Inspection on 20/06/06 for The Elms [Stapleton]

This inspection was carried out on 20th June 2006.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Elms [Stapleton] 21/10/08

The Elms [Stapleton] 05/11/07

The Elms [Stapleton] 13/11/06

The Elms [Stapleton] 03/03/06

The Elms [Stapleton] 17/08/05

The Elms [Stapleton] 18/08/04

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 The Elms Park Road Stapleton Village Bristol BS16 1AA Lead Inspector Sandra Jones Key Unannounced Inspection 20th June 2006 09:30 The Elms DS0000026632.V300704.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 The Elms DS0000026632.V300704.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. The Elms DS0000026632.V300704.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Elms Address Park Road Stapleton Village Bristol BS16 1AA 0117 9584506 0117 9699000 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.brandontrust.org The Brandon Trust Mrs Tanya Abbott Care Home 14 Category(ies) of Learning disability (12), Learning disability over registration, with number 65 years of age (2) of places The Elms DS0000026632.V300704.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Home may accommodate nine named residents whose primary focus of care is their mental health needs (Registration will revert to LD with no additional mental health care needs when these residents leave) The manager must be supernumerary at least three shifts per week. 2. Date of last inspection 3rd March 2006 Brief Description of the Service: The Elms is operated by the Brandon Trust and managed by Tanya Abbott. The purpose of the home is to provide accommodation and personal care for up to fourteen adults with learning disabilities. Within the numbers, nine individuals with learning disabilities for whom mental health care needs is the primary focus of care, are accommodated. The property is situated within its own extensive grounds on Stapleton Village close to shops, bus routes and other amenities. It is arranged over two floors with shared space on the ground floor and bedrooms on both floors. The Elms DS0000026632.V300704.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was conducted over one day in May 2006 and focused on the assessment of key standards of care. Records were examined and a tour of the premises took place to make judgements on the standards of care. Residents’ feedback was sought to confirm the standards of care and the members of staff were consulted on the conduct of the home. What the service does well: What has improved since the last inspection? The introduction of a downstairs shower room has raised the independence levels of residents with mobility impairments. Mental Health Awareness and Learning disabilities training will ensure that staff have the skills and capabilities to meet the residents changing needs. Members of staff are being designated tasks and have been presented with a clear statement of their responsibilities. The staff have taken these responsibilities seriously and are reviewing the systems. The Elms DS0000026632.V300704.R01.S.doc Version 5.2 Page 6 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 Elms DS0000026632.V300704.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 The Elms DS0000026632.V300704.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is adequate. There is sufficient information included within the Statement of Purpose for potential residents to make decisions about living at the home. The information about the staff must be updated when the document is next reviewed. EVIDENCE: The home has an in-depth Statement of Purpose will enable potential residents, their representatives and placing agencies to made decisions about living at the home. Information about the staff at the home must be updated when the document is next revised. There is full occupancy at the home and there is no intention for any of the current residents to leave the home. The Elms DS0000026632.V300704.R01.S.doc Version 5.2 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is poor. Residents participate in the care planning process but Essential Life Plans (ELP) must be developed for each person and Planning for Life Packs must only contain that person’s documentation. A reactive strategy must be developed for the resident that has recently been exhibiting violent behaviour, which must be reviewed and signed. There are restrictions imposed and steps are being taken to provide access to all parts of the home. There are opportunities for residents to make some choices about their lifestyle at the home. Where risks are identified, risk assessments are completed to minimise the level of risk. EVIDENCE: The Elms DS0000026632.V300704.R01.S.doc Version 5.2 Page 10 Planning for Life Packs are in place, which contain documentation on all areas of the person’s life. The pack uses a person centred approach to meeting needs. The manager has indicated that one Essential Life Plan (ELP) was completed since the last inspection. It is anticipated that senior support workers with support workers will compile ELP’s for residents in the group. For the one restructured plan, support plans are sectioned into individuals needs and will other ELP’s will have