Care Home: Elmbank Care Home

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What the care home does well People said they were supplied with sufficient information about the service, in order to make an informed decision about living there. People felt their healthcare needs are met and that their medication is managed appropriately. People said they are afforded appropriate levels of privacy and dignity at all times by staff appropriately training staff. People said that recreational activities are provided within the home and opportunities are available for people to interact within the broader community. People said they enjoyed the meals provided and said they are able to have snacks and drinks as they wish. People expressed satisfaction with regards to the environment and said it is always clean and comfortable. Staff recruitment practices are effective in promoting peoples safety. People felt that the home is run and managed by a person who is fit to be in charge and felt confident that complaints and concerns are effectively managed. What has improved since the last inspection? Recruitment practices have improved. The most recent inspection report is now made available to people and representatives. All care plans now contain relevant risk assessments in relation to the prevention of falls. Medication management is now effective and safe. Reports on the outcomes of quality assurance and monitoring are now made available to people. What the care home could do better: All the key standards were met. CARE HOMES FOR OLDER PEOPLE Elmbank Care Home 35 Robinson Road Mapperley Nottingham NG3 6BB Lead Inspector Steve Keeling Unannounced Inspection 19th August 2008 09:00 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 Elmbank Care Home DS0000026433.V370338.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. Elmbank Care Home DS0000026433.V370338.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Elmbank Care Home Address 35 Robinson Road Mapperley Nottingham NG3 6BB 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) 0115 962 1262 0115 952 3726 isabel.mantle@redwoodcare.co.uk Elmbank Nursing Home Limited Mrs Isabel Mantle Care Home 35 Category(ies) of Learning disability (4), Old age, not falling registration, with number within any other category (35), Physical of places disability (2) Elmbank Care Home DS0000026433.V370338.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Elmbank Nursing Home Limited is registered to provide nursing and personal care at Elmbank Care Home for up to 35 persons of both sexes whose primary needs fall within the categories of: Older Persons, not falling into any other category (up to 35 people). Learning disability (up to 4 people). Physical disability (up to 2 people). Those in the category of Learning disability and Physical disability shall normally be over the age of 50 years. One bed may be used in the category LD to accommodate a named person referred to in Variation application dated 23/09/05. This person was aged 47 years on admission. One bed may be used to accommodate the named person named in the variation application dated November 2006. This person was aged 45 years on admission. 26th September 2007 2. 3. 4. Date of last inspection Brief Description of the Service: Elmbank is registered to provide a service for up to thirty-five older people in single and shared rooms, some with en-suite facilities. The premises are an extended residential house in Mapperley, close to a shopping area and four miles from Nottingham city centre. Both nursing and care staff are provided. The home is accessible for wheelchair users and there are accessible gardens to the rear of the property. A lift provides access to the first and second floors. The fees for care and accommodation range from £334 to £500 per week, depending on assessed level of need and whether or not nursing care is required. A copy of the most recent inspection report is made available to people and other stakeholder s in the foyer of the home. Elmbank Care Home DS0000026433.V370338.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people who use the service and their views on the quality of service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. One inspector conducted the unannounced visit. The main method of inspection used was called ‘case tracking’ which involved selecting people who use the service and looking at the quality of the care they receive by speaking to them, observation, reading their records and asking staff about their needs. The registered manager, two member of staff and relatives of people whom use the service were spoken with as part of this inspection. Documents were read as part of this visit and medication management was inspected to form an opinion about the health and safety of people who use the service. A partial tour of the building was undertaken which included bedrooms, communal areas and the garden to make sure that the environment is homely and safe. A review of all the information we have received about the home since the last inspection was considered in planning this visit, which included an Annual Quality Assurance Assessment (AQAA), provided by the registered manager and the twelve responses to the “have your say” survey which was filled in by people who use the service or a relative on their behalf. The quality rating for this service is 2 star this means the people who use this service experience Good quality outcomes. Elmbank Care Home DS0000026433.V370338.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Recruitment practices have improved. The most recent inspection report is now made available to people and representatives. All care plans now contain relevant risk assessments in relation to the prevention of falls. Medication management is now effective and safe. Reports on the outcomes of quality assurance and monitoring are now made available to people. Elmbank Care Home DS0000026433.V370338.R01.S.doc Version 5.2 Page 7 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. Elmbank Care Home DS0000026433.V370338.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Elmbank Care Home DS0000026433.V370338.