. Copies of this and other inspection reports are available at the home. Elmhurst Residential Home DS0000010404.V333454.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection, which was carried out as part of the Commission’s inspection programme and to check compliance with the key standards, was completed in seven hours. I wish to thank the “expert by experience” who accompanied me on this visit and assisted me in the inspection process. This person has personal experience of residential care services. The expert by experience assisted me by speaking to people who live in the home, the relatives who were visiting at the time, and speaking to staff who were on duty. The expert by experience’s comments are included where appropriate, in the body of this report. The registered manager and deputy were present during the inspection and fully cooperated in the process. The inspection process included a tour of the premises, including bedrooms, reading residents’ case files, and discussing with them about their experiences of living and in the home. We observed the staff interacting with the residents and how they provided care and support to them. Several staff were interviewed individually and in a group, about their knowledge and experience. This was done independently of the management. What the service does well: There is good information available to prospective service users and they are able to visit the home before deciding to move in. Each person has their needs assessed before they are admitted and they are provided with an individualised care plan, based on their needs. There is a good range of healthcare professionals available to the residents and medication is stored and administered safely. The residents are treated with respect and dignity by the care staff, and there is a good variety of activities provided. Residents say the food provided is of a high quality and residents and relatives generally express satisfaction with the service. Elmhurst Residential Home DS0000010404.V333454.R01.S.doc Version 5.2 Page 6 The home environment is generally well-maintained and comfortable and has a pleasant appearance. Complaints are appropriately recorded and responded to and staff are trained in abuse awareness. The staffing levels are good at the busiest times of the day, and the staff are trained in health and safety and the care of people with dementia. The home has a consistent record of meeting relevant health and safety requirements and legislation, and closely monitoring its own practice. What has improved since the last inspection? What they could do better: There is a persistent problem in this home of a residents’ bedroom being used to store other residents’ walking frames. A requirement to address this issue, which infringes the rights of the two residents concerned, is restated in this report. Alternative, appropriate storage must be provided for this equipment. The washbasin tap in Room 16 must be repaired so that it can be operated easily. The worn chair tables in the dining room must be replaced for the comfort of the residents who need support to eat. Room 17 must be thoroughly cleaned to remove the offensive odour. The fire door in the first floor must be repaired to ensure that it can open and close properly in the event of fire. Visitors must sign out when they leave the building to ensure that all people are accounted for in the event of the building having to be evacuated. Elmhurst Residential Home DS0000010404.V333454.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. Elmhurst Residential Home DS0000010404.V333454.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 Residential Home DS0000010404.V333454.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 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a Statement of Purpose that is specific to the individual home, and the resident group they care for. It clearly sets out the objectives and philosophy of the service supported by a Service user Guide. New residents are provided with a Statement of Terms and Conditions/Contract; this sets out in detail what is included in the fee, the role and responsibility of the provider, and the rights and obligations of the individual. Admissions are not made to the home until a full needs assessment has been undertaken. Prospective individuals are given the opportunity to spend time in the home. Elmhurst Residential Home DS0000010404.V333454.R01.S.doc Version 5.2 Page 10 EVIDENCE: At the time of the inspection, there were twenty-nine residents in the home and there was one vacancy. Interviews with residents and their relatives by the expert by experience, confirmed that they were aware of the Service User Guide and the complaints procedure. They also said that they had visited this home and others, before choosing Elmhurst. I sampled the case files of four of the last residents to be admitted. Three people were funded by the local authority, and one person was paying for their care. The manager told me that a service contract had been provided for this person, but at the time of the inspection, it was with the resident’s representative for signing and had not yet been returned. Residents’ case files showed that the manager had carried out an assessment of their needs before they were admitted to the home. There were also assessments that were completed by local authority care managers who also carry out annual reviews to ensure that the home continues to meet the residents’ needs. The home has a lift and there is a ramp to the garden area to assist residents with mobility problems. There is a spacious garden and patio for the residents to enjoy in the good weather. The home is equipped with hoists and adaptations in toilets and bathrooms to assist people with mobility problems. Pressure-relieving equipment, e.g. air mattresses and cushions are available for residents who are at risk of pressure ulcers. Elmhurst Residential Home DS0000010404.V333454.