core similarities. The agreed support will incorporate the person’s likes, dislikes and preferred routines, ensuring that the staff use a person centred approach to complete tasks. During the examination of the Planning For Life Packs, it was noted that information for residents was incorrectly filed. There are five residents that at times may exhibit aggressive and violent behaviour. With one exception, reactive strategies are in place. Risks, contributory factors and actions are described. However, a reactive strategy must be devised for the person that has recently being exhibiting violent behaviour. Also, strategies must be reviewed and dated along with ELP’s. The senior support worker on duty described the restrictions imposed on freedom and choice. It was understood that the kitchen is being assessed to establish the reasons for restricting residents from entering the kitchen. Risk assessments for the kitchen and laundry are in progress and the risks and possible actions to reduce the risk were identified. It is anticipated that individual risk assessments will follow to ascertain the people able to prepare meals. The residents kitchen remains accessible at all times to prepare refreshments and light snacks. There are designated smoking areas and the staff manage the cigarettes for six residents. For residents that staff manage their cigarettes, there are signed agreements. Agreements are specific for the person and mainly it is to assist the person with budgeting. Residents were consulted about the standards of care at the home. One person was aware about their care plan and was able to describe the process. Key workers explain care plans to the resident and residents are able to make comments for inclusion onto the care plan. This individual felt that “ in a way” they were able to make decisions about their daily life. Within Planning For Life Packs is a section for choices and wishes, two of the four records examined were completed. Running reports are kept at the home for each person and staff record decisions and choices made by residents. Evidence that residents make choices include times for bathing, times to rise and recreational activities. It was understood from the senior support worker that advocates are not currently used at the home. The Elms DS0000026632.V300704.R01.S.doc Version 5.2 Page 11 Risk assessments are completed for activities that may involve an element of risk. Risk assessments are in place for safety, falling and personal care. It is evident that the risk assessments were recently reviewed and describe the risks, options and preventative measures to minimise the risk. A member of staff on duty reported that members of staff formulate risk assessments whenever risks are identified. The Elms DS0000026632.V300704.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is adequate. Residents that have community-based activities have opportunities to develop skills. There are little opportunities for the residents at the home to have meaningful activities. Members of staff endeavour to support residents with inclusion into the local community. Residents confirm that visitors are welcome. Residents know the rules for living at the home and more efforts must be made to promote independence. Meals are varied and wholesome. EVIDENCE: The senior support worker, during consultation, reported that four residents are at home during the week while the others participate in structured The Elms DS0000026632.V300704.R01.S.doc Version 5.2 Page 13 activities. It was understood that the residents that remain at the home during the day have chosen not to participate in any structured community based activities. However, there is no structured plan of activities at the home. It is anticipated that with the introduction of the Essential Life Plans (ELP), discussions with residents about their goals and aspirations will take place. It was further stated that three residents can leave the home without staff support and that staff support other residents to go shopping and visit restaurants. The residents are known at the local pub, shops and restaurants. At the most recent residents’ meeting, suggestions for outings were sought. While there is some 1:1 with residents, there is no scheduled 1:1 time with keyworkers. During the inspection the comments from a keyworker was sought. It was stated by the support worker that there is insufficient time allowed for keyworkers to have 1:1 with key residents. One person gave feedback on their lifestyle, it was stated that arrangements are in place for twice weekly community based activities. Relationships and family links are strengthened by weekly visits, walking around the grounds, watching television and shopping with the staff are activities undertaken at the home. This individual also confirmed that keytime is not arranged with keyworkers. Two residents consulted during the inspection confirmed that their visitors are welcome at the home. Visits can take place in shared space or bedrooms and the staff offer their visitors refreshments whenever they visit. The senior support worker stated that there are no expectations that residents participate in household chores. The resident consulted gave