Inspection on 30/11/06 for The Elms Care Centre

This inspection was carried out on 30th November 2006.

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

The inspector 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

The Elms Care Centre 06/11/08

The Elms Care Centre 10/01/06

The Elms Care Centre 20/07/05

The Elms Care Centre 07/12/04

The Elms Care Centre 31/08/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE The Elms Care Centre 108 Grenfell Avenue Saltash Cornwall PL12 4JE Lead Inspector Mandy Norton Unannounced Inspection 29th November 2006 10:00 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 Care Centre DS0000009168.V314687.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 Care Centre DS0000009168.V314687.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Elms Care Centre Address 108 Grenfell Avenue Saltash Cornwall PL12 4JE 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) 01752 846335 The Aldington Group Limited Mrs Ailsa Elizabeth Weaver Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37), Physical disability (6), Terminally ill (6) of places The Elms Care Centre DS0000009168.V314687.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Service users to include up to 6 adults with a terminal illness (TI) Service users to include up to 6 adults with a physical disability (PD) Service users to include up to 37 adults of old age (OP) Total number of service users not to exceed a maximum of 37 Date of last inspection 10th January 2006 Brief Description of the Service: The Elms is one of thee homes privately owned by the Aldington Group Ltd, director Michael Freeland. It provides care for up to 37 older people, the majority of whom have nursing needs. The home is situated in Saltash. Whilst at a distance from the main shopping centre, there is a small supermarket is close by and there is a bus service, which enables active service users to exercise some independence or assists relatives when visiting. Accommodation is provided on two floors linked by a shaft lift and step lift. The majority of rooms are for single occupation, half of which have an en suite facility. There is a choice of communal sitting space downstairs, which comprises two lounges, a conservatory/ dining room and front hall/sun lounge. There is a patio area with seating and car parking in front of the home. The home presents as being well maintained and is clean and tidy inside and out with a display of seasonal flowers at most times. The previous inspection report is displayed in the entrance foyer. The current fees range from £292.25 to £626.50 (information taken from the pre inspection questionnaire dated 18.10.06). The Service Users contracts are dealt with by the groups administrator; she was not at the home on the day of the inspection so the contracts were not examined this time. The Elms Care Centre DS0000009168.V314687.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place from 09.50 until 2.30 pm and was conducted with the manager, with input from the deputy manager. A tour of the home was carried out. The report contains views from the completed staff surveys returned (16) reflected throughout, information taken from the completed pre inspection questionnaire (received October 2006) and views of Service Users spoken on the day of the inspection. The pre inspection questionnaire states that there have been 2 complaints made since the last inspection, 1 of which was substantiated. They had all had been responded to within timescales laid out in the homes complaints procedure. What the service does well: The Elms is homely, comfortable and welcoming. The staff are trained and competent in their jobs and there was a nice atmosphere during the inspection with staff interacting well with the Service Users and a number of visitors in the home. Service Users spoken with said that the staff are ‘kind and helpful’ The information about the home given to prospective Service Users and or their representatives has sufficient detail to allow an informed decision to be made about moving into the home. When possible, prior to admission, the manager or another of the trained nurses visit the person in their current setting to perform a full needs assessment in addition to receiving care plans from other social and health care professionals. Once admitted to the home Service Users needs are set out in a care plan, the plans provide sufficient information for care staff to be able to meet the individuals’ health, social and psychological needs. The processes in place to protect the health and welfare of the Service Users such as the complaints procedure, fire and health and safety procedures and regular training for the staff help to assure the people living in the home that they are well looked after. Service Users are able to maintain contact with family and friends and exercise choice and control over their lives. Service Users receive a wholesome appealing diet; Menu choices are displayed on a chalk board near to the dining room. The manager said that Service Users The Elms Care Centre DS0000009168.V314687.R01.S.doc Version 5.2 Page 6 are asked on the day of the meal what they would like to eat, with alternatives to the menu always being available. The home is pleasantly decorated and furnished and presented as clean, bright and hygienic. There is a formal quality assurance system in place to measure Service Users satisfaction. 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. The Elms Care Centre DS0000009168.V314687.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Elms Care Centre DS0000009168.V314687.