Care Home: Three Elms

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What the care home does well Staff members provide a good standard of care to the people that live at Three Elms. Warm and friendly relationships were seen to exist between residents and staff and those people that commented all said that the staff members were good. This helps to ensure that the home is able to respond to changing needs. One resident said; "Staff members are very respectful, wonderful, they Three Elms DS0000072879.V375676.R01.S.doc Version 5.2 cannot do too much for you. One of the residents has written on a survey form; "There is always someone willing to sit and talk to me", another person has written; "I feel safe and don`t have to worry about anything". There are a number of positive comments on the survey forms received from relatives; these include; "I am really happy that my relative is cared for at Three Elms". Another person has typed a response and attached it to the form; this is very complimentary about a number of aspects of the home including the staff members and the quality of care provided, the food provided, the activities organised, the laundry and the overall hygiene standards within the home. There is a strong commitment from everyone working at the home that helps to ensure that the quality of care is provided to a very good standard. People are treated with respect and dignity and we found that the staff members were able to demonstrate an awareness of the diverse needs of the people they were caring for. Residents confirmed during the visit that routines within the home were flexible and that this gave them some control over their lives and enabled them to be more independent. A staff member has written on a survey form, "We have always tried to promote independence when we can". Three Elms provides a safe, homely and well-maintained environment for residents. A staff member has written on a survey form that they think the home managers consider the needs of the staff members as well as the residents and family members; this creates a good atmosphere within the home. Catering within the home is very well managed and the residents are able to make daily choices regarding the food they eat. All of the residents spoken with said the food was good. What has improved since the last inspection? This is the first inspection of the home since the change in ownership. What the care home could do better: We consider that Three Elms is a good service so rather than state what they could improve we would expect that the home continues to review its practice in order to ensure that the high standard of care provided to the clients at the present time is maintained and where possible improved upon. Key inspection report CARE HOMES FOR OLDER PEOPLE Three Elms Station Road Penketh Warrington Cheshire WA5 2UG Lead Inspector Paul Ramsden Key Unannounced Inspection 15th May 2009 09:45 DS0000072879.V375676.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Three Elms DS0000072879.V375676.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Three Elms DS0000072879.V375676.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Three Elms Address Station Road Penketh Warrington Cheshire WA5 2UG 01925 723274 01925 791985 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) Minster Care Management Limited Mrs Linda Briscoe Care Home 60 Category(ies) of Dementia (60), Old age, not falling within any registration, with number other category (60) of places Three Elms DS0000072879.V375676.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC To people of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Dementia - Code DE The maximum number of people who can be accommodated is: 60 Date of last inspection This is the first inspection since a change of ownership. Brief Description of the Service: Three Elms is a two/three-storey care home standing in its own grounds; access between floors is via a shaft lift or the stairs. The home is situated in the Penketh area of Warrington and is close to the local shops and other community facilities. There are adequate car parking facilities available. The home provides accommodation for up to 60 older people. There are a number of lounge areas within the home available for people to choose from. There are fully accessible patio and garden areas available for residents. The current fee range for the home is between £340 and £400 per week. Further information about fees is available from the home’s manager or deputy. A copy of this inspection report can be obtained from the home on request or via the CQC website. Three Elms DS0000072879.V375676.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means that the people who use this service experience good quality outcomes. This unannounced visit took place on the 15 May 2009 and lasted for a total of eight hours. Paul Ramsden, Inspector, undertook the visit on behalf of the Care Quality Commission. Any references to “us” or “we” in the report refer to the Commission. All of the key standards for older people were looked at. Feedback on the findings of the inspection was given to the home and the area manager for Minster Care [who was also visiting the home on the day] as the inspection progressed. This visit was just one part of the inspection. Prior to the visit the home manager was asked to complete an Annual Quality Assurance Assessment [AQAA] to provide up to date information about the service provided in the home. This is a very detailed questionnaire that provides us with a lot of information about the service before the visit. Survey forms were sent to a random sample of staff members to find out their views and any other information received since the last key inspection was reviewed. Survey forms for clients and relatives were given to the manager upon arrival at the home. We have since received three forms from residents using the service, five relatives and ten staff members. We have also received a letter from a relative, this was very complimentary about the home and the service provided. A number of the comments received have been included in the report. During the visit various records and the premises were looked at. When looking at the documents relating to the type of care each person needs [assessments and care plans] we use a