feedback on the manner in which staff respect their individuality, rights and promote their independence. It was reported that while there are no expectations to undertake chores, maintains bedrooms tidy and will help staff around the home. This individual further stated that there are rules for smoking and post is handed to the person unopened by the staff. There are no structured times to rise or retire and keys to bedrooms are provided. The cook prepares menus and generally there is a light breakfast and lunch with a cooked evening meal. There are two choices of meals in the evenings and alternatives are provided and a record of the alternatives served is maintained. A wide range of fresh, frozen and canned foods are kept and together with the menu evidences that residents have a varied and wholesome diet. A record of the cooked meat and temperatures of the freezer and fridge temperature is maintained. The Elms DS0000026632.V300704.R01.S.doc Version 5.2 Page 14 During the inspection, it was noted that cupboards need repairing, the base cupboard plinths need replacing, the seal around the sink is in need of attention and the water heater must be stabilised. The Elms DS0000026632.V300704.R01.S.doc Version 5.2 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate. Planning for Life must be developed for all residents to ensure that a person centred approach is use to meet physical care needs. Residents health care is monitored by the staff and where necessary referrals for specialist support is sought. For medication systems to safeguard residents, when required medications no longer required must be returned to the pharmacist for disposal. Records of homely remedies must be up to date. EVIDENCE: The completed Planning for Life Pack for one person described the individual’s personal care needs. The identified need along with the agreed support and accompanying risk assessments are in place. Within the agreed support, the actions to be taken to meet the need are specified. The individual’s preferred The Elms DS0000026632.V300704.R01.S.doc Version 5.2 Page 16 routine is incorporated and for the other residents their care plans list the needs with an action plan to meet the assessed need. One resident is having input from the speech therapist and felt that their contributions have been beneficial. The senior support worker stated that staff accompany residents on medical visits. There is access to NHS facilities, the optician visits the home and residents visit the local dentist. One resident is having input from the continence advisor. Eight residents have regular input from psychiatrists and following review meetings confirmation letters are sent to the home on the treatment plan. For residents with mental health care needs, reactive strategies incorporate triggers of deterioration with actions for diffusing the potential situation. Records of medical visits are kept by the staff and documentation held in files evidence that specialist support is sought. Documentation also supported that female residents are invited for routine screening. Members of staff are currently undertaking NVQ level 3 in medication to ensure their competency, with an internal verifier assessing competency. Individual profiles that specify homely remedies with their compatibility with regular prescribed medications are in place for the staff. Information leaflets are appended onto administration records. One support worker was given responsibility to organise the storing, ordering and administration records of medications. It was stated that medications are checked by on coming staff, stock checks are then conducted two weekly to monitor the quantities. The ordering follows from the stock checks. Medications are administered through a monitored dosage system. The records indicate that members of staff sign the records immediately after administering medications. It was stated that where gaps in the recording occur the person responsible is contacted to ascertain the reasons. Should persistent gaps occur for the same person, the manager is informed. A record of medications no longer required is maintained at the home. The pharmacist countersigns the record to indicate receipt of the medication for disposal. While medications no longer required at the home are returned to the pharmacist, stocks of when required medications no longer required remain at the home. Medications no longer required must be returned to the chemist for disposal. Medications are administered when required to a number of residents and the records were consistent with the medications held. Guidelines are in place for The Elms DS0000026632.V300704.R01.S.doc Version 5.2 Page 17 when required medications. However, it was unclear whether staff were aware that guidelines for when required medications exist. Homely remedies are administered from a stock supply when required, which are recorded on the individuals medication administration record. Stock checks of homely remedies are maintained. However, the record of stock checks was inconsistent with the medications held. The Elms DS0000026632.V300704.