Inspection on 10/01/06 for Elim Lodge Limited

This inspection was carried out on 10th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Elim Lodge Limited 06/10/08

Elim Lodge Limited 21/02/08

Elim Lodge Limited 15/06/06

Elim Lodge Limited 15/09/04

Elim Lodge Limited 30/06/04

Elim Lodge Limited 15/01/04

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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 Elim Lodge 54 Cliff Road Hornsea East Riding Of Yorks HU18 1LZ Lead Inspector Diane Wilkinson Unannounced Inspection 10th January 2006 10.00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Elim Lodge DS0000019667.V277159.R01.S.doc Version 5.1 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. Elim Lodge DS0000019667.V277159.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Elim Lodge Address 54 Cliff Road Hornsea East Riding Of Yorks HU18 1LZ 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) 01964 535944 Mr Ghyandass Mungroo Mrs Gillian Lesley Hunt Care Home 21 Category(ies) of Dementia - over 65 years of age (21), Old age, registration, with number not falling within any other category (21) of places Elim Lodge DS0000019667.V277159.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. To admit one service user under pensionable age Date of last inspection 15th August 2005 Brief Description of the Service: Elim Lodge is registered as a care home that offers care and accommodation to 21 older people, including those with dementia. The home is owned by Mr Ghyandass Mungroo and was first registered on the 14th August 1995. The home is situated in the centre of Hornsea, which is a seaside town on the East Riding of Yorkshire coast. All the local facilities are within walking distance. The home is an old building which has been converted to meet the needs of older people. Private accommodation comprises of 15 single rooms and 3 shared rooms and communal accommodation consists of a dining room, a large lounge and a conservatory. There is a lift to the first floor and service users have access to the grounds of the home and the adjacent park area. There is a small car park at the front of the property. Elim Lodge DS0000019667.V277159.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 8 hours, including preparation time prior to the inspection. The inspection consisted of a tour of the premises and examination of documentation, including care plans. The inspector spoke to four service users who were sitting together in the conservatory and other service users who were seen whilst walking around the building. Members of staff, the deputy manager and the manager were also spoken to. What the service does well: What has improved since the last inspection? What they could do better: A genuine choice of meal should be offered at lunchtime. A satisfactory CRB check should be obtained before staff commence work at the home to increase the safety of service users. Care plans should include information about nutritional screening and about the likelihood/prevention of pressure sores. Elim Lodge DS0000019667.V277159.R01.S.doc Version 5.1 Page 6 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. Elim Lodge DS0000019667.V277159.R01.S.doc Version 5.1 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 Elim Lodge DS0000019667.V277159.R01.S.doc Version 5.1 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): 3 Service users are assessed prior to any decision being made about admission to the home and admission only proceeds if assessed needs can be met. EVIDENCE: A service user moved into the home on the day of the inspection. The service user was not visited at their current address prior to admission because they had very recently had respite care at the home and were known to staff. An admission enquiry form is completed initially and an assessment is then undertaken prior to admission – assessments were seen in all care plan files. Community care assessments and care plans from care management are requested as part of the admission process – if they are not received quickly, care staff obtain as much information from care managers as possible as part of the admission process. The registered manager told the inspector that accommodation is not offered to service users if it is considered that the home will not be able to meet their needs. Elim Lodge DS0000019667.V277159.R01.S.doc Version 5.1 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): 7, 8, 9 and 10 There are satisfactory care plans in place and these are reviewed regularly to ensure that current care needs are met. There is insufficient evidence that the health care needs of service users are fully met. The systems for the administration of medication are good and ensure that a service user’s medication needs are met in a safe way. Service users state that they are treated with respect at all times. EVIDENCE: Several care plans were examined by the inspector. Assessment information is used as the basis to develop an individual plan of care. Care plans set out the action that needs to be taken by care staff to ensure that all care needs are met. Risk assessments for moving and handling (including the risk of falls) and more specific risks such as the use of bed rails are undertaken and these records are included in care plans. Care plans are reviewed monthly (although some of these had lapsed a little) and key workers also record time spent with service users. New service users are asked to sign to say that