Inspection on 05/11/07 for The Elms [Stapleton]

This inspection was carried out on 5th November 2007.

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 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 5 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] 13/11/06

The Elms [Stapleton] 20/06/06

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 Sarah Webb Key Unannounced Inspection 5 & 6th November 2007 09:00 th The Elms DS0000026632.V350254.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.V350254.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.V350254.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 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.V350254.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 13th November 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 fees at the home range from £ 422.55 -£630.68 per week. The Elms DS0000026632.V350254.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a Key Unannounced Inspection that took place over two days. Discussion was had with the Manager who helped with the inspection process. People using the service and several of the care team were met during the visit. The inspection process included viewing records in relation to care and support plans, risk management, the administration of medication, and the management of behaviours and interventions. Further information was also provided through the homes Annual Quality Assurance Assessment. A tour of the home was undertaken and interaction between staff and people was seen during the visit. Surveys were received by 4 relatives, and with two from Health Care Professionals. Feedback was generally very positive in the care and support offered to people. As a result of this inspection 5 requirements have been made in relation to several environmental issues. What the service does well: What has improved since the last inspection? Personal care support plans have improved through the involvement of people with their care planning. Plans are now more person centred showing how people should be helped with their personal support needs. Individuals will benefit from the manager involving advocates to help them make decisions about their lives. The manager has involved external advocate in reviewing the house rules. Some repairs and decoration have taken place. The Elms DS0000026632.V350254.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 summary of this inspection report can be made available in other formats on request. The Elms DS0000026632.V350254.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.V350254.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. Peoples’ needs are assessed and action is being taken to find more suitable placements so that needs are met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been no people coming to the home since the last inspection. Care files contained assessments of peoples needs including some copies of those completed by placing authorities. Care plans also seen showed how staff should support people to help meet their needs. Regular monitoring and assessing of peoples’ care through the care planning processes and reviews helps to meets peoples changing needs. The Annual Quality Assurance Assessment completed by the manager stated that the home now knows the proposed ‘future outlook of the Elms’ and that there will be some changes. Some of the people using the service have asked to move to other placements. This will mean that the home will not be taking any new referrals and will downsize. The Elms DS0000026632.V350254.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, & 9 Quality in this outcome area is good. People are better involved in making decisions about their lives and in the planning of their care. Risk assessments help people to take risks more safely. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans looked at showed that a person centred approach has now been taken in line with a requirement made through the previous inspection. This has helped staff to ensure that individualised support is offered and that people have been involved in their care planning. Information showed peoples preferences and how people wish to be supported. Specific goals set showed how these were to be met and all but one person had signed their action plan. Pictorial information helped people understand about their care needs. It was evident that the home has improved in involving people in making decisions about their care. The Elms DS0000026632.V350254.R01.S.doc Version 5.2 Page 10 The manager has made a referral for an individual to be supported through an Independent Mental Capacity Advocate (IMCA). This is good practice and shows that the home is aware of the need for an external advocate to support people in making important decisions about their lives. People have also been referred to People First, an organisation run by people with Learning Disabilities for advocates to support them in making decisions. An individual spoken with said they made choices about places they wanted to go to, how they wanted their bedroom to look and holidays. Risk assessments are completed with people so that they agree with any action to be taken. Risk assessments were detailed and had been reviewed. A survey returned from a relative stated that the well being of the people and their individual needs are always a priority. The Elms DS0000026632.V350254.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, & 17 Quality in this outcome area is good. People who use the service are able to make choices about their lifestyle, and helped to develop their life skills. People are supported with accessing their local community and recreational opportunities. People benefit from support in keeping in contact with their families. People benefit from meals that offer a nutritious and varied choice and encourage healthy eating options. