Inspection on 01/12/05 for Elderthorpe Residential Home

This inspection was carried out on 1st December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 but made no statutory requirements on the home.

Other inspections for this house

Elderthorpe Residential Home 25/04/07

Elderthorpe Residential Home 18/05/05

Elderthorpe Residential Home 26/01/05

Elderthorpe Residential Home 13/10/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Elderthorpe Residential Home 230-232 Bradford Road Shipley Bradford West Yorkshire BD18 3AN Lead Inspector Barbara Grell Unannounced Inspection 1st December 2005 09:30 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 Elderthorpe Residential Home DS0000001144.V268121.R01.S.doc Version 5.0 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. Elderthorpe Residential Home DS0000001144.V268121.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Elderthorpe Residential Home Address 230-232 Bradford Road Shipley Bradford West Yorkshire BD18 3AN 01274 583375 01535 583374 kevin.driscoll1@tiscali.co.uk 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) Mr Kevin Driscoll Mrs Joanne Driscoll Mr Kevin Driscoll Care Home 16 Category(ies) of Dementia - over 65 years of age (5), Learning registration, with number disability over 65 years of age (1), Old age, not of places falling within any other category (16), Physical disability over 65 years of age (3) Elderthorpe Residential Home DS0000001144.V268121.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th May 2005 Brief Description of the Service: Elderthorpe is a Victorian house situated in Shipley that has been converted over time to provide residential accommodation for sixteen older service users. Accommodation is provided on the ground and first floors in both double and single rooms. The house provides a ramp at the rear to enable access for those with a disability. A stair lift is fitted within. Service users are both male and female and a number may be diagnosed with dementia. Elderthorpe is located on major bus routes from Shipley, Bradford, Bingley and Keighley. Parking is provided on road or at the back of the house. Elderthorpe Residential Home DS0000001144.V268121.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced on 01 December 2005. This is the second of two required inspection to be undertaken each year. In line with CSCI policy any core standards not assessed so far were inspected including any previous requirements. Reports and information on this and other social care services can be found on the Internet on www.csci.org.uk. The following methods were used. Ten service users were able to make comment about the care and services provided. The inspector had lunch with the service users and was able to observe interactions and activities. Three staff and the registered provider/manager were on duty and able to contribute to the inspection. Two assessments and service user plans were inspected. Two personnel files were inspected. What the service does well: What has improved since the last inspection? The planned changes in the management structure will eliminate the requirement for the manager to have an NVQ level 4 in care and management. The current deputy manager is working toward this award and is hoping to make application to register. A number of staff have completed their NVQ level 2 training and two more staff are registered on a programme. Elderthorpe Residential Home DS0000001144.V268121.R01.S.doc Version 5.0 Page 6 A new call bell system has been fitted and all lounge chairs replaced. A new WC has been fitted to the first floor. This is a much-needed addition as there was no WC situated on the first floor previously. 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. Elderthorpe Residential Home DS0000001144.V268121.R01.S.doc Version 5.0 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 Elderthorpe Residential Home DS0000001144.V268121.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards not assessed on this occasion. EVIDENCE: Elderthorpe Residential Home DS0000001144.V268121.R01.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11 Care plans give excellent detail of how service users want to be cared for should they fall seriously ill as well as their final wishes. EVIDENCE: The deputy manager has recently undertaken a palliative care course and has been able to review the area of illness and dying and how this is handled in the home. She has been able to fully develop this area and has provided supervision and training to other staff to increase the awareness of this important area. For each service user a care plan has now been established giving details of the service users wishes. There is clear evidence that the areas of serious illness and death have been discussed with service users and their representatives. Their wishes are recorded fully to enable appropriate action to be taken. This standard has been exceeded. Elderthorpe Residential Home DS0000001144.V268121.R01.S.doc Version 5.0 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 & 15 The service users benefit form person centred practices that allows each individual to make choices and control their own routines. The meals are varied, enjoyed and meet individual dietary needs. EVIDENCE: The service users say that they receive a good quality of care and services at the home. They said that they could do as they wished, join activities, be alone in one’s own room, watch TV, chat with staff or other residents or have relative to visit and go out with them. Service users felt that their daily routine matched their expectations. Service users feel that there are few rules and that the staff are helpful, dependable and jolly. There were many visitors during the inspection and good relationships between visitors and staff. Relatives commented that the care and services continue to be good. Visitors are clearly able to discuss any area with the staff on duty. The residents feel that they are well consulted about the routine, services and care provided. Dinner was prepared form fresh ingredients by staff on duty. The service users individual