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 adequate. This judgement has been made using available evidence including a visit to this service. Each resident has a care plan that includes a comprehensive risk assessment, which is reviewed regularly. Management of risk is positive addressing safety issues whilst aiming for better quality of life. The healthcare needs of the residents are being met by a range of healthcare professionals, and medication is stored and administered safely. The residents are generally treated with respect and dignity, but the rights of two residents are being infringed by their bedroom being used to store equipment for other residents. Elmhurst Residential Home DS0000010404.V333454.R01.S.doc Version 5.2 Page 12 EVIDENCE: The four residents’ case files I examined, included individually written care plans. The plans were of a good standard and included a needs assessment, the actions to be taken to address those needs, and there was evidence that the plans were reviewed on a monthly basis. Risk assessments were documented, particularly about the risk of developing pressure ulcers, falls and choking on food. There were records to show that a resident who had a pressure ulcer, was being treated by the District Nurse. This resident was provided with pressure relieving equipment; for example, a seat pad and mattress. The nurses records indicated that the ulcer was responding to treatment. Residents’ files contained records of other healthcare appointments, including visits by the G.P, who routinely comes to the home once a week, and appointments with the optician, chiropodist and dentist. The residents appeared to be generally in good health, were well groomed and looked well cared for. The residents were weighed monthly and if necessary, advice was obtained from dieticians about the need for special meals. None of the residents was self-medicating. On inspection, I was satisfied that the medication stocks were being properly stored and accounted for, including controlled drugs. There were no gaps in the administration records. The expert by experience spoke to a resident who had lived in the home since February this year after being admitted from hospital following a fall. She knew the home, having previously been a visitor. She said she still had trouble walking and during this inspection, she was being visited by an old family friend and her young grand daughter. The family friend said her own mother had been a resident in Elmhurst before she died in 2002. She said that her mother had received excellent care in the home and the management had been attentive to her father when he visited, making sure he returned home safely. In our observations of how the staff interacted with residents, the expert by experience and myself were satisfied that they generally treated the residents with respect and dignity. However, I was concerned to find that Zimmer frames were still being stored in the double bedroom by the lounge. This is an infringement of the rights of those residents who occupy this bedroom and I have brought this same issue to the manager’s attention on previous inspections. A requirement is made for this matter to be properly addressed and finally resolved. Elmhurst Residential Home DS0000010404.V333454.R01.S.doc Version 5.2 Page 13 Elmhurst Residential Home DS0000010404.V333454.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): All these standards were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in the home are involved in meaningful daytime activities of their own choice and according to their individual interests and capability; where possible, they have been fully involved in the planning of their lifestyle and quality of life. People who use the service have the opportunity to develop and maintain important personal and family relationships The meals are balanced and nutritional and cater for the varying cultural and dietary needs of the individuals using the service. Care staff are sensitive to the needs of those residents who find it difficult to eat and give assistance with feeding. EVIDENCE: Elmhurst Residential Home DS0000010404.V333454.R01.S.doc Version 5.2 Page 15 Residents’ likes and dislikes, interests and pastimes are assessed and recorded in their case files on admission to the home. They have a personal activity chart for recording the activities each person takes part in. The general programme includes music, exercise and art and craft sessions. A session on keep-fit and reminiscence is also held twice a week by an occupational therapist. Individual activities include hand massage and manicures. Several residents go to a weekly club that is held in a nearby church hall. This took place during this inspection, and on their return to the home, the residents said how much they enjoyed themselves. In some instances, people who live in the home choose not to participate in planned activities, preferring instead to do their own thing; for example a resident told me that she preferred to read a book or newspaper. I was pleased to see that a new resident had been allowed to bring her cat with her to live in the home. This has proved to be very popular with the other residents. The expert by experience observed that there are some chairs and a settee available at the entrance to the main lounge to enable friends and relatives a little privacy when visiting residents. Relatives can also see residents in their rooms. Those residents who were able to converse, said that they chose their own clothes, when to rise and go to bed, and that they could choose alternatives to the planned menu. The expert by experience and I joined the residents for lunch, which they clearly enjoyed. It consisted of soup, followed by spicy sausages, mash potato, sliced roast potatoes and mixed vegetables; dessert was rice pudding and orange juice was offered. Some meals were pureied for people who had difficulty chewing. The menu offered alternatives to