Inspection on 24/04/07 for Elms Park Care Home

This inspection was carried out on 24th April 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Elms Park Care Home 20/04/06

Elms Park Care Home 14/12/05

Elms Park Care Home 02/08/05

Elms Park Care Home 09/03/05

Elms Park Care Home 13/04/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Elms Park Care Home 11 Elms Park Ruddington Nottingham NG11 6NU Lead Inspector Linda Hirst Unannounced Inspection 24th April 2007 09:30 Elms Park Care Home DS0000008672.V334873.R01.S.doc Version 5.2 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 Elms Park Care Home DS0000008672.V334873.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 Adults 18-65. 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. Elms Park Care Home DS0000008672.V334873.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elms Park Care Home Address 11 Elms Park Ruddington Nottingham NG11 6NU 0115 945 6323 0115 945 6323 h2055@mencap.org www.mencap.org.uk Royal Mencap Society 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) Wendy Cynthia Warner Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Elms Park Care Home DS0000008672.V334873.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Within the total number of beds, a maximum of 8 (eight) may be used for the category LD 20th April 2006 Date of last inspection Brief Description of the Service: Elms Park is a care home providing personal care and accommodation for up to 8 adults with a learning disability. Mencap provides care and support, though Nottingham Community Housing Association owns the building. The home is located in the village of Ruddington with easy access to the village centre. All bedrooms are single and on the ground and first floor. There is no lift, but the ground floor has level access. There is a garden to the rear of the house, which has seating for service users. The fees for the service range between £323.56 and £367.26 per week. Elms Park Care Home DS0000008672.V334873.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for service users and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. This inspection involved one inspector; it was unannounced and took place over 7.5 daytime hours, including lunchtime. The main method of inspection used was called ‘case tracking’ which involved selecting three service users and looking at the quality of the care they receive by speaking to them, observation, reading their records and asking staff about their needs. Three members of staff were spoken to as part of this inspection, documents were read and medication was inspected to form an opinion about the quality of the care provided. A partial tour of the building was undertaken, all communal areas were seen and a one bedroom (with the service user’s permission) to make sure that the environment is safe and homely. A review of all the information we have received about the home since the last inspection was considered in planning this visit and this helped decide what areas were looked at. Six questionnaires were sent out to residents at the home for them to give their views about life at the home, none were returned. At the moment there is discussion with the manager of the home about using a “link” resident to give out and collect the questionnaires to get a better idea of service user’s views before inspections. What the service does well: People who want to live at the home are given lots of opportunities to visit and stay at the home and meet the other people living there before moving in. Their needs are assessed to make sure the staff can provide them with the help they need. The service users help to write their support plans and say what help they want and need and how they would like this to be provided. Service users are encouraged to make their own decisions about their lives and they learn to be independent, cooking, cleaning and shopping. If there are any risks, the staff balance these against what service users want and what they have the right to do and they always try and support people’s choices. Elms Park Care Home DS0000008672.V334873.R01.S.doc Version 5.2 Page 6 People who live at the home do lots of activities, many of these are based in the local community. If people need help to learn to travel independently or to get a paid job, help is provided. People are encouraged to have relationships with their family, friends, girlfriends and boyfriends and the staff make sure they get advice to keep them safe. Everyone who lives at the home has their own keys to the home and their bedrooms and they decide what they want to do with their time. Staff encourage them to make these decisions themselves. Service users decide what they would like to eat, they go and buy the food, plan their menu and do their own cooking. The staff give them advice about being healthy but they don’t tell people what to eat. The staff make sure that people stay well and healthy by making sure they see the Doctor when they need to and have regular health checks. Service users know that they can complain if they want to and they know how to do this and whom they should speak to. They are confident and say what they think. They feel safe at the home and well supported by staff. The home is comfortable, clean and homely. The service users choose how they want their rooms to be decorated. The staff have lots of training to make sure that they understand the needs of the people they support and can help them properly. The home is well run and managed and the people who live there get to say what they think of the service they receive. What has improved since the last inspection? What they could do better: Elms Park Care Home DS0000008672.V334873.R01.S.doc Version 5.2 Page 7 More care needs to be taken with medication to ensure that service users receive this on time, as their Doctor prescribed to make sure they stay healthy and well. The service could provide more staff on a weekend to ensure that service users have more choices in terms of how they spend their free time. Staff files must be available for inspectors to look at so that they can check that people have been properly employed and that the service users are safe from potential harm. 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. Elms Park Care Home DS0000008672.V334873.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Elms Park Care Home DS0000008672.V334873.