Inspection on 02/05/07 for Emmaus House

This inspection was carried out on 2nd May 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

Emmaus House 12/01/06

Emmaus House 20/07/05

Emmaus House 01/12/04

Emmaus House 01/07/04

Emmaus House 01/03/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Emmaus House Walkmill Close Moresby Parks Whitehaven Cumbria CA28 8XR Lead Inspector Nancy Saich Unannounced Inspection 2nd May 2007 08:30 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 Emmaus House DS0000022550.V335508.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. Emmaus House DS0000022550.V335508.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Emmaus House Address Walkmill Close Moresby Parks Whitehaven Cumbria CA28 8XR 01946 591362 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) office@emmaustrust.co.uk Cumbria Emmaus Trust Mrs Patricia Margaret Davies Care Home 24 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (22) of places Emmaus House DS0000022550.V335508.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 24 service users to include: up to 24 service users in the category of OP ( Old age, not falling within any other category) up to 2 service users in the category of DE(E) (Dementia over 65 years of age) The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 12th January 2006 2. Date of last inspection Brief Description of the Service: Emmaus House is a purpose built home that caters for up to twenty-four older people, two of whom may have dementia. The home is owned and operated by the Emmaus Trust, a charitable organisation set up by the Christian Brethren Church. Some, but not all residents are members of this church. Mrs Patricia Davies manages the home. The home is in a residential area of Moresby, a village approximately three miles from Whitehaven, and is within walking distance of village amenities. The home has its own grounds and car parking. The weekly charge ranges from £373 to £434 per week depending on care needs. More information about the home and the cost of staying there is available from the manager or the chairperson of the trust. Emmaus House DS0000022550.V335508.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the main or ‘key’ inspection for Emmaus House. The lead inspector sent out surveys asking for opinions about the care and services provided to residents, relatives, doctors and social workers. She received a high volume of responses and all of them were extremely positive. There are a number of quotes in this report that come directly from these surveys. The inspector also asked the manager of the home to send her various pieces of information and this was done promptly and in depth. This organisation sends two reports every month to the inspector – one from the manager and one from the chairperson of the trust. These are very helpful in that the inspector can see that this is a service that believes in continuous improvement and investment in the entire operation. They also send information about quality monitoring when they have completed the reports – showing that they believe in improving quality all the time not just when they are due to be inspected. The inspector also visited the home unannounced, spent time with residents and spoke to the manager and the staff team. She walked around the building, made general observations about how staff cared for the residents, shared a meal with them and also read files and documents that backed up what was said and what she saw. This home provides an excellent service to the older people who have chosen to make it their home for life. As one residents said: • ‘This is an excellent home and I cannot fault it. It is very seldom that I am unhappy’. What the service does well: The home is good at making sure they give prospective residents information about the service: • ‘I had information before coming to Emmaus on what it was like, I was pleased it was a Christian home…’ • ‘We [the family] were given lots of information and shown around…’ and they visit the new person to make sure they can care for them properly. This home gives very high standards of personal and health care. On the day of the visit everyone was well groomed and most people looked in good health. Emmaus House DS0000022550.V335508.R01.S.doc Version 5.2 Page 6 One or two frailer people were receiving very attentive and sensitive care from the staff team. The written care plans and daily notes showed that the team are very good at delivering care that is targeted to individual needs. The inspector also checked medication and this was well organised. Residents were very satisfied with the level of care – and also with the approach of the management and the staff. These are some of the general things that residents say about the experience of living at Emmaus House: • • • ‘Excellent home, everyone friendly and helpful’ ‘Everyone has been helpful and co-operative’ ‘I am quite happy and content with my life at Emmaus House’ and these are examples of what families and residents together said in surveys: • ‘As should be evident from all my comments we are very happy …and my relative although delicate from ill health absolutely agrees…’ • ‘My mother feels and knows that she is well taken care of and that all the staff – managers, carers, kitchen staff and cleaners are all caring and very conscientious…’ ‘My mother is a frail old lady and every care is given to her. We have no concerns…she is well cared for…’. ‘As far as we are concerned everything possible is done to make my mothers life manageable…’ ‘Care has been excellent during a recent illness…given they are a care home (not a nursing home) the medical support has been excellent…’. ‘Medical attention is always called when necessary.’ ‘My mother receives an exceptionally high level of care and support…’ ‘They are good at engendering a community spirit’. • • • • • • The residents were also very happy with the activities on offer and on how they are allowed to choose the kind of lifestyle they prefer. There are a number of devotional activities on offer but residents also enjoy trips out, crafts and entertainments. This home also respects and values different ways of worship and clergy from different churches are made very welcome in the home. Everyone was very complimentary about the catering: Emmaus House DS0000022550.V335508.R01.S.doc Version 5.2 Page 7 • ‘The food is always nourishing and of excellent quality…my relative is provided with a suitable diet and always given support to eat at mealtimes…’ ‘Plenty to eat.’ ‘The meals are appetising, varied and well presented…’ ‘Food is prepared and served with care…’. • • • The inspector shared a very nice lunch with residents and this was a very positive experience. Each day one of the residents says grace before meals and this is away for residents to play a part in the daily spiritual life of the home. All the surveys showed that residents and their relatives knew exactly what to do if they had a concern or a complaint. However no one had ever felt they needed to complain. There has never been a formal complaint in this home. Residents also said there was nothing abusive or unpleasant happening in the home and they knew how to contact outside agencies if something was to happen. Staff were well aware of how to protect vulnerable people from abuse. The home is modern and purpose built and over the last ten years the Trust have continued to improve the building. The home was warm, welcoming, clean and tidy. This is what the residents said • • • • • ‘The cleanliness and friendliness of the home are outstanding…’ ‘Very high standards in all departments.’ ‘I don’t think anything needs improved at present.’ ‘Everything is spotless…’ ‘Excellent standards of hygiene, both in private and public areas…’ The inspector walked around the home and everywhere was just as residents described. She also went into areas like the kitchen and laundry and they too were clean and tidy. The inspector checked the rosters and the training and recruitment of staff. These were all of a very good standard. She also spoke to staff and found them to be caring, sensitive and very dedicated. This is what the surveys said about the staff in the home: • • • ‘ Only got to ask and you get what you need…always willing to phone or write for you…. always got time for you and make you feel special…’ ‘The staff are always willing to learn something new…’ ‘They look after all the people’s different needs well. They treat each person very specially and support each person in their care…they are very professional’ DS0000022550.V335508.R01.S.doc Version 5.2 Page 8 Emmaus House • • • • • • • • • ‘They address everyone’s different and special needs with care and consideration…’ ‘If any of the staff wish to discuss something it is always done in private…’ ‘They look after spiritual and physical needs in an excellent way…’ ‘Managers and carers give excellent support and are prepared to listen…any likes and dislikes are attended to…’ ‘Dedicated carers…’ ‘The staff respond well to the call bell…’ ‘We have frequent discussions with staff and they are very responsive to mother’s needs and wishes…’ ‘Always available when I want them…’ ‘The staff who care for my mother are exceptional – patient, efficient – carers in the true sense of the word…’ The manager is a person of maturity and skill and has worked on the already good systems to improve and refine them. All management tasks were checked on and all were up to date and efficient. The inspector saw records of resident money, fire safety and food hygiene. She also had the very helpful monthly reports that the Trust and the manager send her. These and the quality reviews the Trust complete show that this is a home that is truly dedicated to giving the best quality care and services they can. The members of the Trust are regular visitors – they take the lead in care matters from their manager but all of them are very committed to running an excellent home. They are all accessible for residents – especially the chairman. Residents said they were asked about the service by the members and several people said • ‘Most days the chairman of the trust visits and sees the residents’ and they all appreciate this. Residents said that the Christian principles of the trust could be seen in the work of the home and its committee. The inspector judged that this was a true reflection of a service whose ideals and practices give residents the best life they can. Emmaus House DS0000022550.V335508.R01.S.doc Version 5.2 Page 9 What has improved since the last inspection? The manager and her team have worked very hard to amend and improve everyone’s written plan that helps staff understand and follow the wishes of the residents. Every plan the inspector saw was detailed and up to date. The manager has further plans in mind to improve the way that care is planned and delivered. As one relative said: • ‘She is making sure that each person is cared for individually’. The manager has also extended the activities on offer. There is now a monthly trip out. Residents had just been on a shopping trip and enjoyed buying their own clothing from a local department store. They also go on cultural trips and visit places of interest. The home has volunteers who help with activities and a member of staff who takes a lead on activities in the home. Residents said they enjoyed a wide range of activities from crafts to discussion groups. A member of staff has started a shop in the home and residents enjoy being able to buy a range of small things like cards or batteries or sweets. One person was writing a card that she had bought from the shop and she said it made her a little more independent and gave her a bit more choice. There has been an extension built to the home. This has provided two improved bedrooms that are large enough to accommodate people who have physical disabilities. A new walk in shower has also been provided with residents’ comfort in mind and a lovely new hairdressing salon that someone said was ‘luxury’. There is a new office and a new meeting room that have improved facilities for the staff team. Staff were also happy with the new spacious laundry that makes their work easier for them. What they could do better: There was nothing noticed during this inspection that caused the inspector any concern. Please contact the provider for advice of actions taken in response to this Emmaus House DS0000022550.V335508.R01.S.doc