Inspection on 16/06/08 for Ellerslie

This inspection was carried out on 16th June 2008.

CSCI found this care home to be providing an Poor service.

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

Ellerslie 29/09/09

Ellerslie 11/12/08

Ellerslie 19/06/07

Ellerslie 14/07/06

Ellerslie 21/11/05

Ellerslie 24/06/05

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Ellerslie 108 Albert Road Pittville Cheltenham Glos GL52 3JB Lead Inspector Sharon Hayward-Wright Key Unannounced Inspection 14:05 16 & 17th June 2008 th 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 Ellerslie DS0000064584.V364418.R01.S.doc Version 5.2 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. Ellerslie DS0000064584.V364418.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ellerslie Address 108 Albert Road Pittville Cheltenham Glos GL52 3JB 01242 514384 01242 255804 manager.ellerslie@osjctglos.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) The Orders of St John Care Trust Mrs Susan Rose Alakija Care Home 31 Category(ies) of Old age, not falling within any other category registration, with number (31) of places Ellerslie DS0000064584.V364418.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th June 2007 Brief Description of the Service: Ellerslie is a large three-storey building, which has been converted and extended to provide accommodation for up to 31 people who require nursing and personal care. It is situated close to Cheltenham town centre, a short walk from Pittville Pump Rooms and the racecourse. The Care Home is equipped with shaft lifts to assist those unable to manage the stairs. In addition, a variety of aids and adaptations have been provided throughout the property to help people who use the service. With the exception of two spacious double rooms, all the bedrooms are for single occupation. Only two rooms have en suite facilities but assisted bathrooms and toilets have been installed throughout the property. The communal facilities consist of three well-appointed lounges and a dining room. A Day Centre has been developed within the property; this is in use 4 days a week but may also be used by people at weekends. The private gardens are easily accessible and may be enjoyed by people in warm weather; they are well protected from the busy main road by tall mature trees. Adequate parking is provided for staff and visitors. The provider supplies information about the home, including the most recent CSCI report in a file at the entrance of Ellerslie. Current fees range from £545 to £763. Information about the Funded Nursing Care contribution (FNC) is provided by the home. Hairdressing, chiropody and any personal items are charged extra. Ellerslie DS0000064584.V364418.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. One Inspector carried out this inspection over two days in June 2008. We asked the home to complete an Annual Quality Assurance Assessment (AQAA). It was received on time and was completed in full. It gave us information about what the home considers it does well and the plans they for improvement. As part of the inspection process we sent survey forms to the home for people who use the service, visitors to the home and staff. We received 2 from relatives and 2 from members of staff. Comments can be found in the relevant sections of this report. Where possible, people living at the home were spoken with to ascertain their views on the care and services provided and any visitors to the home. Staff were observed interacting with people who use the service. The comments received from speaking to people during the inspection have been used in the report. A total of 25 standards were inspected. The Registered Manager was available during the inspection as were other members of the homes team and the staff spoken with throughout the inspection and were helpful and co-operative. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes in to account the views and experiences of people using the service. What the service does well: The home ensures that an assessment of needs is obtained prior to any new people moving into the home. Information about the services the home Ellerslie DS0000064584.V364418.R01.S.doc Version 5.2 Page 6 provides is available in the main entrance of the home in a file containing their Statement of Purpose. People are able to make choices about they would like for each meal. The home is able to cater for people who require a therapeutic diet. People who use the service said they are able to choose where they eat their meal. Comments received from people who use the service all said they enjoy the food provided. Those people who can decide choose how they spend their day; others rely on staff for direction. Visitors are encouraged and made welcome. The home has 70 of care staff with an NVQ qualification or they are undertaking it and 80 of the domestic staff with an NVQ qualification. The home has exceeded the recommended percentage of staff with an NVQ qualification, which is excellent. What has improved since the last inspection? What they could do better: All people who use the service must have care plans in place for all assessed needs as this will provided staff will clear instructions. Risk assessments must be undertaken for people in relation to moving and handling, falls, nutrition, pressure sore and for any other risk that has been identified. The purpose of these is to look at ways of managing the risk and informing staff about them. The home must make sure that care plans are in place for people who have wounds or pressure sores. As this will enable them to monitor and evaluate the treatment that has been prescribed. Ellerslie DS0000064584.V364418.R01.S.doc Version 5.2 Page 7 The home needs to review some of their medication systems to make sure they are not placing people at risk. All staff in the home need to make sure they respect people’s dignity and the use of continence products as seat covers on all communal seating must cease, as this is institutionalized practice. The cleanliness of the home in some areas needs to improve and they need to look at ways to address the odours that were found. The recruitment practices uses by the home are not robust enough to make sure people who use the service are protected. 