the main meal. The residents we spoke to, said that the meals were always very good and they had plenty to eat. After lunch we went into the kitchen and spoke with the cook who has a wellbalanced varied 8-week menu. The cook was able to show us evidence that appropriate meals were provided for residents on special diets or who came from various ethnic backgrounds, and said that the menu was sometimes altered at short notice so that salads could be provided when the weather turned hot. We were shown the cook’s training manual for a “Nutrition Awards” course that she and some other staff had recently attended. We saw a large tray of prepared fresh fruit, which was to be part of the residents’ tea that evening. Elmhurst Residential Home DS0000010404.V333454.R01.S.doc Version 5.2 Page 16 There was plenty of food stocked in the fridges, freezers and dry goods store, and monitoring records were available to show that the food was stored safely. The expert by experience observed that several residents were given lunch where they were sitting in the lounge, as they had difficulty walking to the dining area. Chair tables were provided for some of these residents. However, these tables were in a poor state and a requirement is made to replace them. Those unable to feed themselves were supported carefully and quietly by the staff in a dignified and unhurried manner. Elmhurst Residential Home DS0000010404.V333454.R01.S.doc Version 5.2 Page 17 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 good. This judgement has been made using available evidence including a visit to this service. The home keeps a full record of complaints and this includes details of the investigation and any actions taken. Unless there are exceptional circumstances the service always responds within the agreed timescale. The policies and procedures for Safeguarding Adults are available and give clear specific guidance to those using them. Staff working at the service know when incidents need external input and who to refer the incident to. EVIDENCE: There is an appropriate complaints procedure in place and residents said that they were aware of how to make a complaint. All residents spoken to by myself and the expert by experience, said they were satisfied with the service they received. There is a record of all complaints made to the home. The last complaint was in August 06, which was responded to and resolved satisfactorily. Elmhurst Residential Home DS0000010404.V333454.R01.S.doc Version 5.2 Page 18 Staff records showed that they had attended training in adult protection procedures, and those who were spoken to, were knowledgeable about abuse issues and how to report any concerns. Elmhurst Residential Home DS0000010404.V333454.R01.S.doc Version 5.2 Page 19 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, 22, 23, 24 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that is appropriate to the specific needs of the people who live there. The well-maintained environment provides specialist aids and equipment to meet the needs of the people who use the service. People who use services are encouraged to personalise their bedrooms. The home is well lit, clean and tidy and smells fresh. The management has a good infection control policy; they seek advice from external specialists, e.g. infection control, and encourage their own staff to work to the homes’ policy to reduce the risk of infection. Elmhurst Residential Home DS0000010404.V333454.R01.S.doc Version 5.2 Page 20 EVIDENCE: The expert by experience and I conducted a tour of the premises and agreed that there was a good standard of internal and external décor. The front of the home was particularly attractive with planters and hanging flower baskets and a bench for residents to sit out in. The large rear garden was well maintained and there was ample garden furniture in place. The front and side of driveways had recently been re-surfaced. At the time of the inspection, a new central heating boiler was being installed. The majority of the bedrooms and the hallway had been redecorated recently and the overall décor of the home was of a good standard. We visited several bedrooms at random, and one at the invitation of a resident who was very pleased with her room. Residents’ rooms were clean and tidy and were personalised with photographs, ornaments and soft toys. In bedroom 16, one of the washbasin taps was too stiff to turn and the fire door in the corridor by Room 15, was very difficult to open because it had recently been repainted. There was an unpleasant odour in Room 17, which was unoccupied. The chair tables in the dining/lounge area were very in a very poor state and need to be replaced. The manger acknowledged this and said she was assessing various models to purchase. Requirements are made to address these issues. The laundry was well equipped with appropriate machinery and facilities and was very tidy and well organised and the laundry person had a good system for ensuring that residents’ clothes did not go missing. A member of the proprietor’s family who lives on the premises, provides maintenance in the home and is responsible for minor repairs. Appropriate equipment, for example hoists, special baths, wheelchairs and walking frames were available to support residents who had mobility problems. Elmhurst Residential Home DS0000010404.V333454.R01.S.doc Version 5.2 Page 21 Pressure pads and mattresses were provided to prevent pressure ulcers. There were records of regular servicing of the specialist equipment. There are separate cleaning staff employed. With the exception of Room 17A as noted above, the home was very clean, tidy and fresh. There is and infection control procedure and staff have been trained in this subject. The care staff were observed wearing disposable aprons and gloves when providing personal care. Elmhurst Residential Home DS0000010404.V333454.R01.S.doc Version 5.2 Page 22 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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are