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supplied with sufficient information about the service, in order to make an informed decision about living there. Assessments are performed prior to moving into the home, to ensure peoples needs can be met. Intermediate care services are not provided at the home. EVIDENCE: The pre inspection survey asked, “did you receive enough information about this home before you moved in, so you could decide if it was the right place for you?” twelve people responded, “yes”. The registered manager stated, and people confirmed that a “service users guided” is provided on admission to the home. The guide sets out the objectives and philosophy of the service, the qualifications and experience of Elmbank Care Home DS0000026433.V370338.R01.S.doc Version 5.2 Page 10 staff, facilities available at the home and information relating to how to make a complaint. We spoke to people who use the service and visitors to the home, they confirmed that they had received the guide and felt they had been given sufficient information about the home and the facilities available. A relative of a person who uses the service commented, “I visited some 28 care homes in Nottingham to find the best home for my mother. Elmbank is not the most posh but it provides the best care. Information was supplied, but it was not the basis on which I made the decision, rather impromptu visits at different times of the day and night, made me secure in the knowledge it would support my mother in terms of nursing care and her broad spectrum of needs”. The manager stated that a relative of two people who use the service has agreed to perform a “link relative” role at the home. The role involves providing feedback on care provision, social activities and the homes environment to the manager. In addition potential clients or their relatives can also contact the link relative to discuss the quality of care at the home. We spoke to the designated person who confirmed the arrangements are in place. People are only admitted to the home on the basis of a full needs assessment undertaken by people competent to do so. The assessment process provides the opportunity to identify people’s holistic needs and provides the opportunity to identify people’s needs in relation equality and diversity. The assessment process also uses information from advocates such as social service department when available. Elmbank Care Home DS0000026433.V370338.R01.S.doc Version 5.2 Page 11 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 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The healthcare needs of people who use the service are recorded and met. Medication is managed appropriately and people who use the service are afforded appropriate levels of privacy and dignity. EVIDENCE: The pre inspection survey asked, “Do you receive the care and support you need?” Seven people stated “always” and five people stated, “usually”. We asked a person who uses the service if she felt her needs were being fully met, the response was “I really cannot fault the care I receive, the staff are lovely” Elmbank Care Home DS0000026433.V370338.R01.S.doc Version 5.2 Page 12 We asked a relative about the quality of care provided at the home, her response was “, brilliant, the staff are kind and considerate very affectionate whilst being very professional and caring.” Care plans are in place, which are pre prepared templates. The care plans are personalised with individual names and additional information if required. The care plans provide staff with sufficient information to promote people’s health and wellbeing. The manager stated and staff confirmed that training has been provided in person centred care planning to further personalise their care process and some person centred documentation has been put in place already. All care plans include risk assessments to ensure risks are identified and addressed. The care plans and risk assessments are reviewed on a monthly basis or as required to ensure changing needs are identified and met. The pre inspection survey asked, “Do you receive the medical support you need?” all twelve respondents stated yes. Records showed, and people who use the service confirmed that they have access to the District Nursing team, Chiropodists and their General Practitioner on request. Records also showed and people confirmed that they also attend opticians and the dentist as required. A person who uses the service was asked if she received her medication on time, the response was “always”. A medication round was observed; a qualified nurse administered the medication in a safe manner. The Medication Administration Records (MAR) were filled out correctly and demonstrated medication was administered appropriately. The temperature of the medication fridge was being monitored on a daily basis, records showed that the temperature was slightly outside the required 2-8 degrees centigrade on occasions, the fridge thermostat was altered to address the issue. Three medicines were audited which included a controlled drug. The quantities of the medicines tallied with what had been signed as given. The pre inspection survey asked, “Do the staff listen and act on what you say”, all respondents stated, “yes”. Through discussions with a person who uses the service and observation throughout the day of the visit it was evident that staff always promote peoples respect and dignity. Staff were observed to knock on bedroom doors before entering and peoples privacy and dignity is promoted when performing personal interventions. A person who use the service said, “its very nice here, they always respect me, it’s not like being at home but I do like.” Elmbank Care Home DS0000026433.V370338.R01.S.doc Version 5.2 Page 13 A visitor to the home said “my parents are always afforded appropriate levels of respect and dignity, choice is promoted in relation to meal preferences, daily activities and how they spend their days”. The visitor also said that the staff are always welcoming and respectful and she had never witnessed anything that gave her any concerns. Elmbank Care Home DS0000026433.V370338.R01.S.doc Version 5.2 Page 14 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 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Recreational activities are provided within the home and opportunities are available for people who use the service to interact within the broader community. People