system called case tracking. This is a method that allows us to follow or track a particular situation in order to ensure it was dealt with appropriately. A number of residents, family members, other visitors to the home and staff were spoken with; they gave their views about the home and the service provided. Some of these comments have been quoted in the report. What the service does well: Staff members provide a good standard of care to the people that live at Three Elms. Warm and friendly relationships were seen to exist between residents and staff and those people that commented all said that the staff members were good. This helps to ensure that the home is able to respond to changing needs. One resident said; “Staff members are very respectful, wonderful, they Three Elms DS0000072879.V375676.R01.S.doc Version 5.2 Page 6 cannot do too much for you. One of the residents has written on a survey form; “There is always someone willing to sit and talk to me”, another person has written; “I feel safe and don’t have to worry about anything”. There are a number of positive comments on the survey forms received from relatives; these include; “I am really happy that my relative is cared for at Three Elms”. Another person has typed a response and attached it to the form; this is very complimentary about a number of aspects of the home including the staff members and the quality of care provided, the food provided, the activities organised, the laundry and the overall hygiene standards within the home. There is a strong commitment from everyone working at the home that helps to ensure that the quality of care is provided to a very good standard. People are treated with respect and dignity and we found that the staff members were able to demonstrate an awareness of the diverse needs of the people they were caring for. Residents confirmed during the visit that routines within the home were flexible and that this gave them some control over their lives and enabled them to be more independent. A staff member has written on a survey form, “We have always tried to promote independence when we can”. Three Elms provides a safe, homely and well-maintained environment for residents. A staff member has written on a survey form that they think the home managers consider the needs of the staff members as well as the residents and family members; this creates a good atmosphere within the home. Catering within the home is very well managed and the residents are able to make daily choices regarding the food they eat. All of the residents spoken with said the food was good. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Three Elms DS0000072879.V375676.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Three Elms DS0000072879.V375676.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Information about the service is available and residents are assessed before moving in to ensure their needs can be met at the home. . EVIDENCE: Three Elms provides a range of information to residents; these include the service user guide and statement of purpose copies of which are on the notice board next to the entrance. It was confirmed that a personal copy [including different formats] could be made available on request. We think that these documents give people enough information about the home and what can be provided. Pre-admission assessments demonstrating that the residents individual needs had been assessed in an accurate and consistent way had been carried out for the residents whose files were looked at. The deputy or team leaders usually Three Elms DS0000072879.V375676.R01.S.doc Version 5.2 Page 9 carry out the assessments and they will visit people in their own home, another care home or hospital to gather the necessary information before admitting someone. As far as possible the prospective resident or their relatives are involved in both the assessment and care planning process. This provides an opportunity to make sure the home can accommodate the person and their individual needs. When someone is funded by the Local Authority they also provide an assessment of the persons needs prior to admission. This provides background information as to the reasons why a move to the home is needed and is very useful when combined with the homes own assessment. Intermediate care is not provided at Three Elms. Three Elms DS0000072879.V375676.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The clients care plans we looked at provided sufficient information for staff members to be able to meet an individuals needs. EVIDENCE: The team leaders are responsible for drawing up a residents plan of care. Following the change of ownership a new care planning system has been introduced; this is currently being implemented and approximately 20 of the 57 residents’ files had been changed over to the new system. The care plans seen as part of the case tracking process provided staff members with the necessary information for them to look after a person’s needs. They were up to date and were written in a way that would enable someone reading it to have a good idea of what help and assistance someone needed at that time. Care plans were being reviewed, with input from the residents or their representatives and where necessary, re-written on a regular basis. Risk assessments, including falls had been completed. Three Elms DS0000072879.V375676.R01.S.doc Version 5.2 Page 11 Staff members spoken with could show that they had a good understanding of the people they were supporting and they were able to meet their diverse needs. Care staff work to a good standard in order to ensure that residents receive the care they need. They monitor a resident’s health and emotional needs daily and there was evidence to show that people were receiving the appropriate support from district nurses, GPs etc. A key worker system is in place [This is a system used in the majority of homes and involves particular staff members working more closely with certain residents]. A relative has written on a survey form; “My relative was quite ill recently and the care she received at Three Elms when she returned was excellent”. The changing needs of individuals are discussed as and when required. We were able to see this in practice during the visit when information about an individual was passed onto