Inspection on 04/09/07 for Elmsdene Care Home

This inspection was carried out on 4th September 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Elmsdene Care Home 27/08/09

Elmsdene Care Home 02/05/06

Elmsdene Care Home 13/12/05

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 Elmsdene Care Home 37-41 Dean Street South Shore Blackpool Lancashire FY4 1BP Lead Inspector Mrs Ruth Edgington Unannounced Inspection 04th September 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Elmsdene Care Home DS0000065303.V345150.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. Elmsdene Care Home DS0000065303.V345150.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elmsdene Care Home Address 37-41 Dean Street South Shore Blackpool Lancashire FY4 1BP 01253 349617 01253 400153 b.sheridan1@btinternet.com 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) Sheridan Care Limited Mrs Gillian Appleyard Care Home 33 Category(ies) of Dementia (33), Old age, not falling within any registration, with number other category (3) of places Elmsdene Care Home DS0000065303.V345150.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only: Code PC, to people of the following gender: Either. Whose primary care needs on admission to the home are within the following categories: Dementia: Code DE (maximum number of places: 33). Old age, not falling within any other category: Code OP (maximum number of places: 3). The maximum number of people who can be accommodated is: 33. Date of last inspection 2nd May 2006 Brief Description of the Service: In July 2006 the Commission for Social Care Inspection granted approval to changed the category of residents that could be accommodated in the home. Elmsdene Care Home is now registered to provide personal care for a maximum of thirty three residents of either sex whose primary care needs are those of persons with dementia. Conditions were placed on this registration to enable three residents who did not fall into this category to remain in the home for as long as the home meets their needs. Elmsdene is an adapted property, situated in an area of Blackpool, which is predominantly holiday accommodation. The availability of local shops and facilities could be seen as an advantage for those able to continue to maintain links with the community. The accommodation, which is on the ground and first floor, consists of twentyfive single bedrooms, nine of which have en-suite facilities and four double bedrooms, two of which have en-suite facilities. Each room is furnished to a good standard. The communal space consists of a large dining room, lounge area and a separate lounge, which all provide the residents with the choice of where to sit and who to associate with. There is a passenger lift, which enables easy access between the ground and first floor. A variety of aids are provided around the home to meet the needs of the residents. There is a Statement of Purpose/Service User Guide, which is given to all prospective residents. This written information explains the care service that is offered, who the owners and staff are, and what the resident can expect if he or she decides to live at the home. Elmsdene Care Home DS0000065303.V345150.R01.S.doc Version 5.2 Page 5 All residents receive a copy of the most recent inspection report and a copy is available in the information given to prospective residents. Information received during the visit (04/9/07) showed that the fees for care at the home are from £280.0 to £324.10 per week, with added expenses for hairdressing, chiropody and newspapers. Elmsdene Care Home DS0000065303.V345150.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced site visit was undertaken as part of the Key Inspection and commenced at 9.30am on 4th September 2007 and took place over five hours. Prior to the visit the management team completed an Annual Quality Assurance Assessment document (AQAA), which provided information about the home and how the service provided was meeting the National Minimum Standards. Comments cards were sent out to six of the residents, their relatives and any persons who had significant dealings with these residents. In total only four residents and one relative completed the questionnaires providing their views of about the service. Comment cards were handed out to the staff during the visit to give them the opportunity to make comments. During the visit five members of staff, the homeowner and the manager were spoken to. There was limited discussions with residents due to their abilities, however evidence was gained through the comments made by residents, observations and interaction between the residents and staff. A random selection of residents, staff and administrative records were looked at and a tour of the home took place From observations made, comments received and written documentation examined, the information has been put together to produce this report. What the service does well: This is a care home where the residents are well looked after. They are encouraged to be individual and their personal routines and lifestyles are respected. One resident said that “I feel that I am one of the family, I am happy doing what I do” Caring for the residents also includes supporting the relatives and the home does this very well. Meetings are held monthly to which all interested parties are invited to discuss any issues relating to people with dementia. One relative confirmed that these meetings were very helpful in assisting people to learn more about and have a better understanding of people with dementia and the care required. The staff team work well together and were seen throughout the visit to be very caring in the way in which they looked after the residents and assisted Elmsdene Care Home DS0000065303.V345150.R01.S.doc Version 5.2 Page 7 with personal tasks in a sensitive manner. Comments from staff were very positive confirmed that they felt supported by the management team to undertake their role for the benefit of the residents. There was a good atmosphere in the home and the staff and residents were very relaxed and interacted well. One resident was full of praise for the staff and said “they are kindness it self”. Meals are varied and an alternative choice is available if required. The cooks are very committed to providing good home cooking that is healthy and meets the wishes and dietary needs of the residents. From observations and discussions, evidence was gained to confirm that the manager