Inspection on 18/10/07 for The Elms

This inspection was carried out on 18th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Elms 16/10/06

The Elms 08/02/06

The Elms 14/06/05

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Elms (The) 28 Elms Way Southbourne Bournemouth Dorset BH6 3HU Lead Inspector Maxine Martin Key Unannounced Inspection 18th October 2007 09:45 Elms (The) DS0000063293.V352790.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Elms (The) DS0000063293.V352790.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Elms (The) DS0000063293.V352790.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elms (The) Address 28 Elms Way Southbourne Bournemouth Dorset BH6 3HU 01202 431886 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) Elms Care Limited Mrs Ana Maria Greenwood Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Elms (The) DS0000063293.V352790.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th October 2006 Brief Description of the Service: The Elms is a small home set in its own mature grounds and is in keeping with all the properties in its immediate vicinity. It is situated in a quiet, residential area of Southbourne and is close to local shops and amenities. Bus routes to Bournemouth and Christchurch are easily accessed. The home is registered to accommodate a maximum of four adults of both sexes with a learning disability and had no vacancies at the time of inspection. The property has limited access to service users with physical disabilities. However, the facilities are appropriate for the intended service group, i.e. adults with learning disabilities. Three residents have single rooms on the first floor and there is a further bedroom on the ground floor. Residents share the use of an upstairs bathroom and downstairs shower room. On the ground floor there is a large lounge with a separate dining area and kitchen. The home is well kept and furnished. Outside there is a garden that provides a seating area for eating out and a storage shed. Service users are offered a wide range of opportunities both within and outside the home. Most service users attend day centres whilst one service user has a daily programme provided by the home. Current fees provided on 06/11/06 are between £850 and £1200 per week. Fees do not include personal items such as toiletries, hairdressing, cigarettes and sweets. For further information on fee levels and fair terms of contracts you are advised to referred to the Office of Fair Trading website www.oft.gov.uk. The home keeps copies of all inspection reports that are available in the office and can be seen by service users, relatives and professionals at their request. Elms (The) DS0000063293.V352790.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first Key unannounced inspection of 2007 and took place on Thursday 18th October 2007. It commenced at 09.45 and finished at 14.15; there was a break in the inspection, due to the refurbishment, so actual time was four hours. The inspector spoke with three residents and two members of staff. Mrs Ana Greenwood, registered manager and Mr David Lallana, provider were available for most of the time. The inspector would like to thank everyone involved in this inspection especially as the practicalities on the day were very difficult. The home was undergoing significant refurbishment; at the time of the inspection work personnel were in the home, and due to its size this made it more complex to undertake the inspection. However, premises were viewed, files and documentation inspected, care plans and service user records sampled, medication procedures checked. Prior to the fieldwork visit four service user, two staff, one relative and two professional feedback forms had been received. In addition the Annual Quality Assurance Assessment (AQAA) had been submitted. Evidence was taken from these and the last report to support the evidence for this inspection. For the purposes of this report the term service user and individual will be used synonymously. What the service does well: The home continues to offer a small, family-type provision, set within the local community. Service users are supported to integrate and access the community facilities appropriately. Feedback received confirmed that service users are offered choice and enabled to contribute to the running of the home. Positive feedback received about ‘what the home does well’ includes comments from a health professional: “Reviews, client holidays, varied individual day packages. Recognise training needs of staff” Social care professional: “Provides small care environment” “ Provides one to one support for client to access community and do activities” A Relative said: “ Cares for the individual likes and dislikes, tries to accommodate desires, such as education, leisure and dietary requirements and deals with personal problems. They listen to the person and try to deal with problems as they arise” Elms (The) DS0000063293.V352790.R01.S.doc Version 5.2 Page 6 Service users are involved in planning their care and enabled to keep contact with family and key individuals. Procedures and practice support a culture where service users can feel safe and are protected. 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. The summary of this inspection report can be made available in other formats on request. Elms (The) DS0000063293.V352790.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Elms (The) DS0000063293.V352790.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service and based on the previous inspection report, as there have been no new admissions to the service since October 2007. Taken from last report October 2007: “An admissions process is in place that ensures prospective users are only admitted on the basis of a proper assessment and subsequent trial period ensuring the home is confident the service they provide will meet the service users’ needs.” EVIDENCE: There have been no new admissions - for confirmation of evidence please refer to the previous inspection report of 16th October 2006. In support of the above judgement plans are underway for two service users to move out to another home within the organisation and two new individuals to move in. The AQAA states that they have been undertaking an assessment of their needs and the provider verbally confirmed this during the inspection. Feedback from a relative conferred that a process of planning and consultation is happening. Elms (The) DS0000063293.V352790.R01.S.doc Version 5.2 Page 9 This standard will need to be covered in the next inspection, records relating to the potential new service users were not available at the home on the day of the inspection. The potential date for the move is by the end of December 2007. Elms (The) DS0000063293.V352790.