Inspection on 18/05/05 for Elderthorpe Residential Home

This inspection was carried out on 18th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Elderthorpe Residential Home 25/04/07

Elderthorpe Residential Home 01/12/05

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 230-232 Bradford Road Shipley Bradford BD18 3AN Lead Inspector Barbara Grell Unannounced 18th May 2005 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 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 J52 J03 S1144 Elderthorpe V226299 180505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Elderthorpe Address 230-232 Bradford Road Shipley Bradford BD18 3AN Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01274 583375 Kevin.driscoll1@tiscali.co.uk Mr Kevin Driscoll Mr Kevin Driscoll Care Home Only 16 Category(ies) of Old Age (16) Dementia Over 65 (5) Physical registration, with number Disability Over 65 (3) Learning Disability (1) of places Elderthorpe J52 J03 S1144 Elderthorpe V226299 180505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 26.01.05 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, Bingely and Keighley. Parking is provided on road or at the back of the house. Elderthorpe J52 J03 S1144 Elderthorpe V226299 180505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was undertaken unannounced by one inspector on 18 May 2005 between 9:00 and 14:00. The service users preferred the term residents and hence this will be used throughout this report. The following methods were used: Ten of the residents spoke to the inspector and were able to provide feedback with regard to the services and care provided and their experiences in the home. The inspector joined the residents for lunch. Four of the resident’s visitors were able to provide feedback to the inspector. Additionally a visiting Social Worker was able to discuss the services. The provider/manager Mr. Driscoll was available for most of the inspection and was able to have discussion with the inspector and provide any documents. Two case studies were undertaken in order to inspect the quality of record keeping concerning the residents in the home. Survey materials were left in the home for residents and their visitors to provide written feedback. Six residents and four visitors’ surveys were returned and the outcome will be incorporated in this report. The inspector was able to have discussions with the three staff on duty. They were able to comment on the services and care as well as the management and training provided. Documentation was checked in respect of the training. Mr. Driscoll was able to provide information in respect of developing Elderthorpe. What the service does well: The service is managed and follows an ethos that is resident centred. The resident’s comfort, wishes, preferences and needs underpin the care provided. Residents are involved in the decision-making processes as much as possible and feel in control of their life and routine the routine of the home. The staff are committed to providing a high standard of care and enjoy the training provided and feel that it benefits their practices. Staff question practices in order to improve and develop and consult the residents in order to provide an individualised service. Elderthorpe J52 J03 S1144 Elderthorpe V226299 180505 Stage 4.doc Version 1.30 Page 6 The records at the home are up to date and resident friendly. Assessments and care plans are discussed with the resident and any representative and are signed. Visitors are made welcome by friendly staff and are provided with refreshment. Visitors spoken to are happy with the care and services provided and felt that they had a high degree of involvement in the decision-making and ongoing care. What has improved since the last inspection? 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 J52 J03 S1144 Elderthorpe V226299 180505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Elderthorpe J52 J03 S1144 Elderthorpe V226299 180505 Stage 4.doc Version 1.30 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 standard(s) 3, 4, 5 & 6 The assessments via care management and assessments undertaken prior to admission by the home’s staff ensures that the residents needs can be met. Residents are fully involved in the assessment process and are able to choose family and friends to advocate and act on their behalf. Residents and or their relatives are invited and visit the home prior to admission. A trial period is ensured and review undertaken after that period. EVIDENCE: Both case studies concerned new residents. A member of staff assessed one on the day of admission the other a few days prior to admission. In each case a core care management assessment was available and used by staff for reference in completing the home’s assessment. Visitors spoken to had visited Elderthorpe prior to the admission of a relative/friend in order to see the facilities and speak to staff/manager about the care needs. Residents spoken to relied on their family or friends to visit Elderthorpe and other homes on their behalf when the need arose. They felt that at the time they would not have wanted or been able to visit care facilities themselves. Elderthorpe J52 J03 S1144 Elderthorpe V226299 180505 Stage 4.doc Version 1.30 Page 9 Visitors and residents spoken to stated that they are fully involved in the assessment process and had been asked to provide details of hobbies, life history, interests, likes and dislikes for example. Relatives and residents were assured via this process that the prospective residents needs can be met. The initial month is seen as a trial period after which a formal review is arranged. Such a review meeting was held and the resident, representing Social Worker and the residents’ next of kin were involved. Elderthorpe was represented by the provider/manager. The assessment was discussed and reviewed taking account of the opinion of key people especially the resident. At the end of the meeting a decision was made to continue the placement. The care documentation seen was resident friendly and gave clear details of the assessed needs. Whilst the home provides for short stays it does not provide for intermediate care. Short stay residents would be assessed in the same way as a long term resident Mr. Driscoll said. Elderthorpe J52 J03 S1144 Elderthorpe V226299 180505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 & 10 The resident’s health, personal and social care needs are well recorded in the care plan and acted upon by staff. NHS staff provide any health and nursing input. The medical administration policies are followed by staff and ensure a safe system of administration and storage. Ongoing review ensures