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Inspection on 26/01/10 for Elmbank Residential Care Home

Also see our care home review for Elmbank Residential Care Home for more information

This is the latest available inspection report for this service, carried out on 26th January 2010.

it is an annual review prepared by CQC after examining previous reports and information from the provider. At the time of this report, CQC judged the service to be Good.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

Annual service review Name of Service: Elmbank Residential Care Home The quality rating for this care home is: The rating was made on: two star good service 1 7 1 2 2 0 0 8 A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection We do an annual service review when there has been no key inspection of the service in the last 12 months. It does not involve a visit to the service but is a summary of new information given to us, or collected by us, since the last key inspection or annual service review.   Has this annual service review changed our opinion of the service?   No You should read the last key inspection report for this service to get a full picture of how well outcomes for the people using the service are being met. The date by which we will do a key inspection: Name of inspector: Patricia Collins Date of this annual service review: 1 4 1 2 2 0 0 9 Annual Service Review Page 1 of 7 Information about the service Address of service: Elmbank Woodham Road Woking Surrey GU21 4EN 01483765984 02085783890 elmb4nk@hotmail.co.uk Telephone number: Fax number: Email address: Provider web address:   Name of registered provider(s): Conditions of registration: Category(ies) : dementia old age, not falling within any other category Conditions of registration: Elmbank Residential Care Home Ltd Number of places (if applicable): Under 65 Over 65 14 0 0 14 The maximum number of service users to be accommodated is 14 The registered person may provide the following category of service only: Care home only (PC) to service users of the following gender: Either whose primary care need on admission to the home are within the following category : Dementia (DE) Old age, not falling within any other category (OP) Have there been any changes in the ownership, management or the No service’s registration details in the last 12 months? If yes, what have they been: Date of last key inspection: Date of last annual service review (if applicable): Brief description of the service Elmbank provides 24-hour personal care and accommodation for 14 older people including older people with dementia. It is a detached property situated in a residential area of Woking. One of the registered providers is the homes registered day-to-day manager. 1 7 1 2 2 0 0 8 Annual Service Review Page 2 of 7 Bedroom accomodation is mostly single occupancy, arranged on the ground and first floor. Bedrooms do not have en - suite facilities however each has a wash basin. Communal facilities include a lounge, conservatory and dining room on the ground floor and toilets and bathing facilities on both floors. There is an enclosed garden to the side and rear of the property and a car park to the front. Weekly fees range from 410 to 450 pounds. Annual Service Review Page 3 of 7 Service update since the last key inspection or annual service review: What did we do for this annual service review? We looked at all the information we have received or asked for since the last key inspection. This included: The annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. Information we have about how the service has managed any complaints. What the service has told us about things that have happened in the service, these are called notifications and are a legal requirement. The previous key inspection and the results of any other visits that we have made to the service in the last 12 months. Relevant information from other organisations. What other people have told us about the service. Information received during telephone contact with the registered provider/manager as part of review process. The report will say what we found as it is written on behalf of the Care Quality Commission (CQC). What has this told us about the service? Since the last inspection there has been a change of deputy manager. The newly appointed deputy manager was stated to be working towards achieving a relevant management qualification. The registered provider/manager plans to submit an application to be the registered manager of the other home she owns and manages. The deputy manager of this home is intending to apply for registration as the manager of Elmbank. Currently the provider/manager divides her time equally between both homes. A good response was received to the stakeholder survey carried out as part of the Annual Service Review methodology.Respondents were six people using the service, six relatives, a health professional, six care staff, the activities coordinator and the homes hairdresser. People using services were satisfied with service provision. Their comments included, Food is eatable, room and laundry clean, Staff are helpful and food is lovely, Staff are caring and listen, I am happy in his home. They had no suggestions to make for service improvements. Relatives were also overall positive in their feedback regarding the standard of care, the environment, staff, catering and laundry services. One relative suggested the home could utilise the garden more in fine weather; another suggested the frequency of input from commnity dental services should increase. The general practitioner said the home responsibly manages the Annual Service Review Page 4 of 7 health needs of people using services, ensuring professional input where needed. Staff stated they provide good care, respecting the dignity and privacy of people using services. They said the homes atmosphere is happy and friendly, there is a choice of food at every meal, that team work and communication within the home is good. Their suggestions where improvement can be made included, Change shift times, finishing at 10 p.m. is too late, Need more outdoor activities, More staff for outings, Management should be stricter on some staff who tend to be too relaxed. The AQAA was returned on time however was incomplete. Shortfalls in completion have been discussed with the provider/manager and clarified. The information provided evidenced service improvements since the last inspection. Changes in the past twelve months include further development of the new care planning system implemented in 2008, with additional documents and assessment tools. New quality assurance and quality monitoring systems ensure continuous review of services and practice. This enables prompt response to any change in needs and for improvement in services, where necessary. An extensive refurbishment programme has enhanced the premises. A determined effort has been made to eradicate malodour through replacement of carpets and a continence programme. The menu has been improved affording increased variety of meals. Other developments include appointment of an activities coordinator working two hours each afternoon, during the week and an enhanced social activities programme. An in-house staff training programme has been introduced and expectation for staff to commit to their personal professional development and training. All care staff are stated to have attained a national vocational qualification (NVQ) in care or in health and social care, or equivalent, at level 2 or above. Anti-discriminatory practice is underpinned by the homes policies and procedures. A culturally diverse staff team is employed reflective of the local community though not of the homes current population. The new care plans promote a person-centred approach to meeting the holistic needs of people using services. We clarified with the provider/manager that the homes management is informed of its obligations under the Mental Capacity Act (MCA) deprivation of liberty safeguards (DOLS). The provider/manager confirmed a protocol and procedure had been produced to ensure DOLS assessments carried out, as necessary. It was stated that the staff training programme included awareness training on MCA and DOLS responsibilities of staff. We were contacted earlier this year by a relative with concerns about service provision. This contact was linked to a safeguarding matter under investigation at the time. The concerns were referred to the provider/manager for a response directly to the complainant, under the homes complaint procedure. The homes complaint policy and procedure is clear. The home has not received any other complaints in the past twelve months. A policy and procedure is in place to safeguard people using services from harm and abuse. Staff are trained to recognise and appropriately respond to indicators of abuse. One safeguarding adults multi-agency investigation has taken place in the past twelve months. The matter was understood to be ongoing but not to involve the home. Earlier this year we were not receiving all notifications which the home is obliged to send. This omission was drawn to the provider/managers attention and this has improved. Annual Service Review Page 5 of 7 What are we going to do as a result of this annual service review? It is our judgement, based on all available information, that the home continues to provide good quality outcomes for people using services. We are not going to change our inspection plan and will carry out a key inspection by 17th December 2010. However we can inspect the service at any time if we have concerns about the quality of the service or safety of the people using the service. Annual Service Review Page 6 of 7 Reader Information Document Purpose: Author: Audience: Further copies from: Annual service review CQC General Public 0870 240 7535 (national contact centre) Our duty to regulate social care services is set out in the Care Standards Act 2000. The content of which can be found on our website. Helpline: 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 copy of the findings in a different format or language please contact our helpline or go to our website. 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