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. The summary of this inspection report can be made available in other formats on request. Ellerslie DS0000064584.V364418.R01.S.doc Version 5.2 Page 8 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 Ellerslie DS0000064584.V364418.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 & 6 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There are systems in place to make sure that prospective people and their representatives have information needed to be able to make a decision about the home. EVIDENCE: At the last inspection a requirement was repeated for the home to send to us an up to date copy of their Statement of Purpose and Service User Guide. The Registered Manager confirmed that this has now been completed. The Orders of St John Care Trust has a web site that people can use and it has access to information about each individual home. The systems the home has in place for managing the Funded Nursing Care Contribution (FNC) was examined. A breakdown of the fees is sent to the person or their representative yearly or if any changes to this payment have been made. A representative from The Orders of St John Care Trust said they Ellerslie DS0000064584.V364418.R01.S.doc Version 5.2 Page 10 have information available for people about how they manage this payment included in their new contract. Also included in this new contract is information about how people can access and pay for additional services. A pre admission assessment was examined of a person who had been admitted to the home as an emergency several days prior to this inspection. The admission had been arranged with the Community and Adult Care Directorate (CACD). A copy of an assessment completed by a Social Worker was present in the home. The Registered Manager had filled in an assessment form. From discussion with the Registered Manager she had not visited this person at their home, as this was an emergency admission. She said she had got the information from the Social Worker and their assessment and had spoken to the family. The pre admission assessment form completed by the Registered Manager should contain details of where they have obtained their information. A list of the medication this person requires was also included, which is good practice. The person who was admitted to the home as an emergency was spoken with and they said their family had arranged this admission on their behalf. The home is not registered to provide intermediate care, however in the homes Annual Quality Assurance Assessment (AQAA) they have stated that where rehabilitation and intermediate care is required all staff work with the programme specified by occupational therapist and physiotherapists. This will need to be amended to reflect the registration of the home. Ellerslie DS0000064584.V364418.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. However the lack of appropriate recording in care records and unsafe medication practices place people who use the service at risk. The principles of respect, privacy and dignity are not put into practice by all staff. EVIDENCE: Three people were randomly chosen to have their care examined in detail. This includes reading all care records, speaking to staff and the person if able. One person was admitted to the home as an emergency several days prior to the inspection, another person was on long-term respite care and the third person had been at the home for over 1 year. The person who was admitted to the home, as an emergency had not had any care plans devised or any risk assessments completed despite being in the Ellerslie DS0000064584.V364418.R01.S.doc Version 5.2 Page 12 home for 4 days. This person also had a number of care needs due to their diagnosis and had a wound. This is poor practice due to this person’s complex needs. No care plans had been received from the Community and Adult Care Directorate (CACD). Daily records had been maintained since admission. An entry on the daily records mentions that the wound dressing was intact but no other information. The person on long-term respite had an assessment that is based on the activities of daily living reviewed in April this year. Care plans had been received from CACD but these were dated March 2008 and no reviews were seen of these. Only 2 care plans had been devised by the home and they were for an infection that is now treated and for removal of staples following a hospital admission. No other care plans were available despite this persons assessment detailing a number of care needs. Again this is poor practice as care staff do not have detailed instructions available to them on how to meet people’s needs. Risk assessments were in place for moving and handling and pressure sores. Reviews of these are taking place but not always monthly. Daily records are in place and these include information about GP visits. This person was also on a fluid and food intake chart but there were inconsistencies with this being completed. Information from the hospital was available about their recent admission. The third person had more detailed care records. These include admission details, medical history and diagnosis and a life history. A dependency assessment tool is used and this had been reviewed monthly. The hand written assessment tool based on the activities of daily living had been completed and contained