and staff had a good understanding of equality and the diverse needs of the residents, which ensures that individual needs are met. The manager and staff are committed to enabling residents to live as independent as possible within their capabilities, whilst ensuring their privacy, dignity and opportunity to make their own choices. What has improved since the last inspection? Improvements continue to be made in this home, not only to the care provided but also to the environmental standards. These improvements are due to the commitment of the management team and the staff continually striving to provide a quality service for the benefit of the residents and their relatives. A new manager has been appointed since the last inspection who was able to demonstrate her understanding of the needs of people with dementia and how these needs are to be met. Systems to obtain the views of relatives, residents and staff have been improved to ensure that the wishes, expectations and involvement in the service provided is assured for everyone who has an interest in the home. Training continues to be viewed as a major factor in ensuring that the needs of the residents are met by a competent staff group. The number of staff undertaking and achieving a recognised qualification as increased and staff spoken to confirmed that they were finding the training very beneficial in identifying and meeting the individual needs of the residents. One staff member, who previously had resisted any such training as they had little confidence in their abilities, expressed their satisfaction at achieving a qualification and was eager to undertake further training as they now felt that they had the support that they needed Elmsdene Care Home DS0000065303.V345150.R01.S.doc Version 5.2 Page 8 What they could do better: 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. Elmsdene Care Home DS0000065303.V345150.R01.S.doc Version 5.2 Page 9 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 Elmsdene Care Home DS0000065303.V345150.R01.S.doc Version 5.2 Page 10 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): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admission and assessment procedures are clear to ensure that the care needs of residents are met. EVIDENCE: The admission process of the home includes a full assessment of the needs of any prospective resident, which is undertaken prior to admission in order that they, their relatives and the staff can come to an informed decision about the suitability of the home to meet their individual needs. Prospective residents are encouraged to come for a meal or stay for a short period of time if they wish. The records of three residents were looked at in detail and were found to contain full assessment information that had been obtained prior to admission therefore ensuring that the home could meet their assessed needs. The information included the physical, emotional, dietary, religious and cultural needs. Elmsdene Care Home DS0000065303.V345150.R01.S.doc Version 5.2 Page 11 One resident spoken to confirmed that they had been fully involved in the admission process and the management team and staff had supported them and made them feel at home. From observations made and comments received during the visit, evidence was found that the staff were well aware of the needs of the individual residents. This home does not provide intermediate care. Elmsdene Care Home DS0000065303.V345150.R01.S.doc Version 5.2 Page 12 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 excellent. This judgement has been made using available evidence including a visit to this service. Promotion of health is taken seriously, resident’s welfare is closely monitored and health needs were met. EVIDENCE: Examination of the three residents’ records that had been selected to be looked at in detail were found to contain sufficient information to ensure that their health, personal and social care needs were met. Examination of the individual care records showed that the residents had agreed with their plan of care and that these were being reviewed on a regular basis Risk assessments were included which identified the level of risk and the intervention required by the staff. Significant events were recorded and daily entries made of the care given. Elmsdene Care Home DS0000065303.V345150.R01.S.doc Version 5.2 Page 13 One resident who had neglected their health care needs for many years, confirmed that since they had move into the home they had received treatment from a chiropodist, they could now see to read the paper after a visit to the optician and had seen a dentist and was going to have a set of dentures made. This resident was also being provided with in depth physiotherapy twice a week at the home to improve their mobility, which they said that they enjoyed. Risk assessments identify residents who are likely to develop a pressure sore and confirmation was gained that the district nursing service were contacted to visit and pressure relieving equipment was put in place if required. At the time of the visit only one resident was receiving treatment from a district nurse. Observations of practices and examination of care plans confirmed that staff were meeting the diverse needs of the residents who had a wide range of disabilities. Observation were also made of the caring approach of the staff towards the residents and the practices in the home ensured that residents were treated with respect and their right to privacy was upheld. When meeting the care needs of the residents a very holistic view is taken that includes the relatives, the needs of individual residents and those of the group in order to ensure that all needs are fully met. Three of the residents presently accommodated lived at the home before the home began to take persons in who suffered from dementia. From discussions and observations made during the visit evidence was gained that the needs of these residents were still being met by the service provided. During the visit two of the residents were visited by their doctor to review their care needs and observations made confirmed that the staff worked closely with health care professionals in order to ensure that the residents, needs were being met. All staff were made aware of the medication policies and procedures in the home and training was given to all care staff, this included a four day medication training course for those senior staff who administer the medication to ensure that the residents are protected and that their needs are met. Medication practices observed were safe and good records had been maintained. Elmsdene Care Home DS0000065303.V345150.