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a clear process for admission into the home and service users are assessed before admission to ensure their needs can be met at the home, avoiding unnecessary moves. EVIDENCE: The last person who was admitted to the service was “case tracked” to make sure that he had been properly assessed to ensure the home could meet his needs. His file shows evidence of a planned introduction to the service over a number of visits, gradually increasing in length to help him to make an informed decision about moving into the home; the service user confirmed this had been the case. There is also evidence in the house meeting minutes which shows that the existing service users were asked for their views before his placement became final. There is a copy of his assessment by a social worker, his previous support plans and his current one on file, indicating that a full assessment has been completed. A copy of the service user guide is given to all prospective service users to help them make informed decisions about care. Elms Park Care Home DS0000008672.V334873.R01.S.doc Version 5.2 Page 10 However, staff who were interviewed said they did not receive full information from his previous placement which made it difficult for them to properly support him when he experienced recent difficulties. The service user confirmed that the move had been stressful and he had faced difficulties, though he said the staff had been kind and supportive and he feels he has settled well at the home. Elms Park Care Home DS0000008672.V334873.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The service promotes, actively listens to and supports the decisions and choices of service users in order to improve their quality of life and promote their independence. EVIDENCE: The support plans of the “case tracked” service users were inspected to make sure they are person centred and cover people’s needs in detail. The records show that all staff have had training on person centred planning and the plans are all written in plain English from the point of view of the service user. Service users sign them and each plan is reviewed in detail each month by the service user and their keyworker to check the plan is still appropriate. The staff said only one person has chosen to keep her care plan in her bedroom. The service users who were interviewed confirmed they know about their plans and have regular meetings to talk about their goals. Elms Park Care Home DS0000008672.V334873.R01.S.doc Version 5.2 Page 12 The plans encourage independence and record in some detail the decisions service users have made, or how people are to be supported (E.g. menu planning, shopping, spending money, buying clothes and so on.) Each person has a “pen picture” which they write with their Keyworker and this gives clear information about their likes, dislikes, preferences and it also lets staff know about the people who are important in service users’ lives. Service users who were interviewed said that they make their own decisions in all areas and they enjoy their independence. Staff were observed throughout the inspection encouraging service users to make their own choices. There are risk assessments in place on each service users’ file which balance the benefits of particular actions for service users, their rights as well as potential harm. (E.g. on independent use of public transport, bathing, going out alone and using electrical appliances in the home.) The staff confirm that even though there are risks in some activities they always try and balance these against the rights and wishes of the service user. One service user uses public transport independently and said she enjoys this, it gives her freedom. She has “training” to do this but can do it herself now. Elms Park Care Home DS0000008672.V334873.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Service users have individual and flexible lifestyles which meet their needs, preferences and are in line with their choices providing them with a positive quality of life. EVIDENCE: The staff said that most of the service users attend day services and have at least one day a week off to do chores, menu planning, shopping and paying bills. Two service users have paid employment and a further two are looking for employment with support from the Pathways scheme, supported by MENCAP. The service openly supports and promotes inclusion, equality and independence. Service users’ views are encouraged, recognised and responded Elms Park Care Home DS0000008672.V334873.R01.S.doc Version 5.2 Page 14 to. The staff said they try and ensure that service users go out if, and when they want and they said that on occasion they would join together with staff from other homes to facilitate this. (E.g. staff and service users from a MENCAP home who are going to the pictures may meet service users from Elms Park from their taxis and ensure they get back into their taxis at the end of the night.) Service users who were interviewed said they enjoy, gardening, working, going to the pub, going bowling, going to the cinema, being with their partners and going to church. They said they can do what they want but would prefer more staff on at a weekend so they can do more things, as this is their time off. The staff also said this would be a significant improvement. Service users said they enjoy going out into Ruddington. One person said she likes going shopping in town and prefers to go in alone as she has more time and can relax more. Three service users have personal relationships with others outside of the home and see them regularly. Community nurses have provided appropriate support and advice to service users about protection from pregnancy and infection. One person who was interviewed said she has her boyfriend over to the house and she cooks a meal for them both, she sometimes stays over with him at his home. Service users said that they see their family and friends regularly and they said the people living at the house get along well most of the time. Staff confirmed that people are encouraged to be in relationships if that is their wish and they make sure they are properly protected from pregnancy, infection and abuse by liaising with health professionals. The routines during the week can be governed by the times of day services. That said, people could go to bed when they wish and there is a great deal of information on care plans about service users’ preferences. Those spoken with said they do what they want when they want; they all have their own routines and arrange these to suit themselves. The staff said they give service users choices in all things, if someone does not want to go to a day service one day for a particular reason they will arrange this. All of the service users do chores to keep their home clean and tidy, and their independence is promoted in all things, support is available if needed. Each service user is given a weekly food budget, they use this to plan their individual weekly menu, shop for the ingredients they will need and they said they either prepare these meals independently or with some support. They spoke about “healthy eating” and staff interviewed said they try to promote healthy eating but do respect service user choice. Observations confirm that service users are encouraged by staff to make their own decisions about what to eat. Staff said the service users who are at home during the day will Elms Park Care Home DS0000008672.V334873.R01.S.doc Version 5.2 Page 15 sometimes have a main meal at lunchtime rather than tea, it is their choice. Service users help themselves to hot and cold drinks when they want. The choices and support that service users experience offer them a flexible and supportive lifestyle that exceeds the minimum standards. Elms Park Care Home DS0000008672.V334873.