Inspection on 16/05/06 for Elmstead

This inspection was carried out on 16th May 2006.

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

Elmstead 09/05/07

Elmstead 08/11/05

Elmstead 24/05/05

Elmstead 18/01/05

Elmstead 27/09/04

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 Elmstead Elmstead 104 Elmstead Lane Chislehurst Kent BR7 5EL Lead Inspector Sue Meaker Key Unannounced Inspection 02.00 16th May 2006 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 Elmstead DS0000006930.V289480.R01.S.doc Version 5.1 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. Elmstead DS0000006930.V289480.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Elmstead Address Elmstead 104 Elmstead Lane Chislehurst Kent BR7 5EL 020 8467 0007 020 8295 3133 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) www.bupa.co.uk BUPA Care Homes (CFCHomes) Limited ** Post Vacant *** Care Home 49 Category(ies) of Dementia (14), Learning disability over 65 years registration, with number of age (1), Old age, not falling within any other of places category (34) Elmstead DS0000006930.V289480.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Service User category LD(E) relates to a named service user. The category to be reviewed if the service user leaves the home. 8th November 2005 Date of last inspection Brief Description of the Service: Elmstead is a care home operated by BUPA, and caters for thirty-four elderly frail people and fifteen elderly people with Dementia. The care home is located in Chislehurst, Kent within the London Borough of Bromley. The home is a large three storey detached building situated on a busy thoroughfare in a residential area. There is limited off road parking to the front of the building, and a pleasant secluded garden to the rear of the building with a patio and seating areas. The home offers accommodation to a total of forty-nine residents in single rooms. Nine of the bedrooms in the home have en suite facilities while the rest have wash hand basins and access to toilet facilities and bathrooms within the home; bedrooms are well decorated and furnished to a high standard; as are the communal areas of the home. Bedrooms, bathrooms and toilets are fitted with locks to ensure privacy; however rooms can be accessed by staff in the event of an emergency. All communal areas, within the home, are well maintained and provide pleasant seating areas that are easily accessed by the residents and their visitors; a passenger lift gives residents access to the first floor of the home. Bathrooms and toilets benefit from specialist moving and lifting aids such as hoists and parker baths. Residents have access to a telephone and are able to make calls when they wish; there is also provision for residents to have a telephone in their own room at their own expense. Elmstead DS0000006930.V289480.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over one and a half days; six residents on the residential unit and four residents on the dementia unit were spoken to; as were four relatives who were visiting the home at the time of the inspection. Two comment cards from relatives were received and a comment card from one of the homes’ GP. A care manager from a London Borough also commented on the service provided by the home. Discussions were held with the management team, a care manager of the residential unit, the chef manager, two senior carers and two carers. Unfortunately the pre-inspection questionnaire sent to the home was not completed in time for inclusion in this report. The site inspection included a tour of the home and inspecting care plans, medication charts, health and safety records, the activities programme, the homes’ menu and the staff training records. What the service does well: It was evident from speaking to service users, their relatives and a care manager reviewing a service user on the dementia unit that the home offers a good quality of care; that the staff are committed to meeting the assessed personal, health and social care needs of the service users resident in the home. The home has good care plans individualised to the service user, the files also contained relevant risk assessments and information about the service users medical conditions and how to address these, in some cases, complex needs. The daily evaluation sheets were well documented and gave a clear picture of the daily life of the service user addressing their specific identified needs enabling them to enjoy a good quality of life in the home. Two service users spoken to stated how good the food was and that the chef took time to visit them to ask what they would like to eat and any suggestions they may have to the menu. The staff had empathy with their service users and were very good at promoting the independence of the service users in their care respecting their right to choose how they live their life in the home. Staff felt supported and encouraged by the management of the home; they felt that the recruitment processes were good and that they were offered training courses pertinent to their job, particularly the induction training and training around dementia and challenging behaviour. Elmstead DS0000006930.V289480.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? 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. Elmstead DS0000006930.V289480.R01.S.doc Version 5.1 Page 7 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 Elmstead DS0000006930.V289480.R01.S.doc Version 5.1 Page 8 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 at least once during a 12 month period. 