Inspection on 27/03/07 for

This inspection was carried out on 27th March 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 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

03/08/07

04/07/06

07/02/06

19/09/05

28/02/05

05/07/04

22/10/03

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

CARE HOMES FOR OLDER PEOPLE The Elms Verwood Road Elmhurst Aylesbury Bucks HP20 2AY Lead Inspector Nancy Gates Unannounced Inspection 27th March 2007 4:30 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 The Elms DS0000023063.V327856.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. The Elms DS0000023063.V327856.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Elms Address Verwood Road Elmhurst Aylesbury Bucks HP20 2AY 01296 489530 01296 337991 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) Manager.winglodge@fremantletrust.org The Fremantle Trust vacant Care Home 56 Category(ies) of Dementia (16), Old age, not falling within any registration, with number other category (40) of places The Elms DS0000023063.V327856.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the Home also provides care to the following categories of Service Users under the category `Older People` 1 (One) Service User on respite care who has Dementia 6 (Six) Service Users who have learning difficulties 1 (One) Service User who may have Mental Health Issues. 4th July 2006 Date of last inspection Brief Description of the Service: The Elms is a care home providing personal care and accommodation for fiftysix frail older people. The home is owned by the Fremantle Trust, which is a not for profit charity. It is situated in a residential area of Aylesbury, close to the facilities that a large town can offer. It was purpose built in the early 1970s and has fifty-four single bedrooms and one double bedroom. It is divided into five smaller units, each of which has a lounge and dining area. One thirteen bedded unit provides specialist care for people with dementia. There is a passenger lift. There are pleasant gardens and outdoor sitting areas. The home is well supported by local GP’s and community nurses. The cost of living at The elms ranges from £370.79 per week to £525.56 per week. The home caters for private clients and those supported with their funding from the local authority. Information about the service offered can be requested from the home if required. The Elms DS0000023063.V327856.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of the service was an unannounced ‘key inspection’. The inspector arrived at the service at 4.30 p.m. on the 27th March 2007. The time spent at the home allowed for a thorough look at how well the service is doing. The inspection took into account detailed information provided by the service manager inclusive of information that CSCI has received about the service since the last inspection. The inspector asked for the views of the people who use the service. All household members were in the home at the time of inspection. The inspector also asked the views of others who support the needs of the people who use the service via a questionnaire that the CSCI sent out. Staff and residents were very welcoming. The inspector looked around the home including the bedrooms of the residents at their invitation. Issues regarding a number of records were including a resident’s care plans, staff recruitment records, staffing rotas and maintenance records. The inspector looked at how well the service was meeting the standards set by the government. The report includes judgements about the standard of the service. What the service does well: All service users receive a pre-admission assessment before they are admitted to the home. Service users receive a contract and terms and conditions to ensure that they are aware of services offered. Service users privacy is respected. Visitors are welcomed to the home; service users maintain links with their family and friends. Service users have access to a robust, effective complaints procedure and are protected from abuse. Service users presently live in a home that is reasonably well managed. The storage and administration of medication ensures residents safety. The Elms DS0000023063.V327856.R01.S.doc Version 5.2 Page 6 The physical design and layout of the home enables service users to live in a reasonably well-maintained environment, which encourages independence. Staff are supervised and a quality assurance programme continues. Needs arsing from equality and diversity are well met. From the evidence seen, the inspector considers that this service would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. What has improved since the last inspection? What they could do better: Care plans provide sufficient information to guide staff in meeting the needs of service users, however, whilst structured are not fully effective in guiding staff in how to support individuals to ensure respect for and the dignity of residents is maintained. Residents receive a varied and appealing diet, appropriate nutritional advice has been sought ensuring all residents nutritional needs are met, however, residents’ dignity is not always maintained when assistance is required to eat. The physical design and layout of the home enables service users to live in a reasonably well-maintained environment, which encourages independence, although staff actions compromise the health and safety and welfare of residents. Unpleasant odours within the home do not offer residents a pleasant home. Service users presently live in a home that is reasonably well managed in areas, however, a number of issues present risks to the welfare of residents. The Elms DS0000023063.V327856.R01.S.doc Version 5.2 Page 7 There are shortfalls in ensuring the health, safety and welfare of residents that must be addressed to improve outcomes for all residents. 