that care plans are up to date and accurate. The residents and their chosen representatives are well involved in the care planning process and kept informed via telephone and during visits. EVIDENCE: The care plan is developed using the assessments undertaken. The resident’s wishes and preferences were clearly detailed in the care plans. The care plan is fully discussed and reviewed during formal review meetings with residents and their representatives. The resident and or a representative sign care plans. Most residents spoken to know of their care plan and felt that they had good input in the way that the care is delivered. All felt confident that their needs and wishes underpin the routine and services. Care plans are reviewed by staff on a monthly basis. Al three relatives completing the survey stated that they are well informed of any changes or Elderthorpe J52 J03 S1144 Elderthorpe V226299 180505 Stage 4.doc Version 1.30 Page 11 important matters affecting the resident. Visitors spoken to also stated that they are very satisfied and kept well informed. The residents are assessed in respect to any health care needs including skin viability, nutrition and falls. Any needs are detailed in the care plan and NHS staff provide any nursing input required. All residents are registered with a local GP of their choice. When able residents keep their previous GP. NHS services are accessed via the usual GP referral. The case records seen gave good details about the resident’s health care needs and any monitoring or input provided or needed at any time. GP’s are alerted and assess residents when needed. Chiropody, optical and dental care is provided within the home by visiting practitioners or residents can use services situated in the community as preferred. The care plans consider all of the residents needs and are individualised and include personal, social and emotional needs. A monitored dosage system is provided by a local pharmacist including medical administration records that are completed by staff when administering the medications. Residents are able to administer all or part of their medication within a risk management system. The records seen were accurate and up to date. Staff administer medication in an appropriate way. A staff member was reassuring and assisting a resident who had difficulty swallowing the prescribed tablets. She explained the reason for and use of the medication and offered plenty of water. This lead to the resident being able and wanting to take the prescribed dose. Elderthorpe J52 J03 S1144 Elderthorpe V226299 180505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 & 15 The daily routine and services incorporates appropriate and ongoing activities that meet the resident’s needs and preferences. The visiting times are flexible and encourage regular visits from family and friends. The resident’s needs and wishes underpin the care provided by staff and residents are allowed to exercise choice. The food provided is of good quality and provided good variety. EVIDENCE: The assessments, care plans, life histories and recorded daily routine reflect the individual choices of the residents. All spoken to were clear that they could rise and retire when preferred and made arrangements with staff on duty about any other daily activity such as bathing or going out for example. Residents felt that staff honoured their wishes and were aware of what they enjoyed on an individual and group basis. Residents said that they were allowed to mix with others or be alone in their room if they wished. The residents said that staff have time to talk and undertake tasks unrushed. A number of residents are involved in domestic tasks such as setting and clearing tables by their choice. The staff on duty said that they see themselves as enabling residents and to improve their skill level when able. Examples were given when individuals Elderthorpe J52 J03 S1144 Elderthorpe V226299 180505 Stage 4.doc Version 1.30 Page 13 improved their skill level after admission and with support from staff. Staff felt it was important to support the residents in the way they wish and thought their input had to be tailored to the individual. There are regular activities provided including games, quizzes and sing-alongs. Entertainers visit the home. The hair stylist was in attendance and many of the residents had their hair done. Staff provide for manicures to those who like it. Pictures displayed showed parties and celebrations and many include relatives and friends. Residents stated that there are appropriate activities. All six resident surveys returned stated that the home provides suitable activities. There were many visitors to the home. All commented that the visiting arrangements are flexible and they are made welcome by the staff on duty and offered refreshment. Visitors had good relationships with the staff and there was banter and information giving. Residents are able to leave the home independently or with staff and visitors. The meal provided for choice and was well prepared and presented. Residents were able to eat their meals unrushed and were assisted by staff when needed. Residents enjoyed the meal and said that there is ample and varied food provided. The food stock for the week was delivered and the content included good quality, fresh items in ample quantity. The residents said that menu options are discussed with staff and the manager regularly and their preferred options incorporated. Elderthorpe J52 J03 S1144 Elderthorpe V226299 180505 Stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 Staff demonstrated a good skill level in respect of adult protection and were able to identify aspects of abuse and know how to report any allegations and suspicions of abuse. EVIDENCE: There are appropriate policies and procedures in place pertaining to the protection of vulnerable adults including the local authority Social Services Department Adult Protection Policy. Staff received training during induction and NVQ training and were able to discuss policy and practice. Residents said that they feel safe in the home and would report anything to staff, Mr. Driscoll and their own relatives and representatives and were confident that appropriate action would be taken. Elderthorpe J52 J03 S1144 Elderthorpe V226299 180505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21 & 26 The building meets the standard for an already existing building. The residents enjoy many aspects of the house and gardens. The standard of cleanliness was good. Some areas of the building would benefit from cosmetic upgrade. EVIDENCE: Elderthorpe is a period property that has retained many period features that continue to