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use this service or are prospective Service Users have good information about the home in order to make an informed decision about whether the service is right for them. The personalised needs assessment means that people’s diverse needs are identified and planned for before they move to the home. This home does not provide intermediate care. EVIDENCE: The Elms Care Centre DS0000009168.V314687.R01.S.doc Version 5.2 Page 9 The manager showed the inspector pre admission documentation for an out of area person who is to be admitted to the home in the near future. It included a social service assessment of need, information from the hospital and family about his current condition and the fee levels agreed (continuing care). She said that all prospective Service Users or their representatives receive information about the home and its facilities (Statement of Purpose) and can come and look around at any time. The manager said that if a prospective Service User is local to the area she herself or one of the other senior trained nurses goes to visit the person in their current setting to make an assessment. One completed assessment carried out in this way was examined. It included information about their current abilities, medication, next of kin and equipment required. The manager said that the contracts for Service Users are managed by the group’s administrator. She was not at the home on the day of the inspection so the contracts were not discussed further. The Elms Care Centre DS0000009168.V314687.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 good. This judgement has been made using available evidence including a visit to this service. The manager promotes and maintains Service Users health and ensures access to health care services to meet assessed needs. The homes medication systems generally protect the welfare of residents. Service Users are treated with respect and their right to privacy is upheld. EVIDENCE: Three (3) care plans were examined; in all of those seen there were assessments which provided information about skin integrity, moving and handling, safety - including risk of falls and use of bed rails and nutritional The Elms Care Centre DS0000009168.V314687.R01.S.doc Version 5.2 Page 11 screening. The information generates the plans of care, which provide the basis for the care to be delivered. The care plans were clear and easy to understand and had been regularly reviewed. In some cases it was evident that the plans had been created and reviewed with input from the Service Users and/or their representatives. Records are maintained, in the care plans, for all visits to the home by social or health care professionals (a speech and language therapist visited on the day of the inspection), all Service Users are registered with a GP. Records seen in the communication book, diary and care plans detailed outpatient appointments and GP visits showing that Service Users are enabled to use health resources. The medication system is well managed; some of the controlled drug stock was checked against records and found to be correct The pharmacist supplies medicines in individual bottles and boxes which is kept in individual trays within the drugs trolley. The manager said stock is checked weekly and ordered monthly when possible. Disposal of unused/ out of date medication is safe, well recorded and removed by a licensed contractor. A tour of the home showed that in several rooms there were unlabelled pots of cream with no opening date written on them. It was recommended that the labels are kept on pots /tubes of cream to show they are being used for the person for whom they are prescribed and they have a date of opening clearly marked on them. The Elms Care Centre DS0000009168.V314687.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Effort is made by the home to provide an activities programme and social interaction/stimulation for Service Users. Service Users are able to maintain contact with family and friends and exercise choice and control over their lives. Service Users receive a wholesome appealing diet and are not rushed encouraging the mealtime to be a social event. EVIDENCE: A new activity co-ordinator has been appointed and starts work on 4th December. The activity cupboard had a variety of puzzles, jigsaws, games and books stored in it. A tour of the home showed some Service Users in their The Elms Care Centre DS0000009168.V314687.R01.S.doc Version 5.2 Page 13 rooms watching appropriate TV programmes, reading newspapers and magazines and chatting with visitors. Others were in one of the 2 lounges with their visitors or chatting to other Service Users. The home has 2 budgies, who are cared for a staff member at the moment until the activity co-ordinator starts. A local cat visits daily and spends time sitting on a Service Users knee, her owner collects her in the late afternoon, so the home have no veterinary or feeding responsibilities for it. The daily menu is written on a chalk board near to the lounges. The menus (provided with the PIQ) are on a rolling 6 week system. The manager said that fresh fruit is provided at all times. Service Users are asked on the day of the meal what they would like to eat. Alternatives are always available. Service Users spoken to said the meals were good and well presented. Specialist diets are catered for. A speech and language therapist had visited on the day of the inspection to review a feeding regime in place in the home. A new ‘prescription’ was in place signed by her following the review. Service Users can eat in their rooms or in the dining room. Catering staff spoken to were approachable and well organised. Interviews for a new cook, to complement the exiting catering staff, were taking place on the day of the inspection. The Elms Care Centre DS0000009168.V314687.