dietary needs are assessed and form the basis for menu planning. The service users said that they could have an alternative should Elderthorpe Residential Home DS0000001144.V268121.R01.S.doc Version 5.0 Page 11 they not like the meal or want something else because they do not feel well for example. Service users can have meals in their own room if they prefer. The meal was enjoyed and well prepared and presented. Some use the meal to have a good chat with each other and the staff on duty. Meal times are social occasions and are unrushed. Elderthorpe Residential Home DS0000001144.V268121.R01.S.doc Version 5.0 Page 12 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 There is a good complaint procedure that can be utilised when needed. complaints have been received. EVIDENCE: The home has a complaint procedure and this is part of the statement of purpose and service user guides as well as the home’s policies to ensure access from staff. The service users said that they would tell the registered person or deputy manager if they had a concern or complaint. Those spoken to felt sure that action would be taken promptly to take remedial action. There have been no complaints about the service to the home or CSCI. The managers were clear that they would investigate any complaint and take any complaint serious. Visitors said that there are good communications between themselves and the staff and that this lead to things not ‘getting to that stage’. No Elderthorpe Residential Home DS0000001144.V268121.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards not assessed on this occasion. EVIDENCE: Elderthorpe Residential Home DS0000001144.V268121.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 & 30 The recruitment practices ensure that staff appointed are fully checked prior to starting work. The training needs of staff are met in line with current requirements. 50 of staff are qualified to NVQ level 2 or above and staff are able to improve practices and put new learning into practice for the benefit of service users. EVIDENCE: Two recruitment files were inspected. These provided evidence that employees are subject to appropriate vetting of the individuals credentials. This includes the taking up of two written references, criminal records and protection of vulnerable adults register prior to employment. Evidence of previous training and qualifications achieved was held on file. The training provided is in line with current requirements for the care sector. Staff on duty confirmed that they had appropriate training on commencing employment and that this was dependant on experience and previous training attended. Staff confirmed that they had received training in food hygiene, first aid, and manual handling, death and bereavement and fire safety for example. 50 of staff are now qualified to NVQ level 2 or above. Two more staff are registered with a training provider to complete this training. Staff judged the level of training to be appropriate and felt that a minimum of three days paid training had been provided. It is recommended that ongoing records are kept that show an annual overview of the training provided. Elderthorpe Residential Home DS0000001144.V268121.R01.S.doc Version 5.0 Page 15 Staff were able to give several examples of how they have been able to implement learned information to improve the standards in the home. There has been a full review of the risk assessment and management. Elderthorpe Residential Home DS0000001144.V268121.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 35 & 38 Shortfalls in respect of the manager not yet completing the NVQ level 4 in care and management are being addressed and changes in respect of this registration are anticipated. The financial record keeping systems ensure that service users are protected. The service users benefit from flexibility and choices that suits their needs and wishes. Appropriate risk management and safety checks and systems ensure that the practices and facilities are safe. EVIDENCE: There are some changes planned in respect of the management at the home. Application to register the deputy manager is planned to be made in the near future. The acting manager is undertaking her NVQ 4 in care and management at the present time. The registered provider continues his Elderthorpe Residential Home DS0000001144.V268121.R01.S.doc Version 5.0 Page 17 manager role at present. It is planned that areas of responsibility will be split between the two. Service users are able to deposit money for safekeeping with the managers and staff. Records are kept of any financial transactions and those who use this facility are able to see the records and withdraw money at any time. Service users are also provided with a lockable facility to keep valuables safe. Service users said that their valuables are safe and well managed by the manager, relatives or independently. There are appropriate safety systems such as a newly installed call system, fire alarm and safety systems and risk assessments ensure that all areas are regularly maintained and checked. Records are kept showing the maintenance of the good working order of electrics, lifts and boilers. Elderthorpe Residential Home DS0000001144.V268121.R01.S.doc Version 5.0 Page 18 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 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X 3 X X 3 Elderthorpe Residential Home DS0000001144.V268121.R01.S.doc Version 5.0 Page 19 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 OP29 Regulation 18 Requirement 50 of staff must be qualified to NVQ level 2 or above. (Outstanding from previous inspection.) Timescale for action 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP30 Good Practice Recommendations An overview of training provided should be recorded in order to identify any gaps and to better evidence the level of training provided. Elderthorpe Residential Home DS0000001144.V268121.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Elderthorpe Residential Home DS0000001144.V268121.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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