who use the service benefit from the provision of an appealing balanced diet and are able to have snacks and drinks as they wish. EVIDENCE: The pre inspection survey asked, “Are activities arranged by the home that you can take part in?” three people said “always”, six people said “usually”, two people said “sometimes”, one person said “never” although an explanation was provided within the questionnaire as to why the person did not attend social activities. People who use the service said that the social activities provided at the home, such as sing songs, playing bingo and playing board games. A person said that guest entertainers attend that home on a monthly basis, which they enjoy. Elmbank Care Home DS0000026433.V370338.R01.S.doc Version 5.2 Page 15 A person said that she is provided with the opportunity to go out on trips into the local community. On the day of the visit (PM) people were provided with a trip out to a local beauty spot. Although people are encouraged to take part in activities people said that staff respect their choice if they do not wish to participate. A small secure garden area is available for use in the summer months. The garden area is currently being upgraded with the intention of providing a sensory garden for people’s enjoyment. The garden area is accessible to people with impaired mobility and the area has a range of garden furniture. It is also planned that a “chicken and egg” project will be set up to provide people with the opportunity to care for hens and collect their eggs on a daily basis. The manager stated that an open door policy is encouraged at the home and stated that family and friends can visit as they wish. Visitors to the home confirmed the open access and stated, “I have been coming here for so long that it feels like the staff are part of my family. I am always offered drinks”. The manager stated within the Annual Quality Assurance Assessment “Mealtimes are unhurried, assistance is given when required, and a choice of meals is provided from a varied menu”. The pre inspection survey asked, “Do you like the meals at the home?” two people said “always” and ten people said “usually”. People who use the service said that they were very happy with the meals at the home, stating “the meals are lovely, always very nice, always a choice provided, well presented and plenty”. A visitor to the home said, “the meals look excellent”. Written menus are on display in the dining room to assist people in selecting their meals. On the day of the visit people were provided with a choice of fish and fresh vegetable or omelette and salad followed a sweet of heir choice. The meals were home made, well presented and looked very appetising. People also confirmed that they could have a drink whenever they wish. Elmbank Care Home DS0000026433.V370338.R01.S.doc Version 5.2 Page 16 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 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints and concerns are effectively managed and staff have received training in Safeguarding Adults. EVIDENCE: Information supplied within the Annual Quality Assurance Assessment stated “A copy of the complaints procedure is contained within the service users guide which is issued to all residents”. A written complaints procedure is also displayed in the foyer of the home. The pre inspection survey asked, “Do you know how to make a complaint?” Eleven people said “yes” and one person said, “I would inform my relative”. Comments made in the pre inspection questionnaire included “we wouldn’t hesitate to raise any concerns, the manager is excellent in encouraging comments, suggestions even complaints in order to ensure ongoing quality of service”. People who use the service said they felt safe and felt confident that they could report any concerns to the manager, a person said, “I have nothing to complain about”. Elmbank Care Home DS0000026433.V370338.R01.S.doc Version 5.2 Page 17 We asked a visitor to the home if she was aware of the complaints procedure and was she aware of what to do if she was not happy with the service. The visitor confirmed that she has received a complaints procedure within the service users guide and said, “The home is excellent I only have one concern which is that my parents clothes are, on occasions returned un-ironed, I have discussed this with the manager and steps have been taken to remedy the situation”. The manager was not investigating any complaints at the time of the visit. The Commission for Social Care Inspection has received two complaints since the last unannounced inspection. The complaints were referred to Social Services departments for investigation and records showed that the manager liaised with social service departments effectively in an attempt to achieve a satisfactory outcome. Training records showed that staff have received training in relation to the Safeguarding Adults, staff spoken with confirmed the training had been provided and were able to demonstrate a good knowledge of their roles and responsibilities in Safeguarding Adult procedures. The revised Nottinghamshire Safeguarding Adults policy is available for guidance should staff suspect abuse is happening in the home. Elmbank Care Home DS0000026433.V370338.R01.S.doc Version 5.2 Page 18 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 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People benefit from a safe, well-maintained environment, which is comfortable, and clean. EVIDENCE: The pre inspection survey asked, “is the home clean and fresh?” the twelve respondents stated “always”. We asked a people who uses the service if he they are satisfied with the standard of cleanliness at the home, all comments were very positive and included “Its beautiful, cannot fault it at all, my room is cleaned daily, the dining room and living rooms always nice and clean”. Elmbank Care Home DS0000026433.V370338.R01.S.doc Version 5.2 Page 19 Visitors to the home also expressed satisfaction with the standard of cleanliness stating, “I have never witnessed anything that would give me cause for concern, the rooms are cleaned daily as is the rest of the home”. We performed a partial inspection of the premises, which included people’s bedrooms, communal areas and the kitchen facility. All areas were very well maintained, clean and fresh. People’s bedrooms were homely, safe and personalised with family pictures, a television and small items of furniture. A sample check was made on water outlet temperatures in peoples bedrooms which were satisfactory, restrictors were noted on windows and radiator guards are in place to promote peoples safety. Antibacterial hand scrub is provided throughout the home, which is excellent practice and staff confirmed that protective aprons and gloves were available and staff said that they are used to promote infection control. A small garden area is available for peoples use. As mentioned earlier in the report the garden is currently being upgraded with an expectation that the work will be complete within four weeks. Elmbank Care Home DS0000026433.V370338.