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. The Elms DS0000023063.V327856.R01.S.doc Version 5.2 Page 8 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 The Elms DS0000023063.V327856.R01.S.doc Version 5.2 Page 9 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&6 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. A clear assessment of need is completed before a resident is admitted, giving assurance that care needs will be met and that the placement is appropriate. A contract is provided to individual residents to ensure that they are aware of the services that they are entitled to within the home. EVIDENCE: From information received regarding the service and discussion with residents representatives it is clear that a contract is provided. Potential residents needs are appropriately assessed before admission to the home. This was confirmed through discussions and information received at the CSCI. The Elms DS0000023063.V327856.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Care plans provide sufficient information to guide staff in meeting the needs of service users, however, whilst structured are not fully effective in guiding staff in how to support individuals to ensure respect for and the dignity of residents is maintained. Health care intervention is supported. Safe systems are in place for the storage and administration of medication. EVIDENCE: The manager stated that all care plans have been reviewed and updated following the requirements of the last inspection visit. Care plans are now structured and follow the ‘Freemantle format’ to ensure that information is consistent and support residents assessed needs. Staff commented that the The Elms DS0000023063.V327856.R01.S.doc Version 5.2 Page 11 information available within care plans enables them to support resident’s needs. The manager was appointed in July 2006 and has made considerable efforts in updating care plans following the requirements of previous inspections. The manager has also made efforts in “bringing staff on board.” The inspector welcomes and acknowledges the improvement but there are a number of areas that need to be addressed. Observation of support provided to residents raised concerns for the inspector and demonstrates that care plans whilst structured are not fully effective in guiding staff in how to support individuals to ensure respect for and the dignity of residents is maintained. A number of residents were unkempt and had food spillages and staining on clothing following assistance to eat. Napkins or protective garments were not seen. Interaction with people was, at times, limited. Food was split onto the floor in the dementia unit; no effort had been made to clean up the spillages. A resident within the dementia unit was sat in a lounge chair propped on either side with two bed pillows. This looked very uncomfortable, and caused the person’s arms to rotate inwardly. It was unclear as to whether the person would be able to propel himself or herself out of the chair or how they would indicate that they needed support. On three occasions a resident was heard requesting to be taken outside, in response staff stated that they would “find someone”, the resident’s request was not undertaken. An explanation was not provided to the resident relating to why the request could not be met. Upon entering a room on the first floor of the home there was a strong odour of urine. A commode bowl was on the floor containing urine. Impermeable flooring has been fitted within the room due to the needs of the resident and ease of cleaning for staff. A wet floor sign had been placed within the room as the floor had been mopped but the floor remained sticky underfoot. A staff member stated that the ’behaviour’ of the resident would sometimes mean that the person will “urinate anywhere, in the corridors on the floor in their room; the best option is for the person to go in the bowl even though some goes on the floor.” When asked about the issues raised the manager stated that this is an “ongoing issue and that staff were managing the best they could.” The manager must review the support needs of the individual to ensure that continence and behavioural support needs are being met and to ensure outcomes for the individual and other residents are being met. Discussions with residents and information from some representatives demonstrated that people are appropriately supported from a variety of The Elms DS0000023063.V327856.R01.S.doc Version 5.2 Page 12 professionals in an attempt to meet their healthcare needs and that information is now included within care plans. Systems are in place for the safe storage of medication. Staff were able to provide information regarding the safe storage and administration of medication. A nominated person on each shift manages medication administration to ensure consistency. A daily audit of medication stock administration records ensures the safety of residents. All service users spoken with during the inspection visit reported that privacy is respected; this was confirmed through observation and discussions with staff, although ensuring peoples dignity is maintained was not seen in some areas of the home. The Elms DS0000023063.V327856.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Visitors are welcomed to the home; service users maintain links with their family and friends. Social, cultural and recreational activities have been improved to meet residents’ expectations. Residents receive a varied and appealing diet, appropriate nutritional advice has been sought ensuring all residents nutritional needs are met, however, residents’ dignity is not always maintained when assistance is required to eat. EVIDENCE: In response to the previous inspection a residents’ survey has been completed to establish areas of interest for individuals and for groups of people. An action plan has been produced by the activities co-ordinator reflecting the social, cultural and recreational suggestion of residents. The Elms DS0000023063.V327856.R01.S.doc Version 5.2 Page 14 The manager stated that the review of care plans has allowed for residents’ interests, social and recreational needs to be described within care plan information. Residents commented that activities have improved in the home. Activities continue to be advertised around the home, residents confirming that they had occurred although no records were examined to confirm that these had taken place. The home continues to operate open visiting. There were no visitors at the home on the day of the inspection, but feedback received at CSCI described that visitors are welcomed. The ‘teatime’ meal was served in reasonably comfortable surroundings in the individual smaller dining areas around the home, however, one the upstairs dining rooms is quite small and contains two medication administration trolleys making the room appear cramped. Some residents who needed assistance were not catered for with dignity and respect. During the inspection a number of residents within the dementia unit were being supported to eat ‘Tea’ (Scrambled egg on toast). A number of people had food spilt onto their clothing with no napkins or protection for clothing apparent. Interaction with people was limited. Food was split onto the floor; no effort had been made to clean up spillages. The manager stated that following the last inspection the advice and guidance of dieticians and healthcare professional had been sought regarding nutritional assessment and that all staff, including the chief have received ‘nutritional training.’ The Elms DS0000023063.V327856.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents continue to have access to a robust, effective complaints procedure and are protected from abuse. EVIDENCE: The home has a clear complaints policy available to all service users, staff and visitors to the home. No formal complaints have been received at the CSCI since the last inspection. Six complaints have been received at the home since the last inspection, three of the complaints were substantiated, and the remaining three were partly substantiated. All complaints were responded to within 28 days and investigated and recorded appropriately. Concerns or complaints aired are dealt with in an appropriate manner and in accordance with policies and procedures. Residents and comments received from residents representatives reported that they were able to air any concerns or complaints to staff should the need arise. The Elms DS0000023063.V327856.R01.S.doc Version 5.2 Page 16 The manager stated that all staff have received training in Safeguarding adults and have awareness regarding protection of residents. A policy and procedure remains in place. The Elms DS0000023063.V327856.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 & 26 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables service users to live in a reasonably well-maintained environment, which encourages independence, although staff actions compromise the health and safety and welfare of residents. Unpleasant odours within the home do not offer residents a pleasant home. EVIDENCE: The Elms was purpose built in the early 1970s and has fifty-four single bedrooms and one double bedroom. It is divided into five smaller units, each of which has a lounge and dining area. The Elms DS0000023063.V327856.R01.S.doc Version 5.2 Page 18 One thirteen bedded unit provides specialist care for people with dementia. There is a passenger lift. There are pleasant gardens and outdoor sitting areas. The maintenance programme remains as an ongoing issue, although most resident’s rooms have now been refurbished. However, it was again noted that some areas of the home are still in need of repair and attention to décor. The manager acknowledged that there a small number of areas that need to be “finished” and plans are in place for the work to be completed. Security locks have been fitted to both units on the ground floor, but are used intermittently. The manager stated the doors within the ground floor units are left open during the day to allow residents to access all ground floor communal areas. One ‘security door’ allowing access to the upper floor has been left ajar. A staff member stated that the door should have been closed fully to ensure the safety of residents. The manager and staff must ensure that the security and welfare of resident is upheld at all times. A number of new beds have been purchased no have headboards that fit to the bed meeting the requirement of the previous inspection. Residents bedrooms are of varying shapes and sizes and hold personal items that give individual identity, however, a resident’s room on the upper floor was very sparse. Upon entering the room there was a strong odour of urine. A commode bowl was on the floor containing urine. Impermeable flooring has been fitted within the room due to the needs of the resident and ease of cleaning for staff. A wet floor sign had been placed within the room as the floor had been mopped but the floor remained sticky underfoot. One door on a large fitted wardrobe could not be closed. A staff member stated that the ’behaviour’ of the resident would sometimes mean that the person will “urinate anywhere, in the corridors, on the floor in their room; the best option is for the person to go in the bowl even though some goes on the floor.” The manager must review the support needs of the individual to ensure that continence and behavioural support needs are being met (as stated within the health and personal care section of this report) Bathroom doors on the ground and first floors were propped open, one with a clinical waste bin, and the other with a chair. A staff member stated “it’s easier if you can leave them open”. A number of doors to Household cupboards/sluice rooms were left unlocked with the keys remaining in the locks. A staff member confirmed that the doors should be locked and the key hung upon a hook on the upper part of the doorframe. Staff actions highlight disregard for the health, safety and welfare of residents. The manager and staff must ensure the health and safety of residents at all times. The Elms DS0000023063.V327856.R01.S.doc Version 5.2 Page 19 A black plastic bag, containing household waste was left outside a kitchen/dining area in an upstairs corridor. Staff members offered no explanation of why it had been left on the floor or why it had not been disposed of. Staff actions highlight disregard for the health, safety and welfare of residents. The manager and staff must ensure the health and safety of residents at all times. The dementia unit also had a strong odour of urine, however was clean in appearance. Refurbishment of the bathrooms in the dementia unit offers pleasant bathing areas. There are a number of privacy, dignity and health and safety issues that must be addressed. There is an infection control policy and procedure. The laundry is situated away from the kitchens and has impermeable floors. The washing machines have the capacity to wash at a minimum of 65°C. The Elms DS0000023063.V327856.