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. 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. Service Users and their relatives/friends know how to make a formal complaint. People are safe living in this home. No formal meetings take place for staff or Service Users but there are strategies in place for bringing concerns or complaints to the managers attention. EVIDENCE: The complaints procedure was seen displayed within the home and is in the Statement of Purpose, given to all Service Users and /or their representatives prior to admission. The manager says she carries out a daily ‘round’ at different times of the day and Service Users will often talk to her about any concerns at this time. She said she has an open door policy for Service Users, visitors and staff to approach her and discuss any issues. She feels that this is effective. She said The Elms Care Centre DS0000009168.V314687.R01.S.doc Version 5.2 Page 15 that she doesn’t hold Service Users meetings or staff meetings (unless there is an urgent concern) as she has found these to be ineffective in the past. The pre inspection questionnaire states that there have been 2 complaints since the last inspection, 1 of which was substantiated, all had been responded to within timescales laid out in the homes complaints procedure. The pre inspection questionnaire also states that there have been 3 AP referrals since the last inspection. These discussed with the manager during the inspection when she demonstrated an awareness of safeguarding/adult protection issues and what immediate action to take and when and who to refer any incident on to. These have resulted in 3 dismissals for gross misconduct and 1 POVA referral. Thirteen (13) of the sixteen (16) completed staff surveys indicated they were aware of adult protection procedures (one did not complete that section of the survey). The Elms Care Centre DS0000009168.V314687.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 22, 23, 24, 25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is safe and adequately maintained and clean and hygienic ensuring the Service Users live in a satisfactory environment. EVIDENCE: A tour of the home showed that Service Users rooms contain personal items including furniture, ornaments and pictures. The home appeared well equipped to meet the needs of Service Users identified with moving and handling risks and disabilities that affect their capability to bathe (2 hoists, 2 stand aids, a shower and assisted baths). The Elms Care Centre DS0000009168.V314687.R01.S.doc Version 5.2 Page 17 Specialist mattresses and adjustable beds were seen in place for those Service Users requiring them. There is a call bell system throughout the home, Service Users seen in their rooms all had the bell placed within their reach. There were a variety of toilet facilities for use by Service Users throughout the home. There is a shaft lift and a step lift for access to a number of rooms with steps leading to them. The home has had 2 new sluices fitted since the last inspection. Outdoor space consists of a patio leading from the dining room (there is a ramped access). The area is enclosed so Service Users can sit outside with privacy. The manager said the patio has a range of colourful plants in pots during the summer months, which the Service Users really enjoy. There are 2 lounges on the ground floor, both have televisions in them but the manager said that only one usually has the TV on. One of the lounges had a cage with 2 budgies in it. Both lounges were tastefully decorated and looked comfortable. Service Users were seen being assisted from wheelchairs to sit in comfortable chairs in the lounge. Visitors were seen with their relatives in the lounge and in the privacy of their own rooms. Some Service Users who were independently mobile in wheelchairs had made their own way to the lounge and dining room. Hand washing facilities were seen throughout the home, as were protective gloves and aprons. The laundry has one industrial washing machine, with a disinfecting sluice cycle, and one domestic type machine and a large tumble dryer. The laundry assistant and the manager said that this was sufficient for the washing the home produces. They said that the night staff do put washing on if they have time, the laundry is not near to Service Users rooms, so the noise does not affect Service Users overnight. The kitchen appeared well equipped and large enough to manage meals for the number of Service Users living in the home. The Elms Care Centre DS0000009168.V314687.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are sufficient numbers of staff with appropriate skills and knowledge to meet the needs of Service Users in this home. The homes recruitment procedures protect Service Users from being placed at risk of harm or abuse. EVIDENCE: Duty rotas supplied with the pre inspection questionnaire indicate that the manager works during the day Monday to Thursday. There are usually 2 other trained nurses on during the week and 2 altogether at weekends. There are usually 7 carers in the morning and 4 – 5 in the afternoon. Night duty comprises of 1 trained and 2 carers for up to 30 Service Users this increases to 3 carers when over 30 Service Users. There were 28 Service Users in the home on the day of the inspection, 5 of whom are assessed as needing personal care only the rest requiring nursing The Elms Care Centre DS0000009168.V314687.R01.S.doc Version 5.2 Page 19 care. The home also admits people with ‘continuing care ‘ needs and via the local ‘rapid assessment scheme’ (RAS). The pre inspection questionnaire states that there are 7 Registered Nurses (RGN’s) employed in the home, they are assisted