the team leader. Handover sheets are also used between shift changes; these help to ensure any possible issues are picked up and dealt with quickly. It was seen throughout the visit that residents were being treated with courtesy, respect and good humour by staff. They were seen to be interacting with individuals in an appropriate way, knocking on bedroom doors before entering and addressing people according to their wishes. The residents spoken with during the inspection all said that the standards of care provided were very good and that they had been able to express their opinions and wishes about their daily routines. A visiting relative told us; “My relative is very well looked after, I would complain if I had any issues”. All personal care is carried out in the privacy of a residents bedroom or one of the bathrooms. Minster Care has a written policy on the receipt, administration [including self administration], safekeeping, handling, recording and disposal of medication within its homes. Three Elms uses a blister pack system dispensed by a local pharmacist; the arrangements for the administration of medicines during this inspection visit were considered to be good and the residents were being given their medication as prescribed. All senior staff members have received medication training. Three Elms DS0000072879.V375676.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people spoken with were positive about the home and the support they were receiving. EVIDENCE: People were able to move around freely within the home and a choice of sitting areas was available. Residents spoken with were pleased with the support they received from the staff members. They confirmed that routines within the home were flexible and that they were able to choose how they spent their time during the day; this included, times of rising and retiring, where to spend their time and with whom and participation in planned activities. The residents and visitors spoken with made wholly positive comments during the visit. One resident sitting in a lounge told us; “I like some quiet time so I will spend some time in my room”. The home has two experienced activities co-ordinator whose role is to work with residents, both individually and in groups. A variety of social and other activities are organised and an events calendar is displayed on the residents’ Three Elms DS0000072879.V375676.R01.S.doc Version 5.2 Page 13 notice board; other information such as the minutes of the residents meetings was also displayed. We saw a quiz taking place during the afternoon, this was well attended and people appeared to enjoy it. On the day before our visit twelve of the residents had been to a show at the Brindley Arts centre in the nearby town of Runcorn. Various religious denominations conduct services in the home. People also confirmed that they were free to attend a local church if they wished to do so. Links with the local community are maintained and residents are free to go out on their own [If they are able to] or with their families. Residents regularly go with staff members to a local pub for their lunch. Visitors are free to visit the home at any reasonable time. Mail was delivered unopened, or given to relatives if necessary. Meals can be eaten in the main dining room or in the privacy of a residents own room. The dining room is well furnished and laid out and provides a very pleasant dining experience. There is a menu that has the flexibility to meet individual needs and choices. The catering staff members have a very good understanding of each persons preferences and all of the residents that commented said that the quality of food provided to them was of a very good quality and that choices were available. Special diets can be provided if needed. The kitchen was seen to be clean, tidy and well organised and during a discussion with the cook on duty she confirmed that she had recently updated her food hygiene training. She was able to show that a very good variety of food [not necessarily shown on the menu] was available and that she was fully aware of each resident’s individual likes and dislikes; we feel she is trying her best to give people what they want. Three Elms DS0000072879.V375676.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents and relatives are able to complain and action would be taken to respond to their concerns. Adult protection training is provided for staff in order to ensure the continued safety of the people staying in the home. EVIDENCE: There is a clear complaints procedure for the home; information about complaints is displayed in the entrance area. This is also included in the service user guide and the statement of purpose. The residents spoken with during the visit confirmed that they knew what to do if they were unhappy or wanted to make a complaint; one resident said; “If I had a problem worth complaining about I would”. The home has an Adult Protection procedure (now called Safeguarding) that complies with all of the relevant legislation and good practice guidelines. This is designed to ensure that any possible problems that arise are dealt with openly and people are protected from possible harm. Staff members undertake training in this area. Three Elms DS0000072879.V375676.R01.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 23, 25 and 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. The residents using the service are staying in a safe, homely, clean and comfortable home. EVIDENCE: A tour of the premises was undertaken; this included the lounges, communal areas and a number of bedrooms. Furnishings, fittings and lighting in the lounges and communal areas are of a good quality and are domestic in character. The home is maintained both externally and internally to a good standard. Three Elms is kept very clean, tidy and provides people with a pleasant environment in which to live. We spoke to one of the cleaning staff who confirmed that she had regular training and that in her opinion there were, “plenty of staff to do the job”. Three Elms DS0000072879.V375676.R01.S.doc Version 5.2 Page 16 Bedrooms seen during the inspection were personalised, comfortable, wellfurnished and contained items of furniture belonging to residents’. Three Elms has a passenger lift available to allow access between floors. The home provides adaptations for use by residents with mobility problems: these include bath and toilet aids, hoists, grab rails and wheelchairs. There are well-maintained fully accessible garden areas for people to use if they wish to do so. The laundry is very well equipped and good systems are in place for the care of peoples’ clothes. During a conversation with one of the laundry staff members she was able to show that she had a good knowledge of each residents clothing; this ensures there are no “mix-up” which can cause problems which in turn lead to complaints. The people that commented all said that there clothes were being well looked after. Three Elms DS0000072879.V375676.