details of their care needs. Care plans were in place for their assessed needs. Their care plan for elimination had not been updated to reflect how they are now managing this need as their catheter has been removed. The care plans that relate to moving and handling would benefit from having the sling size and type added as one care plan does mention the type of hoist to be used. Otherwise the care plans for this person were detailed and were personalised to this person and reviews have been taking place. A care plan was also in place for ‘prn’ or ‘as required medication’. This person’s care plans contained information about health professional visits. The care staff spoken to were able to discuss the care they provide to for each person. On person was able to confirm that they receive assistance from the care staff for activities of daily living and a visitor for another person was also able to describe parts of the care their relative received. The 2 questionnaires we received from peoples relatives/representatives were asked if they felt the care home meets the need of their friend/relative and both had answered ‘usually’. Comments include, “I think the level of care regarding health and general well-being is quite good” and “On occasions I have had to clean and cut my relatives finger nails as they have been allowed to get too long. This should not be left to relatives”. In the 2 staff questionnaires we received one had said they ‘always’ are given up to date information about the needs of people in the home. The other member of staff felt that at times the staff in the home have not been able to Ellerslie DS0000064584.V364418.R01.S.doc Version 5.2 Page 13 spend enough time with people because of the increasing pressure of workloads. Medication systems used by the home were examined. Qualified nurses only administer prescribed medication to people who use the service. The majority of people had a front sheet containing their personal details and allergies and a photograph. Records were seen for medications received into the home, administered and where needed returned. The home has a contract in place to return medications that are no longer required. On checking the Medication Administration Records (MAR) it was found that several people have gaps in the recording of administration of some medication. This must be addressed as this was also found at the last inspection. Several people were written up for ‘prn’ or as needed medication, however 3 people were found to be having this on a daily basis at a set time. This will need to be reviewed with the GP. Care plans were in place for people who are prescribed ‘prn’ medication but it would appear that some of these are not always being followed if some people are having certain medications on a daily basis at the same time. One person was prescribed a medication that was to be given three times a day, however for a period of five days it was found to have been given four times. The Registered Manager and nurse on duty were unable to explain why this had taken place and why it had not been identified prior to our visit. This must be investigated to find out why this took place. One person was prescribed a cream to be applied but no evidence was seen that this was being administered. The Registered Manager said the care staff administer this. A specimen signature list was in place along with a medication reference book that was dated September 2007. Stock checks take place on controlled medication; however at the last inspection our pharmacist recommended that records be maintained in the controlled medication register of the administration of Temazepam and not just the stock control. The home has yet to address this recommendation. Temperature checks of the room where medications are stored and the medication fridge are taking place. All medications were found to be stored securely. The systems the home has in place to enable people to self-medicate were not examined at this inspection. The homely remedies had been signed by the GP but this was for February 2007, consideration should be given to updating this, as there will have been a change of people in the home. The Registered Manager said qualified nurses are due a training update in relation to medication. Ellerslie DS0000064584.V364418.R01.S.doc Version 5.2 Page 14 Staff were seen speaking to people in a respectful manner and knocking on peoples doors prior to entering their rooms. One relative had written a comment in their survey that the staff often dress their relative in clothes that do not belong to them or they are dirty and they have observed staff dressing their relative in dirty clothes. This is poor practice. On entering the home it was observed that all communal chairs had a continence product seating cover over them to protect them, this is intuitional practice as with appropriate continence aids or by toileting people on a frequent basis there is no need for seat covers. One of the domestics said they change the seating covers each day. The Registered Manager said they are to protect the chairs but modern day chairs all have a protective coating on them so the use of the seating covers is not necessary. Ellerslie DS0000064584.V364418.