they are aware that there is a care plan in place and contribute towards the content if they are able to do so. Elim Lodge DS0000019667.V277159.R01.S.doc Version 5.1 Page 10 There is evidence that the health care needs of service users are mostly met. There is now a record of a service user’s contact with all health professionals, and the records of contact with GP’s and District Nurses are quite detailed, giving the reason for the visit/contact and any outcome. Service users are referred to other health or support services appropriately. No specific assessments of a person’s risk of developing pressure sores were in place, although the inspector did observe that there is pressure care equipment in place for some service users. Continence care is satisfactory. The inspector saw no evidence of nutritional screening. The records for the administration of medication were examined by the inspector and were found to be satisfactory. The names of staff that have completed accredited medications training are recorded at the front of the administration record book and only these staff administer medication. One service user self medicates but the medication is actually held by the home and given to the service user to administer. Medication is stored appropriately and there is suitable storage for controlled drugs. The administration of controlled drugs is double signed by staff. There are systems in place to ensure that excess drugs are disposed of appropriately. Service users told the inspector that they are treated with respect and that their right to privacy is upheld. Most service users have a single room and are therefore able to see visitors and health professionals in private. Two service users that share a room have their own smoking area and dining area. Staff handovers are held in a private office to ensure that information is not overheard by visitors to the home. Elim Lodge DS0000019667.V277159.R01.S.doc Version 5.1 Page 11 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, 14 and 15 There is an activities plan in place and efforts are made to ensure that social and leisure needs are met. Service users are encouraged and supported to make informed choices. Meal provision at the home is good but service users should be made aware that there is an alternative meal available at lunchtimes. EVIDENCE: Care plans record a person’s life history and details of any hobbies or interests. Key workers record any time spent with service user undertaking these activities or interests. There is now an activities programme in place that includes a variety of activities and an activities co-ordinator has been appointed. Evidence was seen that some service users undertake activities in their own room such as painting, reading and listening to music. Some service users said that they would like to go out for a walk more often, but could only go out when staff had time to accompany them. There is evidence that service users are assisted to exercise choice and control over their lives. Some service users go out for a walk and all care plans record a service users preferred time to get up and go to bed. Service users spoken to confirmed that they can get up and go to bed when they choose and that they make day to day decisions about their lifestyle. Elim Lodge DS0000019667.V277159.R01.S.doc Version 5.1 Page 12 Service users spoken with said that the meals at the home are good. There is no real choice of meal at lunchtime but service users confirmed that there is a choice of meal available at tea times. There is a record in the kitchen of a person’s likes and dislikes and an alternative meal is provided when someone does not like the meal on offer. A menu is displayed. The inspector recommends that there is a choice of meal on offer each lunchtime and that service users are made aware of this. Care plans record any specific dietary requirements of service users and these are met by the home. Elim Lodge DS0000019667.V277159.R01.S.doc Version 5.1 Page 13 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 and 18 The home has a satisfactory complaints policy with some evidence that service users feel that their views are listened to and acted upon. Staff training on the protection of vulnerable adults from abuse would enhance their understanding of this topic and increase the protection of service users. EVIDENCE: There is a satisfactory complaints policy and procedure in place, and a complaints log that allows for the recording of the details of the complaint and any action taken. The grumbles book has been re-established and the inspector observed that some minor complaints have been recorded and dealt with appropriately. Since the last inspection of the home staff have been required to re-read the policies and procedures that are in place around the protection of vulnerable adults from abuse. The registered manager was advised to obtain the training programme provided by the Area Adult Protection Committee so that an in– house staff training programme can be arranged for all staff. There are other appropriate policies in place, such as whistle blowing, dealing with aggression from service users and the protection of service user monies. The deputy manager attends any meetings held about the protection of vulnerable adults from abuse, and keeps staff updated via staff meetings. Elim Lodge DS0000019667.V277159.R01.S.doc Version 5.1 Page 14 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): 19, 25 and 