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff members work well with the people staying in the home and a robust staff recruitment process is in place to protect them from possible harm. EVIDENCE: Care staff on duty and rotas seen demonstrated that staffing levels and the skill mix of staff was able to meet the diverse needs of the residents within the home. The staff members were cheerful and friendly and the residents spoken with were complimentary about their attitude and competence. We saw that the staff team worked well together and relationships between them were relaxed and positive. Staff members have made a number of positive comments on the survey forms returned to us, these include; “I enjoy my job as I know a lot of the staff do, so we go that bit further”, “There is a lovely happy atmosphere here”. The home manager, deputy, administrator, activity co-ordinator and separate ancillary staff such as kitchen and laundry staff members are in addition to the care staff members on duty at any one time. This means that there is always plenty of staff on duty to meet the various needs of the people living in the home. Three Elms DS0000072879.V375676.R01.S.doc Version 5.2 Page 18 According to the records maintained by the home 25 of the 29 care staff members are either qualified [19] or are working towards [6] a National Vocational Qualification [NVQ] level 2 or 3 in care, a recognised qualification for people working in the care profession. The remaining four staff members have only recently started working at the home and are due to start their training shortly. Two staff members were being visited by their NVQ assessor on the day of the inspection. During a conversation with her she said that in her opinion; “The staff work well together, they are keen to do their NVQ and hand work in on time”. The files for the two most recently appointed members of staff seen contained all of the required information and a robust recruitment procedure was in place for the protection of clients. Prospective staff members are checked against the POVA list before employment commences and CRB disclosures are obtained. New staff members are routinely inducted through the home’s induction procedure to ensure that they are suitably trained when starting work. They also undertake Warrington Borough Councils induction scheme. This includes training in fire safety, moving and handling, first aid and food hygiene. Three Elms has provided the opportunities for staff members to attend relevant training and there was evidence that staff had attended a wide variety of courses including mandatory training in areas such as moving and handling, fire safety, first aid and adult protection. The home books places on the training courses provided by both Halton and Warrington Borough Council. The staff members spoken with confirmed that regular training was readily available. One staff member said; “there is lots of training available, I think I am well trained and following a forthcoming course I will be a safer handling trainer”. Training is monitored through the computerised training database maintained by the deputy and administrator. We were provided with a copy of this during the visit. Three Elms DS0000072879.V375676.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is being well run and managed on a day to day basis, this helps to ensure that the needs of the residents are met and that there are appropriate procedures in place to maintain their safety. EVIDENCE: The home has an experienced manager who can demonstrate an awareness of the needs of the people staying living in the home and how to manage the staff team. Both the manager and deputy have completed NVQ level 4 and the Registered Managers Award. The manager and deputy regularly attend courses in order to keep their practice up to date and they are currently Three Elms DS0000072879.V375676.R01.S.doc Version 5.2 Page 20 undertaking a dementia course. The manager is supported by a deputy, two team leaders, an administrator and senior staff members. The staff members spoken with were complimentary about the home and the quality of care being provided. One of them has written on a survey form, The home has good standards and management. A quality assurance survey to ascertain whether residents and families are happy with the standards of care being provided is in place; the most recent survey was undertaken in October 2008; this is an ongoing process and the results are displayed on the notice board next to the entrance area. Residents personal allowances were being handled well and any monies were being kept securely. Those records that we looked at had accurate records, receipts and correct balances. There is a comprehensive health and safety manual as well as policies and procedures in relation to safe working practices in place. All of the maintenance contracts seen were up to date. The fire safety log book showed that the tests on the system and emergency lighting were being carried out at the recommended intervals and that drills and training were also up to date. Three Elms DS0000072879.V375676.R01.S.doc Version 5.2 Page 21 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 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X 3 X 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Three Elms DS0000072879.V375676.R01.S.doc Version 5.2 Page 22 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 Three Elms DS0000072879.V375676.R01.S.doc Version 5.2 Page 23 Care Quality Commission North West Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. 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