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 were inspected. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plan documentation, risk assessments and related records are in place that evidence assessment of needs, service user involvement and reviews. However, improvements in updating these records and increased detail would ensure that service users could be sure that records consistently support positive care practice and enable their needs to be met. EVIDENCE: Two files were case tracked, full assessments were noted and review dates were recorded, however not all current details were recorded on the file. On one file reviews had not been signed and both files contained other records that had not been signed by staff, service user or representatives. One service user was in the process of planning to move to another part of the organisation; this was not detailed in the service user’s main care plans seen Elms (The) DS0000063293.V352790.R01.S.doc Version 5.2 Page 11 during the inspection. Daily records however referenced the move as the service user discussed it regularly. Records did contain information of health needs and appointments. It was discussed at the feedback that key medical information could be entered onto the front of files to ensure all staff are immediately aware of any significant health matters, such as diabetes. Documentation provided evidence that care plans are reviewed and evidenced choices about service user involvement in a range of activities. It was noted that a pictorial format was used positively to facilitate choice and enable communication. Signing and dating of these documents would further support care practice and ensure confirmation of agreement by all parties to actions required. Comment cards received generally contained positive responses of ‘sometimes’ or ‘always’ in relation to making choices and decisions. During the inspection positive care practice was observed where individuals were given choice and this was followed. One service user was in bed and chose to get up later in the day, other individuals were given choice about activities and the process of being involved with the inspection. Staff related very appropriately and caringly to individuals, service users appeared very relaxed and able to express themselves around the staff. The AQAA advised that the philosophy of care is to support and enable service users to make choices and to empower individuals. A person centred planning process has been introduced and is increasing individual choices. A concern raised that could affect choice is around staffing levels at the weekends. In the AQAA the provider plans to review staffing levels. This will be addressed in the management section of the report. Risk assessments were seen that were dated and contained some details. A recommendation was made at the last inspection regarding expansion of the risk assessment framework. Information was noted in the records that could benefit from additional risk assessments, such as self-injurious behaviour. In the AQAA under improvements, the service identifies the need to review the current risk assessment structure. Elms (The) DS0000063293.V352790.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported to make choices and take part in a range of appropriate activities which support integration, maintain key relationships and enables individuals to be respected and valued. Service users are supported to have a healthy diet and enabled to contribute to the planning and preparation of food, which supports individual needs. EVIDENCE: Records contained reference to a wide range of activities including: college, social events, holidays, shopping trips, all of which are appropriate to identified individual needs. Elms (The) DS0000063293.V352790.R01.S.doc Version 5.2 Page 13 Feedback from relatives in relation to the question of ‘what the homes does well’ stated; ”Cares for individuals likes and dislikes, tries to accommodate desires such as educational, leisure and dietary.” Feedback from staff stated “ The service aims to involve the service users in activities within the community where possible” On the day of the inspection one service user was at a day centre, two went out with a member of staff due to the refurbishment. One had a day at home, which was part of their weekly plan. All service users have a range of weekly activities in line with their care plans, there were dates on the care plans that indicated regular reviews. In discussion with one individual they talked about an important relationship and how they are supported to maintain this. Records evidenced involvement by relatives in both planning and social support of service users. The home continues to operate an open door policy. In discussions with the manager and provider it was stated that regular discussions are held with service users and family about the running of the home. They advised that they have been consulted about the significant refurbishment that was underway. In feedback a recommendation was made to keep records of ‘meetings’ and ensure regular dates and times are recorded, which would support the current informal consultation and inform the quality assurance process. Menus were seen that rotate on a four weekly basis, records detailed service users being supported to make choices and be involved in the meal plans and preparation. Generally feedback was positive but with some preference to have occasional nights where more choice was allowed. Care practice on the day evidenced individual preferences being met. Discussions with the manager confirmed that consideration is given to healthy eating and individual preferences balanced with health needs and care plans. Elms (The) DS0000063293.V352790.