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The AQAA stated that the home has got better at giving people more opportunities at going out on activities. This has happened through a day care worker supporting people 3 days a week. Some people requiring more support have separate day care provision. For one person this has helped in a more focused approach in helping to manage their lifestyle. The Elms DS0000026632.V350254.R01.S.doc Version 5.2 Page 12 Timetables showed meaningful activities and daily routines people were involved with. These included people going to day services, work placements and being helped with household tasks in the home. Support plans showed people have made choices through the care planning process setting short and long term goals, objectives and action plans. Daily records showed leisure and recreational activities people are involved with such as painting, trips out to different places, walks, going to the pub and skittles. People also go into the local community to the library and shops. On the night of this visit the home held a bonfire night party. The home has transport helping people in going out both in groups and individually. The local community Dial a ride bus service also supports people. There are some people who go the local community independently; others may need help. This is identified in their support care. Everyone has had a holiday this year. People made individual choices in going to Devon or Cornwall and staying at either a cottage, or a holiday camp. A survey received from a relative stated that staff help people with hobbies, painting and cooking. Overall comments made through the surveys returned were positive in that staff help people to keep in touch with their relative. The home has house meetings where different topics, concerns and any issues are talked about and a record is kept so that outcomes and actions can be followed up. People have been supported in writing their own house rules. The manager said the Elm’s is ‘looking at the possibility of future advocacy participation within house meetings.’ The home employs a cook; menus seen were varied and nutritious. People are involved in making decisions about their choices of food and it was evident that staff have a good understanding of their preferences. The Elms DS0000026632.V350254.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, & 20 Quality in this outcome area is good. Personal support plans show how people want to be supported. Peoples’ healthcare is well monitored by staff. Professional advice is asked for when necessary. People are treated with respect and are safeguarded by the home’s medication practices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection personal care support plans have improved through the involvement of people with their care planning. Plans are now more person centred showing how people want to be helped with their personal support needs. A staff member spoken with said that the staff have good relationships with people. Staff interaction was seen and this showed staff speaking respectfully to individuals. Those people spoken with said they liked the staff and felt they are supported well. This was also stated in the surveys that were received by people. The Elms DS0000026632.V350254.R01.S.doc Version 5.2 Page 14 Healthcare records and profiles show how people need to be helped with looking after their health. Records of visits to different agencies such as doctor, physiotherapist, dentist, and chiropodist help to monitor the outcome of visits and action to take. It was evident that the home works well with other professionals. A survey returned from a healthcare professional stated that the service ‘looks after people very well.’ The home has followed appropriate procedures in supporting an individual with a specific health issue that required consent. Healthcare records showed that their ‘best interests’ were recorded through a multi agency approach. The manager has been given advice from health care specialists and has updated their support plan to helping with their needs being met. The home promotes the mental health well being of people. Regular meetings take place with consultant psychiatrist to review individuals’ medication and any changes they may have experienced. If there are changes then people are supported in making appropriate decisions. This was evidenced through discussion with the manager and an individuals healthcare records showed urgent action taken to support them. Referrals have been made to the Bristol Intensive Response Team (BIRT) through the Community Learning Disabilities Team (CLDT). Care files showed how the team has been involved in supporting an individual and how this is conveyed to staff so that a consistent approach is taken. The procedures and systems for administration, storage and disposal of medication were checked to monitor if the systems are safe. Medication is administered through a monitored dosage system by the staff. The medication administration charts of several people were looked at. These were clearly written and contained signatures of the staff administering the medication. Medication profiles showed protocols for giving “as and when required” medication. These also showed what the medication should be used for and possible side effects. Stock balances were being checked on a weekly basis and all medication was signed in and dated. Medication that was no longer required was being returned to the pharmacist. Risk assessments were seen showing action to be taken when people refused their medication. Staff do not administer medication until they have completed a specific unit on the administration of medication through a National Vocational Qualification. Their competency is also checked on a regular basis. The Elms DS0000026632.V350254.