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ health needs are properly assessed and monitored to ensure they are well and healthy. EVIDENCE: None of the current service users need support with moving and handling, they all are independent in bathing and showering and see to their own personal care needs. Service users and staff who were interviewed confirmed this. This standard is not applicable at the present time. Following a recommendation at the last key inspection a call alarm system has been installed in all bedrooms and bathrooms to enable staff to be summoned in an emergency. The arrangements made for health care were checked to make sure that service users’ wellbeing is protected and promoted. There is good evidence in the service users’ records to indicate that staff are vigilant, (E.g. one person Elms Park Care Home DS0000008672.V334873.R01.S.doc Version 5.2 Page 17 was suspected of having a Deep Vein Thrombosis and a referral was made quickly.) There are good records of visits to the GP, Optician, Chiropodist, Dentist and Nurses. The service users said they organise their own appointments but will often go with staff. The staff who were interviewed said they support people discreetly with health care to make sure they get the help they need. The arrangements for medication were checked to ensure that service users received their medicines as prescribed by their GP. These are stored appropriately and securely. The home is registered with a pharmacist who supplies medicines in individually sealed packs and also provides a pharmacy audit, to ensure safe working practices within the home. Evidence of staff being trained in the safe handling of medicines was seen on files. One service user self medicates and is risk assessed to make sure they can do this safely. Medication Administration Records were inspected to make sure there are accurate records of the medication given. There is one gap in the record, when a staff member forgot to give out the medication to a named person. This was recorded on an incident form and notified to the Commission. Unfortunately, this medication can produce severe side effects if it is missed. Staff did make sure the service user was closely observed for ill effects, and none were seen but in future any omissions (for whatever reason) should be discussed with a GP or emergency medical services. The Commission requires a report to indicate the outcome of the investigation into this issue to make sure that steps will be taken to prevent reoccurrence. Elms Park Care Home DS0000008672.V334873.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service encourages people to raise any concerns with them and service users know how to complain and feel they would be listened to. They feel safe and supported at the service. EVIDENCE: The arrangements for complaints were checked to make sure that service users’ views are heard and responded to. The Complaints Procedure was displayed on a notice board in the dining room and held on each support plan. All of the service users knew exactly how to complain and who to. There has been one complaint about an item going missing since the last inspection, the complaint was not upheld and the records indicate that the complainant was satisfied with the outcome. The staff said they spend a lot of time making sure people know their rights. There have been no allegations of abuse since the last inspection and the service users who were interviewed said they feel safe and secure at the home. The staff demonstrated good understanding of their obligations to report and prevent abuse and to keep service users safe. All of the service users collect their own benefits and hold their money themselves in secure storage. The staff try and maintain records about expenditure but sometimes service users spend money independently so they Elms Park Care Home DS0000008672.V334873.R01.S.doc Version 5.2 Page 19 are not always accurate. Staff were observed going through finances with service users and checking amounts. Service users who were interviewed confirmed they hold and spend their own money and pay their own bills. Elms Park Care Home DS0000008672.V334873.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 28, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service provides a pleasant, clean, comfortable and homely accommodation for the people who live there. EVIDENCE: The accommodation was checked to make sure it provides a safe, comfortable and homely environment for people to live in. The communal space comprises a dining room and a lounge; both spaces are comfortable, clean and well used by service users. They can access the garden by either room and this area is also well maintained and pleasant. Some of the service users expressed a desire to do some work in the garden and staff said they had recently cleared some equipment and this would be a possibility. The kitchen is fully accessible for service users to use and is well equipped having lots of work surfaces and two cookers for service users to prepare and Elms Park Care Home DS0000008672.V334873.R01.S.doc Version 5.2 Page 21 cook food. Each service user has designated storage for their weekly food and they take it in turns to do communal household chores. One bedroom was seen with the service user’s permission and this was personalised and comfortable, he confirmed he had chosen the colour of the room. He said he has keys to the front door, his own room and his cupboard. Service users said they could put what they like in their bedrooms and personalise them. They said they are responsible for keeping their bedroom tidy and alternate chores to keep the home clean and tidy. The staff said they work hard to make sure the home is clean, comfortable and homely for service users. Elms Park Care Home DS0000008672.V334873.