consistently enough staff available to meet the needs of the people using the service, with more staff being available at peak times of activity. The staffing structure is based around delivering outcomes for the people using the service, and is not led by staff requirements. The service ensures that all staff receive relevant training that is focussed on delivering improved outcomes for people using the service. The service puts a high level of importance on training and staff report that they are supported through training to meet the individual needs of people using the service. EVIDENCE: No new staff have been employed since the last inspection, and there were no staff vacancies. Elmhurst Residential Home DS0000010404.V333454.R01.S.doc Version 5.2 Page 23 The rota was examined, which identified the staff on duty that day. However, I noticed that the deputy manager’s duties were not recorded on the rota. This was immediately corrected in my presence. There are normally six care staff on duty during the daytime, and three waking staff at night. The shift hours are arranged to ensure that staff are always available at the busiest times of the day. The care staff are supported by cooks, cleaners a laundry worker and a maintenance person. This level of staffing meets the standard. Staff who were spoken to, said they were satisfied with the level of staffing that was available to support the residents. Seven staff have attained National Vocational Qualification level 2, and two at level three. There is an ongoing programme for all staff to attain this qualification. There were certificates of achievement for staff who attended training on health and safety subjects, for example; food hygiene and first aid and moving and handling. Training in fire safety had taken place and also refresher training in mandatory subjects. The staff said that they appreciated the amount and content of the training that was provided, which supported them in their roles as carers. Other courses the staff attended, included dementia care, diet and nutrition and pressure ulcer prevention. Elmhurst Residential Home DS0000010404.V333454.R01.S.doc Version 5.2 Page 24 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, 35, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Manager has the required qualifications and experience and is competent to run the home. Management processes ensure that staff receive feedback on their work. The home has a consistent record of meeting relevant health and safety requirements and legislation, and closely monitoring its own practice. Elmhurst Residential Home DS0000010404.V333454.R01.S.doc Version 5.2 Page 25 EVIDENCE: The manager is a qualified nurse and has been managing the home for many years. The deputy manager has also been in post for several years. Both the manager and deputy are currently studying to attain the Registered Manager Award. There was a relaxed atmosphere in the home during the inspection and from our discussions with the staff, they appeared to work well together. A member of staff contacted me some days after I completed this inspection, expressing a concern, as a result of which, I have written to the manager of the home asking her to investigate the issues raised by this staff. The manager has recently sent out questionnaires to canvass views from service users and relatives about the quality of the service they receive and responses were awaited. There are regular meetings between the managers and the staff, in which the staff are able to air their views. Minutes of these meetings are published. There were records indicating that staff received formal, regular supervision. The following Health and Safety Standards were examined. The fire alarm system had been serviced in April 07 and a fire risk assessment of the property was done. Fire drills had been carried out. Fire extinguishers were being serviced on the day of the inspection. Portable electric appliances and the water storage system had been tested. Monthly health and safety checks were recorded and any issues arising were addressed. The visitors’ book showed that while visitors are required to sign in, they are not required to sign out. A requirement is made for this to occur in order to comply with fire regulations. The home has employers’ liability insurance cover. Elmhurst Residential Home DS0000010404.V333454.R01.S.doc Version 5.2 Page 26 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 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 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 3 2 3 X 2 3 3 X 2 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X 3 3 X 2 Elmhurst Residential Home DS0000010404.V333454.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP10 Regulation 12(4)(a) Timescale for action Residents’ bedrooms must not 31/07/07 be used to store other residents’ walking frames. Alternative, appropriate storage must be provided for this equipment. This requirement is restated from the last inspection. The previous timescale was 31/10/06. 2. 3. 4. OP19 OP22 OP26 23(2)(b) 23(2)(c) 16(2)(k) The washbasin tap in Room 16 31/07/07 must be repaired. The worn chair tables in the 31/08/07 dining room must be replaced. Room 17 must be thoroughly 31/07/07 cleaned to remove the offensive odour. Requirement 5. OP38 23(4)(c)(ii The fire door in the first floor 31/07/07 i) must be repaired to ensure that it can open and close properly. 23(4)(c)(ii Visitors must sign out when they 31/07/07 i) leave the building to comply with fire regulations. 6. OP38 Elmhurst Residential Home DS0000010404.V333454.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Elmhurst Residential Home DS0000010404.V333454.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Residential Home DS0000010404.V333454.R01.S.doc Version 5.2 Page 30 - 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. 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