Version 5.2 Page 10 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. Emmaus House DS0000022550.V335508.R01.S.doc Version 5.2 Page 11 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 Emmaus House DS0000022550.V335508.R01.S.doc Version 5.2 Page 12 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. Emmaus House is careful to only admit new people who they can care for and who will fit into the existing group of people. EVIDENCE: The survey responses explained how people had made the decision to come to the home. During the visit the inspector met a number of people who talked about how they came to the home. They said that they were given plenty of information and had been visited by the manager before they made a decision. They had all been able to visit before they moved in. The manager discussed how she went about admitting new residents. The inspector saw notes about admissions that the manager had written. She also saw social work and health assessments. These were all of a good standard. Emmaus House DS0000022550.V335508.R01.S.doc Version 5.2 Page 13 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. The residents felt that their personal and health care needs were met in an excellent way and this helped them to be as well and as happy as possible. EVIDENCE: The inspector read a selection of care plans. She judged that they were detailed and up to date. She could see that a lot of progress had been made in writing these plans that help residents tell staff what they need and want. The manager discussed ways she was planning to make them even better and easier for staff to use. A problem with daily notes was dealt with during the visit and the manager agreed to change the systems slightly to make things clearer for staff. Residents were aware of their care plans and felt that they were working well. One survey said: Emmaus House DS0000022550.V335508.R01.S.doc Version 5.2 Page 14 • ‘The care plan was completed upon moving in and is regularly amended as my relatives needs are changing…’ The surveys also showed that residents get good health care. On the day of the visit the residents spoke about the support they got. Local G.Ps and nurses have positive things to say about the way care is delivered. The inspector checked on medication kept on behalf of residents. This was all in order. The residents had nothing but praise for management and staff and the surveys were very positive. The inspector spoke to staff and also just watched them as they went about their work. They were polite, positive and very sensitive to residents needs. People were treated with dignity and patience, kindness and affection. Emmaus House DS0000022550.V335508.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents in this home have varied and suitable opportunities to live life to the full. EVIDENCE: The inspection started around 8.20 a.m and some people were sitting at the breakfast table reading the local newspaper. Other people were still in bed or having breakfast in their rooms. Residents said they got up and went to bed when they chose. They also said they could choose how they lived their lives and were never forced to do anything they didn’t want to. There are no restrictions on people. One person said to the inspector: • ‘I am never in – I have such a good social life…’. They all said they had visitors whenever they wanted. The inspector met a number of friends and relatives on the day. One of them said he had enjoyed sharing a meal with his mother the day before. The surveys showed that family and friends were all made very welcome and given a lot of support. One relative said: Emmaus House DS0000022550.V335508.R01.S.doc Version 5.2 Page 16 • ‘Staff are superb at providing me with emotional support.’ This home provides a range of activities for residents. They said they don’t have to join in but are encouraged to participate. This is a Christian home so some of the activities are devotional. There are twice weekly services and residents go out to services and if possible they go to the annual Keswick Christian convention. They do however have other activities such as quizzes, handicrafts, baking sessions and flower arranging. There are some activities that are about how people look and feel. Residents enjoy foot spa and manicures, hairdresser visits and buying clothes from a mobile shop or during shopping trips. The home tries to arrange shopping trips and often go out to places of interest or to have coffee or afternoon tea. They also go to concerts and musicals at local theatres. The day before the inspection around twenty of the residents had gone to Workington to shop and ‘have a nice spend up’ as one person said. A number of people told the inspector how much they had enjoyed buying their own clothes when they went to a department store. The inspector was around during breakfast and lunch – and enjoyed a nicely prepared meal with the residents. Everyone ate very well and a lot of people felt that the meals helped them to stay well. Staff helped people in a sensitive way if they needed some support. The menus and food hygiene were of a very high standard. Residents’ surveys were extremely positive about the food provided. Emmaus House DS0000022550.V335508.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This home is good at listening to residents, protecting them and taking the right kind of action to prevent anything going seriously wrong. EVIDENCE: Neither the home, nor the Trust have received any complaints since the home opened. The inspector has had no concerns or complaints sent to her. Residents said they knew how to complain but never felt the need to as any issues were always dealt with quickly to their satisfaction. Residents and staff were asked about protection of vulnerable people. Everyone said that there was nothing abusive going on in the home and that if there were they would know who to go to. Residents said they would go to the manager or the chairman of the trust if anything concerned them. Staff would also take this route but they also said they would contact outside agencies if they had to. Emmaus House DS0000022550.V335508.