by 21 care assistants, 50 (10) of whom have achieved a National Vocational Qualification (NVQ), level 2 or above, in care. There is also 14 ancillary staff (catering, laundry, domestic, activities and maintenance) employed in the home. The inspector examined the training file which provided evidence of individual training planned and provided, including: fire safety training, first aid, manual handling, health and safety, infection control, syringe driver update, continence care and NVQ’s. An NVQ assessor was in the home during the inspection assessing staff currently undertaking the training. The inspector saw training sessions available advertised in the staff room and office. A new system of pad provision has been implemented in Cornwall recently for which staff have had to have training and guidance, the manager said that this has been a difficult time for staff adjusting to the new system. Thirteen (13) of the sixteen (16) completed surveys confirmed that there are no ‘group meetings as part of supervision’. Some indicated that they would like to have staff meetings, nine (9) indicated that they are observed in their work and six (6) indicated that they receive formal one to one supervision. Seven (7) indicated that they have no regular meetings with the manager (the surveys included night staff and ancillary staff|), one (1) stated that the ‘person who does your induction reports back to the matron on your progress’. The inspector was shown a copy of the induction standards (provided by Skills for Care formerly TOPSS) that is now in use within the home for any new care staff. The inspector looked at 2 staff files; these contained 2 written references, interview records, proof of Criminal Records Bureaux (CRB) checks and identity information. Service Users spoken to said the staff were kind and helpful. During a tour of the home staff were heard interacting appropriately with Service Users. The Elms Care Centre DS0000009168.V314687.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed by an experienced 1st level Registered Nurse. There is a formal quality assurance system in place. Personal money held in the home on behalf of Service Users is managed appropriately. The registered provider shows a responsible attitude toward promoting and protecting the health, safety and welfare of Service Users and staff. The Elms Care Centre DS0000009168.V314687.R01.S.doc Version 5.2 Page 21 EVIDENCE: The manager of this home is a 1st level registered nurse who is undertaking a Registered Managers Award. She took on the manager’s post in February of this year, but had managed another home in the group for many years previously. The previous manager decided she did not want the role anymore and is now the deputy. The group has its own robust complaints process and recruitment practices and offers numerous training opportunities. The administrator picks at random 3 Service Users a month to ask about their satisfaction with the service provided. She also asks their relatives or representatives to meet with her or discuss any issues they may have about the Service Users care. The responses are documented and any actions required are taken and details of the actions written on the completed quality assurance form. ‘Regulation 26’ (unannounced monthly visits made by the registered provider or his representatives) visit reports have been sent to the commission as required following previous inspections. The manager said she also has an open door policy for staff and visitors to bring any issues or concerns to her. Safety notices were displayed throughout the home including action to be taken in case of fire. It was recommended that even though hot water notices were seen above some sink units in Service Users rooms, where there are no thermostatic controls, individual risk assessments must be carried out for Service Users in those particular rooms. There was no evidence that the temperature of the fridge in the staff room (that does store some supplement drinks for Service Users) had been taken and recorded. The manager thought that catering staff did it but they said they did not. Before the end of the inspection the manager had made arrangements for the catering staff to take on this responsibility. The completed pre inspection questionnaire indicates that all equipment is regularly maintained and tested. Portable electrical test (PAT) testing stickers were seen on electrical equipment throughout the home. The fire and accident books were examined and found to be completed as required. The inspector was shown the records and storage of personal money held in the home on behalf of Service Users. Best practise systems are in place for the protection of both residents and staff – 2 signatories are sought for each transaction, all receipts are kept for auditing purposes and the money is stored securely. The Elms Care Centre DS0000009168.V314687.R01.S.doc Version 5.2 Page 22 The Elms Care Centre DS0000009168.V314687.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 The Elms Care Centre DS0000009168.V314687.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 OP9 2 OP38 Refer to Standard Good Practice Recommendations It is recommended that all pots of creams should have a pharmacy label with the Service Users name on them and a date of opening clearly written on them. It is recommended that risk assessments of individuals be carried out on those in rooms where the taps are not thermostatic controlled and the water is very hot. The Elms Care Centre DS0000009168.V314687.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Care Centre DS0000009168.V314687.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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