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): 12,13,14,715. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The social activities and meals are both well managed, creative and provide variation and interest for people living in the home. EVIDENCE: Information recorded on each resident’s file includes their preferences, interest, social, religious and cultural needs, which is used to ensure individual needs are identified and met as far as possible. Evidence was gained that some form of activity was carried out three times per day and a list of these was seen on the notice board in the lounge area. The manager confirmed that a great deal of thought had gone into these arrangements to ensure that individual needs and abilities were catered for. This included group activities and also very individual attention. A handicraft instructor visits the home twice weekly and the results of the residents’ achievements were evident around the home. Entertainers come into the home and recently a harpist visited to provide a different type of entertainment, which information received confirmed that the residents had enjoyed. Elmsdene Care Home DS0000065303.V345150.R01.S.doc Version 5.2 Page 15 Residents also enjoy trips out and photographs were displayed of a recent visit to the zoo, which those spoken to said that they enjoyed. The manager said that some residents had indicated through discussions that they would enjoy going swimming and this was being looked into. A monthly meeting has been set up which is known as the ‘Dementia Café’ and is open to relatives, healthcare professionals and anyone who has dealings or cares for someone suffering from dementia. At each session a different topic is discussed relevant to dementia care, which helps people understand the principles and also enables the staff to work with the relatives and give them support. This was confirmed through comments made by a relative, they said,” Relatives are invited to learn more and have a better understanding of dementia and the care required” One relative who did not live close to the home confirmed that they were always made very welcome at any time they called, and they were given a lot of support. Meals are seen as a very important part of the day and care is taken to ensure that residents are provided with a varied and balanced diet. Information recorded on each resident’s file indicated his or her dietary needs and their likes and dislikes. A record is kept of all meals served. The cook stated that new monthly menus had been produced and these were being worked through to ensure that the individual needs of all the residents were met. At the time of the visit there was only one resident requiring a special diet and the cook confirmed that they had obtained appropriate recipes, some of which had come off the Interne to ensure that their needs were appropriately met. Comments made by the residents confirmed that they were satisfied with the meals provided. One resident said,“ The food is wonderful, especially my breakfast. I always have a cooked breakfast”. Observations were made of assistance being given to residents were required. Meals are taken when residents wish them and they are not rushed. Through discussions and observations evidence was gained that the practices in the home enable equality and diversity for the residents. Elmsdene Care Home DS0000065303.V345150.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 good. This judgement has been made using available evidence including a visit to this service. The arrangements in place for handling complaints ensure that people feel confident that their complaints will be listened to, taken seriously and they will be protected at all times. EVIDENCE: There is an appropriate complaints procedure in place, which is clearly written and easy to understand. This is included in the information provided to the residents, copy of which is kept in each bedroom. The homeowner confirmed that all complaints were taken seriously and acted upon promptly and they were aware of a concern that had been brought to the attention of the Commission for Social Care (CSCI). This was discussed with the management team and from the explanation received evidence was gained to confirm that this matter had been dealt satisfactorily. Residents spoken to were confident that they could speak to anyone in the home if they had a problem. Through discussions evidence was gained that the staff have a good understanding of the procedures to be followed in the event of any allegation or suspicion of abuse or neglect. Elmsdene Care Home DS0000065303.V345150.R01.S.doc Version 5.2 Page 17 The homeowner confirmed that two of the management team had attended a course on ‘Time for Action on Elder Abuse’ and they intended to access further training, that was being provided by the local authority in relation to Safe Guarding Adults, to ensure that staff continue to update their knowledge for the protection of the residents. Elmsdene Care Home DS0000065303.V345150.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 7 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a planned maintenance and renewal programme for the redecoration and refurbishment of the home to ensure that residents live in a comfortable, homely, clean and safe environment. EVIDENCE: The home has been well maintained and decorated for the comfort of the residents. Since the last visit there have been many improvements made throughout the home The homeowner stated that research found that visual perception was important in caring for persons with dementia and to this aim the furnishings and decoration throughout the home played a great part. Lightwood flooring in the main communal areas and downstairs corridors had replaced the patterned carpets, dark furniture had been replaced with lighter coloured furniture and decorations throughout were being changed. Doors were also in Elmsdene Care Home DS0000065303.V345150.R01.S.doc Version 5.2 Page 19 the process of being colour co-ordinated, which again was felt to be benefit for persons with dementia in relation to finding their way around. Chairs had been replaced and settees provide to give residents a greater range of the type of setting available to them. The residents spoken to say that they were very happy with the improvements being made. A tour of the building confirmed that residents’ bedrooms had been personalised with their own belongings. Future plans for the home include an extension to provide additional space in which activities can be undertaken without impinging the daily lives of others in the home. Also proposed for the future is a sensory and memory garden for residents to enjoy. The home was found to be clean and hygienic ensuring a pleasant environment in which to live Elmsdene Care Home DS0000065303.V345150.