be enjoyed by the residents. The house provides for gardens and some seating is provided to the rear of the building. Many of the residents said that they liked sitting in the garden during the warm weather and several residents sat out during the afternoon of the inspection. The staff were hoping to do some planting in pots with residents who are interested. The communal rooms meet the size standards for an already existing registration. There is a dining area and lounge. The dining area is also used to undertake some of the activities. There are a shower and two bathrooms; one is assisted for communal use. WC’s are situated in adequate numbers around the building close to communal Elderthorpe J52 J03 S1144 Elderthorpe V226299 180505 Stage 4.doc Version 1.30 Page 16 rooms and bedrooms. Mr. Driscoll is hoping to extend the building and add further communal space during this process as it is felt that at times conditions can become cramped due to the increase in walking aids that clearly need additional space at times. The residents like the dining room and enjoy watching meals being prepared and to chat to staff. The lounge is situated to the front of the building and residents enjoy looking out of the large bay windows at this busy road, kids going to and from school and life passing. The lounge is equipped with a TV, video and audio equipment. A domestic undertakes the cleaning and the home was clean, bright and smelled fresh. The laundry is situated in the basement and provides adequate equipment. Staff follow good hygiene procedure and ensure that there is no cross infection. Residents stated that the home is kept clean and tidy at all times and were satisfied with the system of laundering. Some areas would benefit from cosmetic upgrade and replacement of carpets in staircases and corridors would improve the look of the home. Mr. Driscoll is hoping to upgrade the existing building alongside the extension and an action plan is required alongside any application for variation of the current registration. Elderthorpe J52 J03 S1144 Elderthorpe V226299 180505 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 & 28 The home meets the current requirements in respect of skill mix and staffing levels. The NVQ levels must be raised to 50 of staff being qualified to NVQ level 2 or above by the end of 2005. EVIDENCE: There were adequate numbers of staff on duty and the duty rota seen showed sufficient hours covering management, caring, cooking, cleaning and administration. The staff have varied experience and there was a good skill mix. Most of the carers have gained experience over time. Staff and resident’s felt that the staff numbers and skill level was good and that that level is maintained at all times. The staff team is stable and residents said that they know all the staff and are used to them. Staff on duty were able to discuss the benefits of the NVQ training and felt well motivated within their job. 33 of staff had completed the NVQ level 2 or above compared to the last inspection when 25 had completed. The deputy manager is commencing her NVQ level 4 and is already looking into course content and any general reading. Staff had a good attitude to learning and felt well supported, enabled and encouraged by the providers and manager. Several other staff are booked onto appropriate training courses to undertake this training in meeting this standard by the end of 2005. Elderthorpe J52 J03 S1144 Elderthorpe V226299 180505 Stage 4.doc Version 1.30 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33 &37 The home is well managed and the service focused on meeting the resident’s needs and wishes and aiming at improving the quality of life for the residents. The management systems are transparent. The records meet the minimum standards as well as being resident friendly and easy to follow. EVIDENCE: The provider/manager Mr. Driscoll leads the team on a day-to-day basis and undertakes supervision, quality assurance and assessment of residents. He has a high profile in the home and residents are confident that he tries very hard to ensure that the standards are consistently high. Mr. Driscoll involves the residents and the staff in the decision making process by ensuring regular meetings with groups and individuals in order to ascertain opinions. Meeting minutes are kept to provide a record. Mr. Driscoll is able to be self-critical and evaluates the standards objectively and addresses any shortfalls. He strives to achieve a high level of resident Elderthorpe J52 J03 S1144 Elderthorpe V226299 180505 Stage 4.doc Version 1.30 Page 19 satisfaction and the focus is resident oriented. He leads by example and his ethos is reflected in the high level of resident orientation amongst the staff team also. The resident’s comfort and well being is paramount. Residents said that they are given regular opportunity to talk to Mr. Driscoll in private and are actively encouraged to state opinions. Residents were sure that any concerns are appropriately dealt with. Mr. Driscoll has completed a self-assessment against the minimum standards and reviews areas at regular intervals. Mr. Driscoll says he ensures regular contact with residents and their family and friends in order to ensure that all is well. Quality assurance is ongoing and records are kept of the findings. The records seen during this inspection were accurate and up to date. The records reflected resident centred practices and safeguarded the individual’s well-being and good ongoing instruction and communication. The assessments and care plans are recorded in an easy to read format that is resident friendly. Elderthorpe J52 J03 S1144 Elderthorpe V226299 180505 Stage 4.doc Version 1.30 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 3 x 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 3 3 3 x x x x 3 STAFFING Standard No Score 27 3 28 3 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 3 3 3 x x x 3 x Elderthorpe J52 J03 S1144 Elderthorpe V226299 180505 Stage 4.doc Version 1.30 Page 21 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. 2. Standard 29 31 Regulation 18 9 Requirement 50 of staff must be qualified to NVQ level 2 or above. The registered manager must be qualified to NVQ level 4 in management. Timescale for action 2005 2005 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 Good Practice Recommendations Elderthorpe J52 J03 S1144 Elderthorpe V226299 180505 Stage 4.doc Version 1.30 Page 22 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 J52 J03 S1144 Elderthorpe V226299 180505 Stage 4.doc Version 1.30 Page 23 - 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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