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. Residents feel that their views are sought and would approach staff with complaints. Members of staff know the procedure for safeguarding residents from abuse. EVIDENCE: Eight complaints were received at the home since the last inspection. Three complaints were received through residents meetings. During residents meetings residents, opportunities are available to residents to raise concerns. The nature of the complaints is recorded along with the actions and outcomes. The level of satisfaction must be included within the records of complaints. Residents giving feedback confirmed their awareness of the complaints procedure. It was also reported that keyworkers or the manager would be approached with complaints. Training records confirm that all staff have attended external POVA training. The member of staff of duty was clear on the procedure to be followed for protecting residents from abuse. It was further reported that the training was enlightening and from the training reflection occurred on past practices. The Elms DS0000026632.V300704.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is poor. The property is in urgent need of attention. The carpets and walls must be cleaned; repairs made to residents rooms; the upstairs toilet must be refurbished; the kitchen, residents kitchen and laundry must repaired and redecorated. The ventilation in the smoking lounge must be assessed. Members of staff and residents must be able to unlock the upstairs bathroom. Risk assessments for the resident that is smoking in the upstairs bathroom must be conducted for fire safety. EVIDENCE: The Elms is a large period property set in its own grounds in a village environment. It is close to amenities, shops and bus routes. Accommodation is arranged over two floors with shared space on the ground floor and bedrooms on both floors. The Elms DS0000026632.V300704.R01.S.doc Version 5.2 Page 20 Since the last inspection steps to maintain the property to a reasonable standard has been taken. A disabled shower with toilet was installed. One resident reported that the shower had increased their level of independence because staff’s assistance with getting in and out the bath is no longer necessary. A tour of the property was conducted during the inspection. The carpets in the corridor are dirty and require cleaning as well as the walls particularly to the rear, where the residents’ kitchen is. On the ground floor are two lounges, dining room and residents kitchen. Smokers use one of the lounges and ventilation is provided. It is not, however, suitable for the number of people that smoke in this room. The dining room is adequate and offers sufficient seating for all the residents to sit together and have their meals. In terms of the residents kitchen, the area was dirty and the flooring requires attention. In the kitchen the cupboards need repairing, the base cupboard plinths need replacing, the seal around the sink is in need of attention and the water heater must be stabilised. Overall residents bedrooms are decorated to a reasonable standard, the combination of the home’s furniture and residents’ belongings, reflect their personalities. However, the carpet in a downstairs room requires attention and the hole near the sink must be filled in an upstairs bedroom. The bathrooms require some redecoration, in the first floor bathroom, the wallpaper is chipping and it is evident that residents have been smoking in this room. A risk assessment must be formulated for the resident that is smoking in this room. Another upstairs bathroom is kept locked and cannot be opened by all staff. There is an upstairs toilet that is in need of urgent attention. The laundry is separate from the kitchen, the walls are painted and the flooring is vinyl for easy cleaning. However, the room requires repainting and the flooring must be repaired or replaced. There are two domestic washing machines that can reach 95 and one tumble dryer. The member of staff assisting in the tour of the premises stated that ancillary staff are roistered on a part time basis. It was understood that the member of staff cleaning the home has reduced hours from full time and the cleaning is not taking place as often as previously occurred. The Elms DS0000026632.V300704.R01.S.doc Version 5.2 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34 & 35 Quality in this outcome area is poor. Staff personnel files are kept at the Trust office. A further inspection to check these records will take place in the future. Residents assessed needs are not met by the staffing levels at the home. Steps are being taken to ensure that staff have the skills and competency to meet residents needs. EVIDENCE: Staff personnel files are kept at the Trust office and a checklist of the recruitment details is kept at the home. The manager views application forms, CRB disclosures all staff and written references at the Trust office. There is a checklist completed by the manager for each person’s personal details, references and CRB disclosures viewed at head office. The Elms DS0000026632.V300704.R01.S.doc Version 5.2 Page 22 The member of staff on duty stated that there is one senior and one support worker’s post vacancy. During the inspection there were three members of staff on duty and clearly