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are able to make choices about their daily lives. Recreational and social activities are provided but they may not meet all people’s expectations or needs. EVIDENCE: The Registered Manager said the home is looking to appoint a person to undertake activities with people who use the service. A member of the care staff has taken on the role of coordinator. The home has an ‘activities board’ that has the weekly plan for activities displayed on it. Outside entertainers visit the home and one was planned for that week. The member of care staff who is coordinating the activities said that care staff do provide one to one sessions with people and one person was observed having a hand massage. No communal activities were seen taking place during the inspection and people were observed sitting watching TV or sleeping. However 2 members of the care staff team said that they had undertaken some activities during the inspection and explained what they had done. Ellerslie DS0000064584.V364418.R01.S.doc Version 5.2 Page 16 Two relatives in their surveys commented that ‘more one to one interaction and company would be nice’ and ‘I do wish the residents could occasional sit out in the gardens on nice days’. Two people who use the service said they were happy to undertake their own activities and they liked to stay in their rooms. The Registered Manager said that services are provided to meet peoples spiritual needs, however one relative had written in their survey that they had to arrange for the Parish Priest to visit their relative as nothing had been offered by the home. The homes Annual Quality assurance Assessment (AQAA) states that want to improve by providing more activity hours. Visiting to the home is not restricted and a visitor confirmed this. They also said that the person they are visiting is often taken out of the home by their family. They were also able to recall that a member of care staff had taken this person Christmas shopping and they had enjoyed it. People who use the service who were spoken with said they are able to make decisions about their daily lives. Two people explained about the choices they are given for mealtimes and that they like to spend time in their rooms. Several rooms belonging to people were seen and their personal belongings were on display. The homes AQAA states they have information about advocates available for people who use the service and their representatives. A copy of the homes menu is on the notice board but the font on this is very small and some people who use the service may not be able to read them. The Cook said that the menus are devised with the Registered Manager and have recently been reviewed. These can also be changed to meet people’s choices. Health and safety checks are undertaken in the kitchen but the home needs to record alternatives to the menu and where people are receiving a special diet. The AQAA states they have 2 sittings for mealtimes and this was observed on one of the days of the inspection. At the first sitting people were eating their meals at 12.40pm. At 13.50pm people were seen to still be eating their meals. It was observed that one person did not have the first course of their meal in their room until 13.35pm and when the member of staff was asked if they were going to offer them a choice of pudding, the person said that was the first time they had been offered a pudding since moving into the home 4 days ago. The home needs to make sure that people are receiving their food at a time that is suitable for them and that people are not being forgotten because they choose to have their meals in their room. Staff were observed offering people assistance sensitively and allowed them time to eat and have a drink which is good practice. Two people explained that they are offered choices for each meal of the day and this includes a cooked breakfast. People who were spoken with all said they enjoyed the food provided by the home. One relative had commented in their survey that ‘their relative tells me the food, though rather bland and uninspiring is generally palatable’. Ellerslie DS0000064584.V364418.R01.S.doc Version 5.2 Page 17 The home has been awarded 3 stars from the local Environmental Health Department. Ellerslie DS0000064584.V364418.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service and their representatives have access to a complaint procedure that makes sure the views of people are listened to. But some people feel actions are not always put in place to address these. Procedures are in place to protect people from possible risk of harm or abuse. EVIDENCE: The Registered Manager and the homes AQAA stated that they have received 4 complaints in the last 12 months. One of these has been upheld. Records relating to one complaint were examined. A copy of the homes complaints procedure is displayed on the notice board in one format. One relative in their survey said they know how to make a complaint and the other relative in theirs was unsure about how to make a formal complaint but would always raise any issues with the home manager. The survey asked if the home responds appropriately if they have raised any concerns, 1 relative said ‘always’ and the other said ‘sometimes’ and they had commented “I have had a response and assurances of improvement over some matters, but with some exceptions the problems still continues”. The home has policies and procedures in place to protect people who use the service from possible harm or abuse. These include whistle blowing, Ellerslie DS0000064584.V364418.R01.S.doc Version 5.2 Page 19 management of aggression, abuse and reporting procedures. The home uses a training video to teach staff about abuse and this involves a questions session at the end. The homes senior carer undertakes this training and they have undertaken trainer training. Some staff have done the e learning about POVA provided by the company that manages this home. One group of staff are left to undertake the video training and that was planned for the week of the inspection. No copies were seen of the ‘alerters’ guide, which provides information about the local reporting procedures in relation to allegations of abuse. None of the staff have undertaken the ‘alerters’ guide training which the local Council provides or the Registered Manager completed the enhanced training and consideration should be given to this. Staff spoken with confirmed they have completed the training provided by the home in relation to abuse. Prior to the inspection an allegation was made against a member of staff and the home followed the correct procedure in reporting and managing the situation. However we have not received a copy of the outcome of their investigation, which they said, would be sent following the inspection. This must be sent to us without delay. The employment records that were checked on a number of staff that have started work since the last inspection provided evidence that Criminal Records Bureau Disclosures (CRB’s) had been returned or applied for and POVAfirst checks were in place. Ellerslie DS0000064584.V364418.