26 Service users live in a safe, well-maintained and homely environment. The home was clean and hygienic on the day of the inspection. EVIDENCE: The home is accessible, safe and well maintained. The maintenance person was at the home on the day of the inspection undertaking minor repairs and maintenance. Grounds are kept tidy, safe, attractive and accessible to service users and allow access to sunlight, especially at the rear of the building in the conservatory and corridor. There is now a programme of routine maintenance in place at the home. The premises used to be owned by the town council and housed the town hall and courtroom. Several service users told the inspector that they remembered the building when it was used as such. There is only a small garden attached to the property, but the home has the permission of the local council to use the adjoining parkland. There is evidence that the building complies with the requirements of the local fire service and environmental health department. Repairs that were required as a result of the last inspection have been carried out, i.e. the call bell in Room 18 and the carpet in Elim Lodge DS0000019667.V277159.R01.S.doc Version 5.1 Page 15 room 10A. The vinyl in the corridor on the way to a toilet and the laundry room is beginning to wear and poses a trip hazard – this must be replaced. On the day of the inspection all communal areas of the home were warm. Some bedrooms were cold because windows were open to allow them to ‘air’ – the inspector was informed that windows are closed after lunch to ensure that bedrooms are warm again by the time people want to return to them. All radiators are covered. Bedrooms are centrally heated and heating can be individually controlled. All bedrooms have appropriate lighting. Some bedrooms are spacious and allow space for furniture to be brought in from a service user’s own home. Water temperatures are tested at every outlet in the home by the handyman every 3 months. A spot check is undertaken every month in a different room. All records show that water is around 43° when tested. There is no test in place to detect the presence of Legionella in the water, and no evidence that the water is stored in such a way as to control the risk of Legionella. The home was clean and hygienic on the day of the inspection - there were some minor malodours but all were being controlled satisfactorily. Laundry facilities at the home meet required standards and these include separate hand washing facilities for staff. There is a separate sluicing room. The shift leader is now in charge of putting service users’ clothes away following laundering and this has reduced the ‘mixing up’ of clothes. The home is cleaned on a regular basis by domestic staff and there are appropriate systems in place to prevent the spread of infection. Elim Lodge DS0000019667.V277159.R01.S.doc Version 5.1 Page 16 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): 28 and 29 Qualification records evidence that service users are in the hands of trained staff. Recruitment policies and practices at the home do not fully ensure the safety of service users. EVIDENCE: The deputy manager has achieved NVQ Level 4 in Care and the Registered Manager’s award. Two care staff have achieved NVQ Level 3 in Care and two care staff have achieved NVQ Level 2 in Care. Other staff are in the process of applying for funding to enable them to undertake NVQ training. The home are on target to achieve the requirement for 50 of care staff to achieve NVQ Level 2 in Care – they are currently at 40 . Recruitment records for a new member of staff were examined by the inspector. These evidence that an application form is completed that includes an employment history, and that documents confirming the identification of the employee are retained by the home. Two written references are obtained prior to the person commencing work at the home, but there is evidence that staff have commenced work at the home before a satisfactory POVA first check or full CRB check has been obtained. All staff have a contract of employment and all staff have been issued with the code of conduct and practice set by the General Social Care Council. Elim Lodge DS0000019667.V277159.R01.S.doc Version 5.1 Page 17 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, 33, 35, 36, 37 and 38 The home is managed by a qualified, experienced and competent person. The quality assurance system needs to be expanded to ensure that service users, staff and other stakeholders are able to affect the way in which the home is run. Service user monies are kept securely but receipts must be obtained to evidence the financial transactions that have taken place. Care staff and ancillary staff are appropriately supervised. The health, safety and welfare of service users is promoted and protected. EVIDENCE: The registered manager is a trained nurse and has had many years experience in the caring profession. She keeps her practice up to date by attending training sessions and reading literature. The registered manager intends to ‘step down’ from her role as registered manager to become the administrator for the home. The deputy manager has applied to the Commission for Social Elim Lodge DS0000019667.V277159.R01.S.doc Version 5.1 Page 18 Care Inspection to become the registered manager. She has completed NVQ Level 4 in Care and Management. The home has achieved the Investors in People award and the local authority quality scheme (QDS parts 1 and 2). The registered manager informed the inspector that surveys have taken place in the past and that another quality survey is due to take place in March or April this year – this will include service users, relatives/visitors and health professionals. Staff meetings are held every 4 – 5 months and service user meetings are now held on a more regular basis. The role of running service user meetings has been delegated to a member of staff and these now take place every two months. There is no annual development plan in place. At the next inspection it should be possible to accurately assess the effectiveness of the quality assurance programme of the home. The results of quality surveys must be published and made available to the Commission for Social Care Inspection. Some service users hold their own personal allowances and lockable storage is provided to enable money and valuables to be held securely. Some monies are held by the home and there is a safe to ensure security. Financial records were examined by the inspector – these were found to be satisfactory and balances of money held were accurate. However, the home should ensure that receipts are given to relatives when money is ‘handed over’ to be held on behalf of service users, and receipts should be obtained for all purchases made on behalf of service users. Receipts are currently obtained for large purchases, but not for small purchases, hairdressing and chiropody. There is now a satisfactory staff supervision system in place. These records were seen by the inspector and they evidence that the home is on target to ensure that staff have supervision six times per year. Two of the six annual meetings are appraisal meetings. Catering and domestic staff have two appraisal meetings per year. Regulation 26 visits are undertaken by the registered provider and a copy of the record of these visits is sent to the Commission for Social Care Inspection. Records that are required to be held in respect of service users and staff were in place and available for inspection. Service users have access to their records and have opportunities to help maintain their personal records. The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users. There is a fire risk assessment in place and the fire alarm system, including fire extinguishers and emergency lighting, have been checked by qualified contractors. In-house weekly fire tests take place and a fire drill was held on the 5th January 2006. Monthly checks take place on fire equipment and fire doors. The electrical installation was tested in September 2005 and a portable appliance test took place in October 2005. There is evidence that two mobility Elim Lodge DS0000019667.V277159.R01.S.doc Version 5.1 Page 19 hoists and a bath hoist are satisfactorily maintained and that the passenger lift has been serviced recently. There is a current certificate of gas safety in place. Accidents are recorded and reported appropriately. Training records evidence that staff undertake training on health and safety topics, both at the time of induction and as refresher training. The home operates thorough policies and procedures for securing a safe working environment. Water temperatures at outlets throughout the home are tested and the temperature of the water boiler is tested on a regular basis. However, there is no evidence that water temperatures are monitored to control the risk of Legionella – see Standard 25. Elim Lodge DS0000019667.V277159.R01.S.doc Version 5.1 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 1 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 X X X X X 2 3 STAFFING Standard No Score 27 X 28 2 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 1 3 3 3 Elim Lodge DS0000019667.V277159.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? Yes 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 OP8 Regulation 12 & 13 Requirement There must be evidence that nutritional screening takes place and that service users are assessed to identify any risk of developing pressure sores. The vinyl in the corridor leading to a toilet and the laundry room poses a trip hazard and must be replaced. A POVA first check or full CRB check must be in place prior to staff commencing work at the home. There must be an annual development plan in place that is based on the outcome of quality surveys. The outcome of surveys must be published and made available to the CSCI. Receipts must be obtained when receiving a service user’s money from relatives, and when monies are spent or purchases made on behalf of service users. Timescale for action 10/02/06 2 OP19 12, 13 & 16 10, 18 & 19 24 28/02/05 3 OP29 10/01/06 4 OP33 30/04/05 5 OP35 13, 17 & 20 10/01/06 Elim Lodge DS0000019667.V277159.R01.S.doc Version 5.1 Page 22 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 2 3 Refer to Standard OP15 OP18 OP25 Good Practice Recommendations There should be a genuine choice of meal at lunchtimes and service users should be made aware of this. All staff should undertaken training on the protection of vulnerable adults from abuse to ensure that they have a full understanding of this topic. There should be evidence that the risk of Legionella is controlled. Elim Lodge DS0000019667.V277159.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Elim Lodge DS0000019667.V277159.R01.S.doc Version 5.1 Page 24 - 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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