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The number of staff employed at the home meets people’s needs and staff have received appropriate training. Recruitment practices are effective in promoting safety. EVIDENCE: The pre inspection survey asked “are staff available when you need them? Ten people said “always” and two people said “usually” A person who use the service said “sometime you have to wait a little time but not very often, the staff they are lovely”. A visitor to the home said, “staff are always available, I visit most days and always lots of staff available”. Records showed that members of staff only commence employment once satisfactory Protection of Vulnerable Adult (POVA) checks and Criminal Record Bureau (CRB) checks have been obtained to promote the safety of people. Elmbank Care Home DS0000026433.V370338.R01.S.doc Version 5.2 Page 21 Records showed and staff confirmed that on commencing employment staff are enrolled on an induction programme based on the “Skills for Care” common induction standards. Records showed that additional accredited training is also provided in relation to dementia care, fire safety, health and safety, moving and handling, first aid, continence promotion, fall prevention, abuse awareness and managing challenging behaviour, infection control and equality and diversity. Information provided by the manager within the AQAA showed that the service has achieved the target of 50 of staff trained to a National Vocational Qualification (NVQ) level two and above with the remaining 50 of staff working towards the qualification. The “Investor in Peoples Award” has been recently attained. The manager stated that the award has motivated staff thus improving outcomes for people who use the service. Elmbank Care Home DS0000026433.V370338.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 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 run and managed by a person who is fit to be in charge and the safety and welfare of people who use the service is promoted. EVIDENCE: The registered manager has been in post since August 2006. She is a Registered Nurse and has experience of working with the elderly both in hospital and the community setting. The manager has recently attained a degree level Registered Mangers Award. Elmbank Care Home DS0000026433.V370338.R01.S.doc Version 5.2 Page 23 The pre inspection survey asked, “is there anything else you would like to tell us”. Comments included “the home is well run, the manager is on the ball, there is a good atmosphere and staff are well motivated to care for people”, “I feel this is a very well run home” and “I’m really happy here”. A member of staff said that she felt supported by the manager, she said, “This manager is really good, she can sort anything out, very supportive, cooperative and professional. She gives direction and guidance”. Records showed and staff said that supervision sessions are performed on a monthly basis and said they find the supervision process to be “useful and supportive”. Staff said that policies and procedures are readily accessible and information within the Annual Quality Assurance Assessment showed that the policies and procedures are updated appropriately. Satisfaction surveys are performed on a three monthly basis. The surveys are sent out to three people who use the service and a relative. The outcomes of the surveys are forwarded to quality assurance manager within the organization so any concerns can be highlighted and addressed. We examined some satisfaction surveys, comments included “we are very pleased with the care provided and the patience displayed to our relative” and “what I like about the home is its homeliness”. Additional quality auditing processes are in place to determine the satisfaction levels of people who have been in residency for a short period, for example respite care. Comments made within resent questionnaires included “ the rooms were comfortable and very clean, the meals are nice and varied and the staff are excellent. Everyone was always ready to help and advise, I was provided everything to make me feel comfortable”. People are provided with the opportunity to store small amounts of spending money within a secure area at the home. The manager stated that all financial transactions for example hairdressing and chiropody services are recorded. Receipts for financial transactions are obtained to ensure that people are protected from financial abuse. An examination of the financial records showed that people’s finances are well managed and secure. The health, safety and wellbeing of people who use the service is promoted by the provision of effective routine maintenance. Information provided within the Annual Quality Assurance Assessment shows that an up to date electrical circuit safety certificate and gas certificate is in place. Elmbank Care Home DS0000026433.V370338.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 4 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 x x x x x x 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 Elmbank Care Home DS0000026433.V370338.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 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. Refer to Standard Good Practice Recommendations Elmbank Care Home DS0000026433.V370338.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Elmbank Care Home DS0000026433.V370338.R01.S.doc Version 5.2 Page 27 - 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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