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service do not always live in a clean and hygienic environment. EVIDENCE: A tour of the home took place with a number of rooms belonging to people who use the service were seen. Ellerslie is not a purpose built home but some improvements have been made to the environment and one example is on the top floor a ‘wet room’ has been put in place. The homes Annual Quality Assurance Assessment (AQAA) mentions that in the last 12months major redecorating has taken place and new corridor flooring, lounge and bedroom carpeting and new sluicing facilities in the new wing. The home has plans for re carpeting of the stairs and corridors, re-furbishing of external fire escape route and roof and window repairs. Ellerslie DS0000064584.V364418.R01.S.doc Version 5.2 Page 21 During the tour of the home a number of issues were identified that need to be addressed, these include, Room 18 was odorous. The domestic cupboard where they store chemicals was not secure. The stairs carpet had visible debris on it, as did the top-landing floor. Room 22 the carpet was heavily stained. Room 25 the carpet was heavily stained. The visitor toilet did not have a window restrictor in place, which could pose a risk; this was addressed during the inspection. One relative had written in their survey “general standards of cleanliness in their relatives room and the home generally are rather poor”. The other relative had written, “They would like to see their relatives room hovered at the weekends”. Since the last inspection the laundry area has been updated. The laundry assistant said it is now much improved, as there is a separate area for sorting people’s clothes. A procedure is in place to manage soiled linen. The laundry assistant said that clothes belonging to people are put out in places around the home for the care staff to put away. Late in the afternoon clothes were still seen in places waiting to be put away which does not make a good impression of the home and looks untidy. Staff confirmed that protective clothing is available for them when needed. Ellerslie DS0000064584.V364418.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. A training programme is provided for staff to ensure they are able to maintain their skills and the home is confident that the number of staff on duty can meet the needs of people who use the service. EVIDENCE: The duty rotas were discussed with the Registered Manager and she was confident that the staffing numbers they have meet the needs of people who use the service. Ancillary staff are available to help the care staff. The night rotas were examined and it was noticed that certain nights the home had only 1 qualified nurse and 2 care staff where as other nights they had 3 care staff and 1 qualified nurse. Due to the layout of the home and the care needs of people who use the service the home needs to make sure they always have the 3 care staff for the night shift. The home needs to review the domestic cover they provide to make sure the home is clean as issues were identified at this inspection and as 2 relatives commented about it in their surveys. People who use the service who were spoken with said the staff are very good and friendly. One relative commented in their survey that “I think the level of care regarding health and general well-being is quite good”. Several members of staff were spoken with and they all said they enjoy working at the home and they have a good team of staff. Ellerslie DS0000064584.V364418.R01.S.doc Version 5.2 Page 23 The homes AQAA states they have 70 of care staff with an NVQ qualification or undertaking this training and 80 of their house keeping staff with an NVQ qualification. This is excellent. Four personnel files of staff that have started work at the home since the last inspection were examined. The first file had all the required checks except for a full employment history and as this was not in place no gaps could be explored. This member of staff also requires a photograph. The second member of staff only had 1 written reference instead of 2 prior to them starting work, however the Registered Manager said she had obtained a verbal reference but records of this were not available. The third member of staff also had gaps in their employment history and no photograph. Again this person only had 1 written reference and the Registered Manager said she had obtained a verbal reference but no records of this were available. The fourth person had only 1 written reference received prior to them starting work at the home and they claimed on their application form they had a qualification but the home had not requested to see their certificate or taken a copy of it. This is poor recruitment practices and could potentially place people who use the service at risk. The homes AQAA states they have a ‘robust’ recruitment policy in place. All four members of staff had Criminal Records Bureau Disclosures (CRB) in place and POVAfirst checks. One member of staff was found to have a conviction on their CRB and the home had not undertaken a risk assessment. The homes senior carer books staff on to training courses and a matrix is in place to record this and each member of staff has a record of training. The home has plans to introduce more ‘in-house’ training and staff can access e learning. Recent training that has taken place includes abuse and dementia training provided by the Alzheimer’s Society. Staff spoken with also confirmed this. Training planned includes infection control and nutrition. Moving and handling training is provided in-house. Training for qualified nurses is available. Staff confirmed that a variety of training is available to them. Induction training was examined and the senior carer said it is based on the common induction standards. Each new member of staff receives a booklet and they are allocated a supervisor. Ellerslie DS0000064584.V364418.