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Recruitment practices are robust. Staff are trained in mandatory areas, however, shortfalls in practice do not ensure that service users needs are fully met or that their safety is maintained. Staffing numbers at the time of inspection were sufficient to meet the needs of residents. EVIDENCE: Recruitment practices are robust. The manager confirmed that staff personnel files are in order. Staff training continues to improve since the previous inspection visits staff having completed mandatory training. Additional training has been provided to all staff e.g. nutritional assessment, supporting people with dementia (‘Look again’ training). Whilst training has improved staff must revisit their knowledge regarding the upholding residents dignity and ensuring that the health and safety of residents is of paramount importance and maintain at all times. This relates to The Elms DS0000023063.V327856.R01.S.doc Version 5.2 Page 21 issues identified within the Health & Personal Care, Environment and Management & Administration sections of this report. At the time of the inspection visit the home appeared to have an appropriate number of staff on duty to meet the needs of the residents. Staffing rotas accurately reflected the staffing numbers on duty at any one time. The manager stated that a more consistent staff group has been established, resulting in the staff team being “more open…they’ll go on training courses and will now come forward with suggestions…they now have access to things they didn’t even know existed.” There are four National Vocational Qualification assessors employed with twelve members of staff undertaken an NVQ at either level 2 or level 3 in care. The manager is aware of the target that needs to be met regarding NVQ stating that every effort will be made to meet targets. The Elms DS0000023063.V327856.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Service users presently live in a home that is reasonably well managed in areas, however, a number of issues present risks to the welfare of residents. Staff are supervised regularly and commitment has been made to and a quality assurance programme. There are shortfalls in ensuring the health, safety and welfare of residents that must be addressed to improve outcomes for all residents. The Elms DS0000023063.V327856.R01.S.doc Version 5.2 Page 23 EVIDENCE: A new manager was appointed to the home on the 10th July 2006. The manager has experience of being a registered manager in a service for people with learning disabilities and has obtained relevant management qualifications. The manager described experience of working within older people services and has attending training to support people with dementia. The deputy manager was described as “A champion for people with dementia” and therefore a balance of skills is available within the management team. A number of shortfalls raised at the previous inspection have been addressed, however a number of improvements to the service must be made to ensure that outcomes for service users are appropriately met. Staff supervision has continued to improve since the previous inspection visit with all team leaders carrying out supervision sessions with allocated staff. The manager confirmed that all supervision sessions are up to date. Within the tour of the building the manager stated that issues with the heating/hot water system within the home are ongoing. There are times when there is only a limited amount of hot water available, “sometimes we can only get two or three baths of hot water, and this can obviously make it difficult in the mornings.” The pre-inspection questionnaire, completed by the manager on the 30th January 2007 indicates that issues with the central heating were ongoing as “TENCER awaiting parts for Heat Exchanger.” The inspection was completed on the 27th March 2007 indicting a further three months with the heating/hot water system not functioning effectively. This is does not promote and protect the health and welfare of residents and must be addressed. Health and safety systems viewed appeared to be in order; fire systems are now checked on a weekly basis in line with the requirement of the previous inspection. There were a number of areas identified within the tour of the building that raised concern to the inspector and these have been highlighted within previous sections of the report. An additional cause for concern was raised. Upon arrival at the home the reception entrance was partially blocked by equipment belonging to an entertainer who had been at the home. Whilst it is acknowledged that it would be moved, all visitors to the home must be aware of health and safety risk when blocking entrance/exits. The Elms DS0000023063.V327856.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 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X 2 2 STAFFING Standard No Score 27 3 28 2 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 1 The Elms DS0000023063.V327856.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP10 Regulation 12;4 (a) Requirement Timescale for action 30/04/07 2. OP26 3. OP38 The registered person must ensure that residents are respected and their dignity is upheld at all times. Staff practice must be reviewed. 16 (k) The registered person must ensure that offensive odours are minimised to ensure residents are provided with a pleasant home. Floor coverings and furniture must be cleaned regularly. 13:4 (a) & The registered person must (c) ensure that staff are aware of how their action in relation to health and safety risks impact on the health, safety and welfare of residents. Staff knowledge must be reviewed and updated. 30/04/07 31/05/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. The Elms Refer to Good Practice Recommendations DS0000023063.V327856.R01.S.doc Version 5.2 Page 26 Standard The Elms DS0000023063.V327856.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Elms DS0000023063.V327856.R01.S.doc Version 5.2 Page 28 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!