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 needs of service user are competently assessed to ensure that the home is able to meet the personal, health and social care needs of the individual. EVIDENCE: Service users are usually referred to the home via Local Authority Social Services Departments, although some relatives do contact the home in a private capacity when looking for suitable accommodation for an elderly relative. When the referral is from Social services an assessment of need has already been undertaken by a care manager, the information is them passed to the home to see if the home is able to meet the service users needs specified in the plan of care. The home manager then makes arrangements to undertake a pre admission assessment; the care manager and the family of the service user are contacted and a suitable location, date and time are arranged. After the pre admission assessment has been completed; the service user is given a Elmstead DS0000006930.V289480.R01.S.doc Version 5.1 Page 9 copy of the homes’ Statement of Purpose and Service User Guide giving information of the services the home provides enabling them the make an informed choice about whether the home is able to meet their assessed personal, health and social needs. The prospective service user and their family are invited to spend time at the home, to meet other service users and the management and staff, have a meal, tour the home and ascertain the facilities available to them. A trial period is then arranged for the service user and their family a review is held and the placement is made permanent if all\ parties are in agreement. Service users and relatives spoken to at the time of the inspection confirmed that they were very much involved in the assessment process; one service user, who had recently come into the home, said that she had come to the home from the local hospital, stated that she had visited the home to look around and that she had received lots of information and had been consulted about her likes and dislikes and what she liked to do, she said that she found the staff very supportive and responsive to her needs; she had recently moved to a larger room so that she is able to have more of her own furniture in her room; this is currently being sorted out by the home in conjunction with the service user and her advocate. Please note that Standard Six is not applicable to this home. Elmstead DS0000006930.V289480.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Care plans reflect the personal, health and social needs of the service user, information is agreed with the service user and their relatives and advocates; enabling staff to deliver care as specified respecting the service users rights relating to choice, dignity and privacy. . EVIDENCE: Care plans were looked at in detail, six care plans from the residential units and four care plans from the dementia units. The care plans have a generic format but are personalised to the individual service user. Care plans are related to Maslows Theory of Need and Basoll – the behavioural assessment scale of later life. One care plan looked at confirmed a conversation with the service user; care plans specific to this service user gave information on how the medical needs identified were to be met, it was evident that the service user and his family were involved in the care planning process. Another care plan looked at Elmstead DS0000006930.V289480.R01.S.doc Version 5.1 Page 11 related to the poor mobility of the service user, there was evidence that this issue had been discussed with the service user and family, the information on the care plan reflected procedures put in place to minimise risks. It was evident from looking at the care plans and talking to residents, relatives and staff that care plans are reviewed on a monthly basis and that all parties are invited to contribute to this process; any changes agreed are implemented and monitored. All the service users are registered with a GP of their choice and this information is recorded on the individual care plan; the home is able to access additional services via the Primary Care Trust. The home maintains contacts with opticians, dentists, podiatrists, district nurses, community psychiatrists and dieticians. It was evident from the care plans seen relating to specific health care needs of service users gave information enabling the staff to meet these needs. The home has robust policies and procedures relating to the safe administration of medication; currently there are no service users in the home who have their own medication. Medication comes into the home via prescription from the GP, medication is ordered from the pharmacy on a monthly basis and administered via a Nomad System (Monitored Dosage System). All service users have a Medication Administration record, identified with a photograph; the trained staff record medication given or refused on the MAR form. Staff responsible for the administration of medication receive training, training records seen confirmed that this training had taken place. The training Co-Ordinator in the home confirmed that further medication had been requested for staff and that dates were being arranged. Whilst visiting the home it was noted that the staff observed, spoke respectfully to the residents encouraging and supporting them in personal activities; service users spoken to said that they were well looked after and that they felt comfortable in the home and that the staff were good to them and that they felt well cared for in the home. Relatives spoken at the time of the inspection said that the care in the home was good and that staff seemed to have empathy with the service users in their care. Elmstead DS0000006930.V289480.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service The home endeavours to provide appropriate activities to the service users, supporting and encouraging them to maintain their chosen lifestyle in a residential care home environment. EVIDENCE: Since the last inspection in November 2005; the home has recruited an Activities Co-ordinator this is a full time post of thirty-five hours per week. The home now has a structured activities programme tailored to suit the needs of the service users. However relatives spoken to felt that there was not enough going on in the home, but did say that they were hoping that more would be happening in the near future; there had been a very successful outing to Wisley Gardens in April 2006. twenty-five service users in wheelchairs went on the trip with their relatives and members of the management and staff team of the home. All who took part thoroughly enjoyed this outing, they are now looking forward to a trip into the Kent countryside and hopefully a trip to the seaside. The home is in the process of setting up a social committee to organise outings and events, hoping that service users their families and friends and staff will all be involved. The home has converted one of the quiet Elmstead