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): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. This is a home that is easy for frail older people to live in but has a homely and comfortable feel to it and this creates a safe and relaxed environment for everyone. EVIDENCE: The inspector walked around the building and spoke to residents and staff about the environment. She saw the new extention to the building that has refurbished two bedrooms, created a new office, meeting room,hairdressing salon, shower room and laundry. Residents said the home was always clean and comfortable and that their clothes and bed linens were kept fresh and clean. The inspector saw for herself that what they said was true. This home is well decorated and comfortable for the residents. Everyone seemed very relaxed in his or her own rooms and in the large lounge-dining area Emmaus House DS0000022550.V335508.R01.S.doc Version 5.2 Page 19 This home provides accommodation in single rooms with ensuite toilet and wash hand basin. The two new bedrooms provide plenty of space for people with a physical disability. Staff appreciated the new laundry, meeting room and office and felt that these changes made their job easier. The home has pleasant gardens for residents and plenty of parking for visitors. Everywhere – both inside and out – was well cared for and comfortable. Emmaus House DS0000022550.V335508.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): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. This home has a well-trained, highly motivated and very capable staff group who have residents care at the heart of everything they do. EVIDENCE: The manager sent the inspector copies of the rosters for the staff team. Normally there are four carers in the morning, three in the afternoon and evening and two people awake at night. There are also housekeeping and catering staff who keep things running smoothly. If the home is very busy extra staff are provided. The home has a team of volunteers who organise activities in the home. This is a very settled team and no one has left since the last inspection. Over 82 of the carers have a national Vocational Qualification in Care. All the care staff have first aid certificates. The inspector saw evidence to show that staff had received extensive training since the last inspection. Staff records show that they have had training as follows: • team building • staff appraisal • control of substances hazardous to health • fire safety training Emmaus House DS0000022550.V335508.R01.S.doc Version 5.2 Page 21 • • • • • • • • medication management/ safe handling of medication protecting vulnerable adults controlling infection moving and handling care planning caring for people with dementia health and safety looking after leg ulcers. The manager also said that there were new training courses planned for next year. Many of these are updates to knowledge and skills the team already have. The inspector noted that they are introducing a new course on Equality and Diversity. The inspector thinks that this is an indication that the manager is well ahead of trends in social care and promptly puts things in place. New starters have thorough checks to make sure they don’t have a criminal record nor have been dismissed from any other care setting and that they are the right kind of people to look after vulnerable older people – and indeed who fit into the Christian ethos of the home. Emmaus House DS0000022550.V335508.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): Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. This home is very well managed in all areas and this gives residents the confidence to feel relaxed and safe in the home. EVIDENCE: Emmaus house is run by a charitable trust. The members of the trust meet regularly to discuss how the home is operating. Different people on the committee take responsibility for different aspects of the way the home works. Every year members of the trust undertake a quality audit of the home and then hold a management review to look towards future planning. The committee deal with the business and financial planning. These reports are also sent to the inspector so she has an idea of how well things are working. Emmaus House DS0000022550.V335508.R01.S.doc Version 5.2 Page 23 The inspector judged that the registered manager and the committee ensure that the home runs smoothly and residents have a worry free life. Pat Davis has been the registered manager for just over two years and has worked with the Trust for three. She has completed her training and has a qualification in homes management at NVQ level 4. She is an experienced nurse and has made a good transition to residential care. The evidence was there to show that she can care for the whole person and has helped to maintain and enhance the social and recreational needs of residents whilst maintaining the homes reputation for excellent personal, health and spiritual care. The Trust has every confidence in her leadership and more importantly residents and their families said they trusted and respected her. She has the full backing of her staff team. The inspector checked on the maintenance records. She is updated on this on a monthly basis and judged that the home is good at routine checks, maintenance and upgrades of all the systems that keep the building safe and comfortable to live in. Things like checks on the water, the gas and electricity and all of the machinery and equipment were up to date and met the legal requirements. Fire safety and food hygiene were up to date and checked through the quality assurance system. There were extensive policies and procedures in the home. The trust was updating some as part of their ongoing quality monitoring. Generally everything in the home was running smoothly and efficiently. Emmaus House DS0000022550.V335508.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 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 4 3 X X 4 Emmaus House DS0000022550.V335508.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NA 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. Refer to Standard Good Practice Recommendations Emmaus House DS0000022550.V335508.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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