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are mainly supported in a way that meets their needs and supports their independence and choice. A holistic care approach ensures that physical and emotional needs are identified. However further detail in records and consistency in follow up would ensure service users know that their health care needs are supported appropriately. EVIDENCE: During the inspection positive care practice was observed that supported service users’ dignity and enabled choice. Records contained information on daily personal care requirements. Discussions with staff confirmed a good detailed knowledge of individual’s personal needs. In the AQAA the service states they have a “comprehensive understanding of our service users complex needs”. Elms (The) DS0000063293.V352790.R01.S.doc Version 5.2 Page 15 Health professional feedback was generally positive in response to the home’s support of individuals for health care services, however one issue raised was the need to ensure consistent attendance at outpatient appointments. Documents detailed contacts with a range of health professionals to support health needs. In the last report a recommendation was made to consider using one method of recording visits to health care appointments to prevent any confusion. On this inspection it was difficult to track all medical appointments and information in the files. One record of weight was not up to date; this record is significant in the support of this individual’s health care. One file contained a record of an appointment in April 2007 from which action would be required: no follow up actions were recorded. However, it was clear from daily records that appropriate actions are in place. In the last report individuals also held their own personal health records in yellow folders; these were not seen during this inspection as service users were mainly out due to the refurbishment. Discussions were held about the possible use of an overview form for health appointments and an increase in detail, including follow on actions. In the AQAA reference is made to monthly reviews of medical appointments; no records of these were available on the day. The home’s medication policy and procedure were inspected and found to be adequate; currently no one self medicates. Medication is kept in a locked cupboard in the kitchen, MAR sheets inspected were found to be correct. After the refurbishment the provider advised there is a plan for a new medication cabinet in the refurbished office area of the home. Elms (The) DS0000063293.V352790.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported in a culture that enables them to make choices and provides support to discuss conflicting needs. Staff training, positive care practice and an open door policy ensures service users are protected. EVIDENCE: The home continues to operate a formal complaints procedure as well as encouraging regular discussion of any concerns. Feedback generally said that service users and other parties knew how to make a complaint and that they felt staff responded or would responded appropriately if necessary. Care plans and records evidenced choice and the involvement of service users; this is supported by observed care practice where individuals during the inspection appeared confident and able to clearly communicate their preferences. There have been three complaints/concerns since the last inspection that have been dealt with through the adult protection investigative procedure. In the last inspection a requirement was made to notify any concerns to the commission under Regulation 37, information had been submitted in report format. A discussion was held with the provider to request that all future submissions either have the Regulation 37 form attached or are clearly marked as ’Regulation 37 information’ to ensure they are recorded in the appropriate system. Elms (The) DS0000063293.V352790.R01.S.doc Version 5.2 Page 17 Two staff files were viewed that evidenced that POVA and CRB checks had been undertaken and that all necessary documentation was in place to ensure safe employment practice. Training records showed attendance on Adult Protection Training. The AQAA stated that all staff have attended POVA training and that as a service they encourage advocacy involvement in the home. This is supported by the feedback received from service users and professional staff. Policies and procedures were in place relating to adult protection and related procedures. The home states that it actively encourages the involvement of advocates and is pro-active in trying to set up advocates for service users. An open door policy continues and the home has many regular visitors including family to a range of service providers. Service users were observed to be confident to state their own views to staff and enabled to make decisions. Elms (The) DS0000063293.V352790.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in a homely well-furnished environment that is clean and provides an appropriate safe home for individuals to be supported in. EVIDENCE: Due to the refurbishment on the day of the inspection the majority of the evidence is taken from the feedback forms and based on the last inspection report. A brief tour of the premises indicated that the usual standards within the home are of an appropriate level. Areas were found to be clean and hygienic. The current refurbishment programme will improve the environment; a new boiler had just been fitted in the property. The whole home was in the process of being re-decorated and the provider advised that new furniture is on order that will improve the home. Elms (The) DS0000063293.V352790.R01.S.doc Version 5.2 Page 19 The provider advised that service users and family have been involved in the consultation regarding the refurbishment. Discussions were held with the provider that additional risk assessments during the refurbishment might support safety within the home. One feedback received said, “provides a comfortable homely environment”. One service user was very proud of their room and processions, they agreed to show the inspector round. The room clearly reflected personal choice and interests. The room did contain a significant level of electrical equipment, which necessitated the use of extension leads. In discussion with the manager and provider additional risk assessments and professional electrical assessment of the room was agreed. Elms (The) DS0000063293.V352790.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are trained and appropriate recruitment procedures are in place so that service users can be sure that staff have the range of skills required to meet their needs and ensure their safety. EVIDENCE: Two staff files were inspected and evidenced that the necessary recruitment processes are in place. POVA and CRB checks have been completed and evidence of induction training was seen. Additional evidence of induction training was submitted on the 30th October 2007 and confirmed discussions held during the inspection. Further training records are now available on staff files. The deputy manager has just commenced the NVQ 4 Registered Managers Award. Discussions were held regarding an overview training record, which would provide a quick reference to training needs. Staff levels on the day were seen to be adequate although changes had to be made due to the refurbishment. Elms (The) DS0000063293.V352790.R01.S.doc Version 5.2 Page 21 The AQAA states that they have a highly skilled team who are very motivated. Care practice on the day was seen to be positive and indicated ongoing good relationships between service users and staff. Service users were very relaxed and able to express their opinion freely with staff. Recruitment and training are given priority to ensure appropriately checked and skilled staff support service users. Feedback comments included ”As far as I am aware my relative is very well looked after.” Staffing levels, particularly at weekends, were identified through the feedback as an area of concern. In the AQAA the provider stated that they are in the process of recruiting additional staff as the needs of the service users change. This was confirmed on the day of the inspection. Elms (The) DS0000063293.V352790.