DS0000006930.V289480.R01.S.doc Version 5.1 Page 13 areas in the home to a “Pub”, with the help of staff and relatives this area has been themed so that service users can go to the pub a range of activities are on offer including pub games and sing a longs. The home is also in the process of turning another area on the ground floor into a café, so that service users can experience “going out” to the café for tea and cakes with their relatives and friends. The home is to be congratulated on implementing these very good ideas and the service users will benefit from having these social areas to enjoy. During the visit to the home there were a number of relatives and friends visiting their relatives, affording opportunity to chat to them and obtain their views about the home, everyone spoken to was very positive about the standard of care offered in the home and the way in which the home was making an effort to provide activities, events and outings for the service users. They said that they felt welcome and that the management and staff were on hand to discuss any queries or concerns, and that issues were dealt with quickly and sensitively. Service users are supported and encouraged to maintain their links with the local community and to avail themselves of facilities within the vicinity of the home; staff accompany service users to the local shops, the post office, the bank, the library and the chemist all of which are within easy reach of the home. The home is also on a bus route enabling service users, if they wish, to go to the shopping centre, the theatre, restaurants and leisure centres within the London Borough of Bromley. Lunch was being served on the second day of the inspection; the food was well presented, looked appetizing and nutritious in content. Some service users needed help from staff in eating their meal and it was noted that they were being assisted unobtrusively by staff; this was being done in a sensitive manner and the service users, particularly on the dementia unit seemed to be appreciative of the help they were being given. Service users said that they enjoyed the food and that there was plenty of it and that they could choose alternatives if they wished. The chef manager explained that he varied the menu particularly summer and winter thereby taking advantage of food in season; and that he was aware of healthy eating and the menu seen reflected this concept. The kitchen has a Clean Food Award from London Borough of Bromley Environmental Health. Elmstead DS0000006930.V289480.R01.S.doc Version 5.1 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has policies and procedures relating to the complaints and the Protection of Vulnerable Adults; staff undertake training appertaining to these issues; thus ensuring that the service users feel safe and protected within the home. EVIDENCE: The home has a complaints policy and procedure that complies with the National Minimum Standards; this document forms part of the homes’ Statement of Purpose; and is included in the Service User Guide given to every service user in the home. The complaints policy and procedure is also displayed in all communal areas throughout the home. The home maintains a complaints log; complaints are initially investigated by the home manager and the outcome communicated to the complainant. Residents and relatives confirmed either at the time of the inspection and by returning their comment cards that they aware of how to make a complaint; however they did say that if they have any issues they bring them to the attention of the home management and they are dealt with efficiently and effectively. The home has a robust policy and procedure relating to the Protection of Vulnerable Adults; in conjunction with the Local Authority Guidelines; both these documents are available to staff and staff also confirmed that they have completed training courses about these issues. Elmstead DS0000006930.V289480.R01.S.doc Version 5.1 Page 15 Staff interviewed during the inspection showed an understanding of how an allegation of abuse is taken forward using the homes’ policy and procedure and the London Borough of Bromley Guidelines; they were also aware of how to instigate the “Whistle-blowing” policy and procedure. . Elmstead DS0000006930.V289480.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The home provides a safe, clean, comfortable and well-maintained environment for service users enabling them to enjoy their preferred lifestyle. EVIDENCE: Generally the home is in a good state of repair; the home employs a full time maintenance person who is responsible for the day to day routine maintenance of the home; areas in need of redecoration are identified by the maintenance person in discussion with the home manager and the estates manager. The home has a budget for redecoration and refurbishment and there is an annual maintenance plan in place. It was evident from touring the home at this inspection, that a lot of work has been put into improving the decoration in service users bedrooms, bathrooms and communal areas; furniture and carpets have been replaced and the home has a homely, comfortable feel to it; the “pub” area has been well thought out and the decoration in keeping with Elmstead DS0000006930.V289480.R01.S.doc Version 5.1 Page 17 the theme. Plans for the “café” are ongoing and should be implemented very soon. The housekeeper and her team are to be commended for keeping the home clean and tidy and free from unpleasant odours. It was evident from observing and talking to the domestic staff that they are aware of COSHH regulations and infection control. Elmstead DS0000006930.V289480.R01.S.doc Version 5.1 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The management of the home ensures that staff team are able to meet the personal, health and social needs of the service users; this is achieved by implementing the organisations stringent recruitment and selection policies and procedures and implementing a good induction training programme complemented by additional training to update staffs skills. EVIDENCE: Rotas were looked at to ascertain that there were sufficient staff on duty, with the necessary skills to meet the personal, health and social care needs of the service users; from the rotas seen this was the case, the