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. The recruitment procedures and training provided for staff ensure that the residents are protected and cared for by staff who are competent and qualified to undertake their role. EVIDENCE: Staffing levels were sufficient to meet the needs of the residents living at the home. The records of two staff members were looked at in detail and were found to contain all the documentation to confirm that the correct recruitment procedures had taken place to ensure that residents were protected. Comments received through questionnaires also confirmed that the staff had undergone a formal recruitment and induction procedure. The staff spoken to during the visit were able to demonstrate their commitment to provide the residents with a quality service that met their individual and group needs. Staff said that they were clear about their role and worked well as a team to ensure the individual and collective needs of the residents were met. Records showed that over 50 of staff had achieved a National Vocational Qualification and many were working towards the next level of NVQ training, ensuring that the residents were being looked after by a well trained and competent staff team. Elmsdene Care Home DS0000065303.V345150.R01.S.doc Version 5.2 Page 21 Discussions with staff and examination of records confirmed that training had been provided to ensure that staff had a clear understanding of the specific care needs of the residents accommodated. They all receive training in the research based dementia care and are encouraged to update their knowledge and skills to ensure that residents receive the correct care to meet their needs. The senior care staff are all to work towards obtaining level 4 NVQ to ensure that they have an understanding of the responsibilities of management and that residents are cared for at all times by a staff group who are capable to meet their needs. Staff spoken to said that they felt supported and included in all aspects of the residents care. Comments included, “The manager worked along side me during my induction which was very helpful and will often make suggestions when needed”. “ Our care home is very good, all the staff work together as a team and I enjoy my job”. Comments received residents and a relative indicated that the staff were always cheerful and helpful. Elmsdene Care Home DS0000065303.V345150.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): 31,33, 35 &38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and run in the best interests of the residents. EVIDENCE: The registered manager, who has worked in the home for a number of years as a senior care assistant, has only been in her present post for approximately four months and has proved to be very competent and able to undertake her role to a high degree. The manager is presently undertaking level 4 NVQ training and has enrolled to begin a management qualification. The homeowner is a qualified nurse who is very experienced in the care of the elderly and who works along side the manager to provide a professional management team. Elmsdene Care Home DS0000065303.V345150.R01.S.doc Version 5.2 Page 23 The homeowner has undertaken training in London through the Alzheimer’s Society, which as previously stated looks at the research undertaken in the care of dementia. The homeowner is also undertaking a professional counselling course, which she feels will further benefit the residents and their families in the support offered. Prior to the visit the management team completed the AQAA (Annual Quality Assurance Assessment) in a very detailed and professional manner, which clearly showed what they did well and how they felt that they could improve the service for the benefit of the residents. There was a clear understanding of the principles of equality and diversity and that residents should receive equal treatment and access the same resources without favouritism or discrimination. Quality assurance systems were in place to gather the views of residents and visitors. These included three monthly audits with the families to ensure that the residents’ needs continue to be met. Regular staff and residents meetings are held to discuss issues that affect everyone in the home and staff confirmed that they are listened to and action taken if required. A system of benchmarking was being introduced, which involves meetings with the senior care staff to identify issues that will improve the service provided for the residents and how these will be achieved. The manager confirmed that all relatives are made aware that she will make herself available for them every Tuesday if they want to discuss anything. The manager said that this did not prevent relatives and others from contact with the management team at other times, but provided relatives with the opportunity to have quality contact time if required. Information was provided that confirmed that all safety equipment was regularly service. The policies and procedures in the home ensure that the health, safety and welfare of the residents and staff are promoted and protected. Elmsdene Care Home DS0000065303.V345150.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 x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 4 x 3 x x 3 Elmsdene Care Home DS0000065303.V345150.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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP31 Good Practice Recommendations The registered manager should obtain the required management and care qualifications to ensure that the care practices in the home continue to meet the needs of the residents. Elmsdene Care Home DS0000065303.V345150.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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 Elmsdene Care Home DS0000065303.V345150.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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