the staffing levels were insufficient. One member of staff took residents to various day care activities and food shopping, leaving two staff at the home. These two staff were involved in personal care, food preparation and concentrating on residents that needed attention. Opportunities for residents to have 1: 1 personal development were not available during this period. It was further stated by a member of staff that there is insufficient staffing for all residents to have meaningful activities. At weekends, residents are restricted from undertaking activities because of poor staffing levels. It was understood from a member of staff on duty that the Trust has a training programme and staff can choose from the programme any appropriate training courses. During supervision senior staff are approached from training courses and usually accommodated. Training records were examined and it is evident that staff attend statutory training and vocational qualification is encouraged. Three staff are undertaking NVQ level 2 and one is on level 3. It was reported that in November, staff will have mental health and learning disabilities training. The Elms DS0000026632.V300704.R01.S.doc Version 5.2 Page 23 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 &42 Quality in this outcome area is poor. Members of staff and residents made favourable comments about the skills of the manager. Steps must be taken to provide a safe environment for residents. Risk assessments must be formulated for the residents that are at risk of falls and for one resident that is currently exhibiting violent and aggressive behaviours. EVIDENCE: The manager was not on duty at the time of the inspection. Residents and staff made positive comments about the managers’ leadership skills. The Elms DS0000026632.V300704.R01.S.doc Version 5.2 Page 24 The records that relate to fire safety practices and checks were examined. The records indicate that checks and practices are conducted at the stipulated frequencies. The manager takes steps to comply with associated legislation by the checks of system and appliances. However, the checks for the boiler and electrical appliances are overdue. A record of accidents and incidents is maintained at the home and since the last inspection fourteen accidents involving three residents have occurred. Eleven are related to one person exhibiting aggressive and violent behaviours and a multidisciplinary strategy meeting has been arranged. One is for a resident that is falling and another is for a resident that is exhibiting aggressive and violent behaviour. The risk assessment for the resident at risk of falls must be reviewed. A reactive strategy must be developed for the resident that is exhibiting aggressive and violent behaviour. The Elms DS0000026632.V300704.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 2 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 3 23 3 ENVIRONMENT Standard No Score 24 1 25 x 26 x 27 x 28 x 29 x 30 1 STAFFING Standard No Score 31 x 32 x 33 1 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 x 2 x LIFESTYLES Standard No Score 11 X 12 1 13 3 14 x 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 x 3 x x x x 1 x The Elms DS0000026632.V300704.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13(2) Requirement Timescale for action 30/07/06 2. 3. YA24 YA6 23 (2) 12(3) PRN Medication which has not been used for some time must be properly reviewed and returned to the Pharmacy. (Previously recommended 31/12/05) Repairs and redecoration must 30/10/06 take place as detailed in the body of the report. a) Residents signatures must be 30/11/06 included in their action plans. b) The individual’s decisionmaking process must be included into their person centred plans (pcp). c) Individual pcp must be developed for the residents accommodated. d) Personal care plans must be developed using a person centred approach. e) A system for monitoring the quality and content of pcp must be developed.(Previously required 31/12/05) a) Risk assessments must be dated and reviewed along with pcp. b) For restrictions imposed, risk assessments must be clear about the manner in which the decisions were reached. c) Reactive strategies must be DS0000026632.V300704.R01.S.doc 4. YA9 13(4) 30/11/06 The Elms Version 5.2 Page 27 formulated for the resident that is currently exhibiting aggressive and violent behaviour e) The risk assessment for the resident that is at risk of falls must be reviewed. f) A risk assessment must be formulated for the resident that smokes in the bathroom 5. YA33 18(a) Staffing levels must be organised 30/10/06 to provide continuity and stability. a detailed assessments of the staffing levels must be undertaken. (Previously required 31/12/05) The Statement of Purpose must be reviewed to update staff information. Boiler and electrical appliances checks must be conducted by a competent contractor 30/06/07 30/07/06 6. 7 YA1 YA42 6 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Elms DS0000026632.V300704.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Elms DS0000026632.V300704.R01.S.doc Version 5.2 Page 29 - 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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