rotas were well thought out and looked to reflect the needs of the service users making sure that the number of staff on duty at any time of the day were sufficient in number and that they had completed appropriate training enabling them to meet the assessed needs of the service users in their care. The organisation has policies and procedures around the recruitment and selection; these policies and procedures incorporate the organisations disciplinary and grievance procedures; staff spoken to were aware of their employment rights and how to implement these procedures if it became necessary. All staff spoken to confirmed that they had been CRB checked and that they were aware of the POVA register. Elmstead DS0000006930.V289480.R01.S.doc Version 5.1 Page 19 A number of staff were spoken, one had recently been recruited to the home, to and confirmed that the recruitment process was thorough and that the questions asked at interview properly reflected the work they were required to undertake; staff also stated that they completed the induction period with a mentor, and that they had mandatory training in moving and handling, health and safety, food hygiene and fire training. The training Co-ordinator was interviewed during the inspection and was able to demonstrate that training needs were identified and appropriate training courses accessed for staff; this included all the induction training, mandatory training and the availability of NVQ 2 and NVQ 3 training. All members of staff have a personal training record that is updated by the training Co-ordinator on a regular basis. Staff confirmed that they are kept fully informed about training courses offered by the organisation and are encouraged to put their names forward. These courses include understanding dementia, challenging behaviour, medication, health and safety, infection control, nutrition and COSHH. The home has a stable staff team who appear to work together well, supporting and encouraging each other in the work they do, the home has regular staff meetings and team meetings where they are able to voice any concerns they have about the home and the service provided. Elmstead DS0000006930.V289480.R01.S.doc Version 5.1 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Although the home has a temporary effective and efficient management structure in place, this situation needs to be reviewed and formalised. The home has effective and efficient financial, administrative and health and safety systems in place ensuring the stability of the home and safety of the service users, their relatives and staff. EVIDENCE: The issue of the Registered Manager of this home is still not resolved satisfactorily; it is understood that the Registered Manager of the home is on long term sick leave and has been for nearly two years. During this time the home has been managed by the Operations Manager assisted by a deputy manager this management structure is still under review and needs to be Elmstead DS0000006930.V289480.R01.S.doc Version 5.1 Page 21 regularised. The organisation must appoint a permanent manager to the home and subsequently apply to the commission for the appointed manager to be registered and the registration certificate to reflect the new structure. The Registered Manager must also undertake the Registered Managers Award and complete as soon as possible; and notify the Commission of a start date and a completion date. Two requirements have been made relating to this issue. The present management team facilitated the inspection and adequately demonstrated that they had the skills and experience to deliver a good quality service. Service users and relatives confirmed that the management and staff of the home were always ready to listen to any concerns they had and that these concerns were dealt with effectively and efficiently. From records seen it was evident that the home holds regular staff and team meetings; and staff confirmed that they now receive regular supervision and that they have an annual appraisal. The Commission has a copy of the homes’ business and financial plan for the coming year that show that the home is financially viable; budgets are allocated by the organisation and managed by the home manager and appropriate records are kept. The Commission has a copy of the resident/relatives questionnaire sent out by the home; also the management team undertakes monthly regulation 26 inspections of the home and sends a copy to the Commission; these documents form part of the quality assurance processes implemented by the home to monitor the quality of care delivered to the service users. Health and Safety certificates were inspected and copies taken, these documents complied with relevant current legislation detailed in the Care Homes Regulations – National Minimum Standards. Currently there has been no change to the organisations policy and procedures relating to the safekeeping of the service users personal allowance; in most instances their relatives have taken responsibility for managing their personal allowance. All personal allowances administered by the home are kept in one account; however individuals are able to access a personal statement of monies held, all transaction are recorded on the computer system and receipted. Elmstead DS0000006930.V289480.R01.S.doc Version 5.1 Page 22 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 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 3 X 3 X X 3 Elmstead DS0000006930.V289480.R01.S.doc Version 5.1 Page 23 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 2 Standard OP31 OP31 Regulation 8 8 Requirement The Registered Person must ensure that the home has a Registered Manager in post. The Registered Person must ensure that the Appointed Manager undertakes the Registered Managers Award and advise the Commission of the start date and the envisaged completion date. Timescale for action 31/07/06 31/07/06 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 Elmstead DS0000006930.V289480.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: 0845 015 0120 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 Elmstead DS0000006930.V289480.R01.S.doc Version 5.1 Page 25 - 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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