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34, 35 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The staffing arrangements meet the needs of service users and ensure that service users are supported and protected by well trained staff. EVIDENCE: The arrangements for staffing were inspected to make sure that there are enough suitably qualified staff on duty to support people with their needs. The staff rota was inspected and this indicates that there are a minimum of two staff on duty between 09.00 and 22.00. This is an improvement since the last inspection and staff and service users said these arrangements were better than previously. However the staff and service users who were interviewed said it would be beneficial to have a third member of staff on duty at the weekends to offer people more choice in terms of activities, as that is their time off. The staff files could not be accessed during this visit to check that staff are recruited properly and in a way which protects the people living at the home. Elms Park Care Home DS0000008672.V334873.R01.S.doc Version 5.2 Page 23 The manager was not on the premises, and she has the only key. This is not acceptable; staff files must be available for inspection at any time in order to check service users are protected. Contingency plans must be made to enable access to staff files for inspection purposes. The reports on the provider’s monthly visits provides evidence that staff files have been checked and contained the correct information and documents. A staff member who was interviewed indicated that she had all of the necessary checks before she started work. She confirmed that she did a Learning Disabilities Award Framework induction when she first started work and this document had been completed. The staff training file was inspected to make sure that staff have had the training they need to work positively and safely with service users. This provided good evidence that a wide variety of training has been provided in the past year, including Person Centred Planning, Autistic Spectrum Disorders, Protection of Vulnerable Adults, Diversity, No Bullying and there was evidence that staff have completed compulsory health and safety training. The staff said they get access to good levels of training and can request any training they need. They could not think of any training which would be beneficial, but as one person has specific mental health needs, information or training on this illness may be helpful to staff. The service users said staff support them well. Elms Park Care Home DS0000008672.V334873.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The service is well managed and runs safely and in a way which takes into account the views of service users. EVIDENCE: The manager was not on duty during this inspection, but the home was well organised and ran well in her absence. The records are easy to read and well managed. There is evidence on her staff training record that the manager continues to update her own knowledge and training to ensure the service runs well and benefits service users. Staff and service users praised the manager and said she was approachable and supportive. Staff said they receive regular supervision every six weeks. Elms Park Care Home DS0000008672.V334873.R01.S.doc Version 5.2 Page 25 The last Quality Assurance surveys were done in July 2006 and the results were seen. The service user questionnaire is in picture format as well as written form. The responses seen were positive about care and support but service users said they would like more staff on duty (x2), more outings, the provision of a games room and conservatory. Specific comments made by service users included, “I need more space sometimes,” “it’s got a lot better,” “I get good support,” “I like my support worker” and “I would like more help with domestic chores as I feel that I used to be able to do things now not so able.” The action plan for the last quality assurance has not yet been completed so it is not possible to say what action has been taken in response to these issues. The staff members on duty could not tell me what action had been planned following the audit. The staff and service users who were interviewed said that people are asked for their opinions at house meetings (records seen), monthly reviews and by annual questionnaires. The Health and Safety Records were inspected to make sure that the servicing of equipment and appliances is carried out at the suggested intervals. There is written evidence that all checks and servicing is carried out at the correct intervals and staff said their health and safety is protected and they have enough training for meeting the needs of residents safely. Elms Park Care Home DS0000008672.V334873.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 Adults 18-65 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 X 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 3 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 N/A 2 X 3 X 3 X X 3 X Elms Park Care Home DS0000008672.V334873.R01.S.doc Version 5.2 Page 27 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13(2) Requirement Timescale for action 25/05/07 2. YA34 19, Sch 2 The outcome of an investigation into the omitted medication must be sent to the Commission to show how such incidents will be avoided in future. Arrangements must be made to 25/05/07 ensure that staff files are available for inspection by the Commission for Social Care Inspection to ensure appropriate recruitment procedures are in place to protect service users 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. Refer to Standard YA20 YA33 YA35 Good Practice Recommendations In the case of the medication indicated if it is not given advice should be sought from the GP to ensure that the service user concerned will not suffer ill effects. More staff should be employed at the weekend to ensure that service users have more choices about how to spend their free time. Training should be provided on the specific mental health DS0000008672.V334873.R01.S.doc Version 5.2 Page 28 Elms Park Care Home 4. YA39 need indicated to make sure staff understand the needs of all service users. Action plans should be produced after every quality assurance audit to indicate how the service will be improved taking account the views of service users. Elms Park Care Home DS0000008672.V334873.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Elms Park Care Home DS0000008672.V334873.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. 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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