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users appear confident and benefit from the experience and training of the manager and providers. They are supported to access the community and make choices enabling them to be valued and respected individuals in their local community. Ensuring regular meetings and improvements in documenting consultation would enable service users to feel confident their views are taken into consideration in the development of the home. Current health and safety practices need to be consistently managed to ensure the risks to service users and staff are minimised. EVIDENCE: The home has a stable management team supported by the registered providers, all of whom have qualifications in working with people with a learning disability Elms (The) DS0000063293.V352790.R01.S.doc Version 5.2 Page 23 Service users and family advocates confirm that positive care is given and communication is maintained between the service and themselves. Care practice observed during the inspection reinforced the good relationships between staff and service users. Service users appear confident and able to raise any areas of concern in a caring environment. The ethos of the home is to enable service users to maximise their potential, feel valued and respected, this was confirmed in feedback and observed practice. However a theme from the feedback is staffing levels, which potentially limits the opportunity for individuals to go out on activities, particularly at weekends. The provider confirmed that they are in the process of recruiting additional staff and have identified it as an area for development, to continue to meet the needs of residents and to increase opportunities for activities. Staff generally feel supported and are enabled to undertake training to support them in their work. Quality assurance is undertaken through informal discussion and the provider intends to utilise the contents of the AQAA to develop this further. No records were available at the inspection of meetings with service users as a group, regarding the home or refurbishments. A recommendation is made that records should be kept of meetings held involving consultation on the running and development of the home. Person centred plans are undertaken, general improvements in consistency and further details in documentation would improve record keeping and support care practice. On the day of inspection, in relation to health and safety, three immediate requirements were issued at the inspection. Hazardous items were found in an unlocked bathroom cabinet and no risk assessment was in place for these to be left out. The senior on duty took prompt action to remove the containers/creams and place them in a locked area. However, the lock on the secure cupboard in the kitchen was broken. The senior advised that this was a recent occurrence. An immediate response was made by the provider and manager to rectify these matters. No records of Fire Drills since June 2006 were available, although other fire records such as smoke alarm checks, fire servicing were up to date. Portable electrical appliances had not been tested (P.A.T.). In one resident’s bedroom electrical extensions were in use with a range of equipment that could benefit from a risk assessment and inspection by qualified electrical provider. Elms (The) DS0000063293.V352790.R01.S.doc Version 5.2 Page 24 The provider and manager responded immediately to take appropriate action. A letter was received at the commission on the 2/11/07; at the time of writing the commission is awaiting a copy of the fire records, which the provider has confirmed is being sent. Elms (The) DS0000063293.V352790.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 2 X X 1 X Elms (The) DS0000063293.V352790.R01.S.doc Version 5.2 Page 26 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. 1 Standard YA42 Regulation 13 (2) & 4 (a) Requirement The provider must ensure that all hazardous substances are stored in a secure cupboard at all times, protecting residents from harm. Timescale for action 18/10/07 An Immediate Requirement was issued on 18/10/07 –The provider has taken appropriate action and confirmed this in writing. 2. YA42 23. 4 (iii) Fire drills must be undertaken according to the requirements of Dorset Fire and Rescue keeping people living and working in the home safe from the risk of fire. 28/10/07 An Immediate Requirement was issued on 18/10/07 –The provider has taken necessary action and confirmed this is writing. 3. YA42 23 To undertake risk assessment to protect service users, whilst Portable Electrical Appliance Testing is planned and undertaken. 28/10/07 An Immediate Requirement was issued on 18/10/07 –The provider has taken necessary action and confirmed this in writing. Elms (The) DS0000063293.V352790.R01.S.doc Version 5.2 Page 27 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 Good Practice Recommendations Standard YA6 It is recommended that all service users’ care plans contain relevant details of service users support needs and the arrangements in place for the management of their medication and finances. It is also recommended that plans are signed and dated to evidence when reviews have been carried out. YA9 It is recommended that the service expands it risk assessment framework to provide more comprehensive strategies to minimising/reducing risk and that these are regularly reviewed to ensure service user have the opportunities to learn new skills and increase their independence in a framework designed to manage and minimise risks. It is recommended that the service consider using one method of recording service users’ visits to healthcare professionals to improve consistency and ensure there is no confusion for members of staff. Records need to contain clear follow on actions so all staff are aware of what is required. It is recommended that the service establish systems for more formalised consultation on the running of the home and that records are kept. These formalised processes will support the ongoing development of effective quality assurance system in the home. 2. 3. YA19 4. 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