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. People benefit from effective systems for complaints but cannot be confident that they will be protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a formal complaints procedure; there are easy read formats of the procedure that may help some people to understand how to make a complaint; this also includes appropriate contacts and timescales to respond to any complaint. Peoples’ views and concerns are recorded through house meetings and on a 1:1 basis. Three surveys received from relatives stated that they knew how to make a complaint but and that they did not want to. One survey stated that they did not know how to make a complaint. This was passed on to the manager. The complaints log book was seen showing that there have been eight complaints received at the home since the last inspection. Many of the complaints are to do with the challenging behaviour of an individual and their aggressive actions. The manager said that she was concerned that people were not complaining any more as challenges are still continuing. It is evident that an individual’s placement has broken down due to their behaviour escalating and presenting aggressive behaviour. This has affected the other people living at the home and the staff. Since the last inspection, we have been notified of further incidents of violent and aggressive behaviour towards people living at the home and staff. The Elms DS0000026632.V350254.R01.S.doc Version 5.2 Page 16 This is not acceptable and measures are now being taken to protect people living in the home and how best to meet the individual’s needs. Referrals have been made to both care direct and safeguarding adults coordinator; meetings have taken place through safeguarding procedures and minutes of meetings showed that other professionals have been involved in the protection of people living in the home. A requirement has not been made as action is being taken. There are policies and procedures in place relating to the issue safeguarding of vulnerable adults from abuse. Training records indicated that staff have attended training in abuse and that this is part of ‘core’ training that is implemented annually by the organisation. The home has guidelines in place for supporting people who may present challenges to the service. These identified individuals’ known triggers, behaviours displayed, and both proactive and reactive strategies to help diffuse difficult situations. The staff team has also had training in Positive Response in helping to deal with challenging behaviour. The home has strategies for when people leave the home and ongoing safety issues. A risk assessment showed the action staff must follow; the home has also liaised with the local police to also help ensure their safety. The Elms DS0000026632.V350254.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 28, & 30 Quality in this outcome area is adequate. People live in a homely, safe and clean environment that meets peoples care needs; there are still areas that need to be redecorated and refurbished. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Elms is a large period property set in its own grounds within 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. Western Challenge, a housing organisation, currently owns the property. The manager said that there are proposals to convert the property into 10 bed-sits with ensuite facilities in the future. The home has continued to make improvements to both the decoration and refurbishment of the home. A new kitchen has been fitted and laminate flooring has replaced the carpeting in the foyer and corridors on the ground floor. This has helped the general appearance of the home in looking spacious The Elms DS0000026632.V350254.R01.S.doc Version 5.2 Page 18 and clean. Peoples’ art work lined the foyer walls helping to show that there is a homely atmosphere. There are two lounges; since the last visit, one used to be the ‘smoking’ area but an organisational decision has now been made for people to smoke outside. The Annual Quality Assurance Assessment reflected that more use of this lounge now needs to be encouraged and the home will need to redecorate and provide new flooring to update this room. The second lounge is used more as a ‘quiet’ room. A new television has been bought for this area. There is enough seating in both these lounges. The designated smoking area is now outside within a courtyard. The manager said that a new covered area is being planned and that the existing panoply in this area is in the process of being investigated, as there are concerns that there may be asbestos in this. The dining room is spacious and has enough tables for people to sit comfortably; some people were seen during the lunchtime meal choosing to sit on their own. Not all peoples’ bedrooms were seen but those that were shown to be decorated as people wanted, and displayed their personal belongings. Some people have had new furniture and flooring fitted since the last visit. The home has enough toilets and bathrooms for people to use. An upstairs toilet has been converted into a urinal for the men and an extra long bath was installed in the adjacent bathroom. A unit needs to be resealed in this bathroom and further redecoration and refurbishment of another bathroom needs to be carried out. Staircase walls leading to the staff sleep in room need to be decorated due to stains where rainwater had penetrated through the roof tiles in the past. The laundry is a separate area; a requirement is unmet for the room to be repainted and new flooring to be repaired or refitted. There are two domestic washing machines and one tumble dryer. The home was advised to carry out a risk assessment, as there have been some occasions when people have been using the washers independently resulting in some clothes being damaged. A cleaner is employed and it was evident that this helps in keeping the home clean. Surveys were received from 5 people; of which 3 stated that the home is ‘always’ fresh and clean whilst 2 said ‘sometimes.’ Records showed that a competent person has checked the lightening conductor. The Elms DS0000026632.V350254.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, & 35 Quality in this outcome area is good. People benefit from a staff team who have received relevant training to meet the needs of people. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There are 13 staff employed at the home including 12 bank staff who cover vacant shifts. The manager said that the home tries to ensure regular bank workers are used who have a good understanding of peoples needs and for consistency. Those staff spoken with demonstrated a good understanding of peoples needs. All new staff complete a 2 week Trust induction programme including the Learning Disabilities Award Framework and progress to NVQ level 2 awards. The corporate induction also includes the philosophy of the organisation. The home has 6 staff who have achieved a National Vocational Qualification level 2 or 3, whilst there are 2 staff working towards this qualification. Training records showed that staff were up to date with their mandatory training including food hygiene and first aid. Records showed that people are The Elms DS0000026632.V350254.R01.S.doc Version 5.2 Page 20 booked to complete courses in manual handling, the mental capacity act, and advocacy awareness. A joint training event has been booked with another home in understanding autism. Staff personnel files are kept at the Trust office and a separate inspection to examine these records will be undertaken by an inspector. The Elms DS0000026632.V350254.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, & 42 Quality in this outcome area is good. The manager is motivated to bring about improvements in peoples quality of life. People benefit generally from a well run home with their views listened to. There are processes to monitor health and safety to ensure people are safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager Ms Abbott is experienced in the care of people with a learning disability. She has the Registered Manager Award and is currently in the process of completing a National Vocational Qualification at level 5. There are 3 other senior staff who also share the management responsibilities and tasks associated with the monitoring of the home; tasks are also delegated to members of the staff team. The Elms DS0000026632.V350254.R01.S.doc Version 5.2 Page 22 Staff spoken with were confident in the managers leadership and felt well supported to do their job. Staff meetings are held on a regular basis to help inform staff and to discuss relevant issues in the care of people. Regular house meetings are held to access the views of people on the quality of life and services in the home. Surveys returned by people stated that they were happy with the care and support offered. The relatives surveys all agreed that they were satisfied with the overall care provided. The home has a written fire policy and procedure. Fire records evidenced that the home has completed a fire risk assessment identifying any fire hazards and how to keep the home safe. This includes an agreed action plan to be taken if there is a fire during both the day and night and individual risk surveys showed areas of concern. Fire equipment checks were taking place and all staff had attended fire drills and training. Annual Health and Safety Audits are carried out by the Trust and monthly inhouse checks carried out. Records such as the portable appliance testing, lightening conductor test, and environmental audits showed the health and safety systems in place helping to ensure people are protected. Generic risk assessments were seen showing specific hazards and controls to help keep both people and staff safe. An external home manager or a senior manager carry out Regulation 26 visits on a monthly basis to monitor the management of the home; copies of these reports are sent to us The certificate of employer’s liability was displayed with the registration certificate. The Elms DS0000026632.V350254.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 Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 3 32 3 33 x 34 x 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x The Elms DS0000026632.V350254.R01.S.doc Version 5.2 Page 24 YES Are there any outstanding requirements from the last inspection? 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 YA24 Regulation 23 (2) Requirement Timescale for action 31/01/08 2. 3. 4. 5. YA24 YA24 YA24 YA24 23 (2) 23 (2) 23 (2) 23 (2) Decorate laundry room walls and replace or repair flooring. Unmet requirement (30/03/07) Decorate and replace flooring in 30/04/08 the lounge that was once the ‘smoking’ room. Reseal bathroom unit on second 31/12/08 floor. Decorate and refurbish bathroom 31/03/08 assigned for an individual. Decorate staircase walls leading to staff sleep in room 30/04/08 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.V350254.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection South West Regional Office 4th Floor, Colston 33 33 Colston Avenue Bristol BS1 4UA 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 DS0000026632.V350254.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. 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