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has a qualified manager in charge of the running of the home, and quality assurance systems in place. However these have not identified certain areas that could potentially place the health and welfare of people who use the service at risk. EVIDENCE: There have been no changes to the management of the home since the last inspection and the Registered Manager has been at the home for a number of years. She is a first level registered nurse with a masters degree, the ENB 941 course and a diploma in management services. Ellerslie DS0000064584.V364418.R01.S.doc Version 5.2 Page 25 Staff felt they could approach the Registered Manager if they had any concerns. A number of issues have been highlighted in this report that require immediate action to rectify and the outstanding requirements issued at the last inspection must also be addressed. The quality assurance systems used by the home were examined. An external audit of the home takes place once a year and since the last inspection the home has had 2 audits undertaken by the company that manages them. Regulation 26 visits are taking place and the reports for these must now be sent to us. The results of the resident’s survey that took place in 2007 were seen and the Registered Manager said they are due to repeat this about August this year. A comments book is by the front door and 2 comments were seen in there. The Registered Manager said that residents and staff meetings take place. The Registered Manager said she audits care plans and medication systems but does not maintain records of this. The system the home has in place for managing peoples monies were examined. Two were randomly selected and the money was checked against the records maintained by the home. Both were correct. Receipts are kept. Staff supervision systems were examined. A matrix is in place and the Registered Manager said that senior staff supervise other staff. Records were seen of supervision sessions and appraisals but the home is not meeting the recommended 6 times per year for care staff. Of the records checked the most sessions staff were receiving was 2 except for one member of ancillary who had 3 sessions in one year. The home should look at ways of meeting the recommended 6 times per year for care staff. Maintenance records were examined and these provided evidence that checks are taking place in relation to fire equipment and water temperatures. Dates for yearly maintenance checks were provided in the AQAA. The Registered Manager said that Legionella testing has taken place recently and a recent disinfection of the water systems. The homes fire risk assessment and evacuation procedure were not examined at this inspection. Ellerslie DS0000064584.V364418.R01.S.doc Version 5.2 Page 26 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 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 1 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 2 28 4 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 3 Ellerslie DS0000064584.V364418.R01.S.doc Version 5.2 Page 27 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 OP7 Regulation 15 Requirement All people who use the service must have care plans in place that provide staff with the information they need to meet their care needs. These must also be reviewed to make sure peoples care needs are current. Risk assessments must be is place for all people to make sure any risks are identified and actions put in place to minimise the risk. This will help to make sure the peoples health and welfare are maintained. All people that have a wound or pressure sore must have a care plan in place that details the action to be taken and records of reviews to make sure monitoring is taking place. When medication is administered to people who live in the home it must be clearly and accurately recorded and given in accordance with the doctor’s directions. There must be up to date medicine care plans to clearly describe how to use any medicines prescribed to use ‘as DS0000064584.V364418.R01.S.doc Timescale for action 01/10/08 2. OP8 13(4c) 01/10/08 3. OP8 15 01/10/08 4. OP9 13(2) 01/10/08 Ellerslie Version 5.2 Page 28 5. OP9 13(2) 6. OP10 12(4)(a) required’ or ‘as directed’. This will help to make sure people receive the correct levels of medication. Time scale of the 31/07/07 was not met. The medication error that was 01/10/08 found during the inspection must be investigated and a copy of the finding sent to us. People who use the service must 17/06/08 have their dignity and privacy respected at all times. A copy of the investigation findings in relation to the allegation made against a member of staff must sent to us. The home must make sure that the home is clean, and any carpets. To make sure people who use the service are not placed at unnecessary risk. The home must address any odours in the home to make sure people live in a pleasant environment. The domestic cupboard where the home stored chemicals used for cleaning must be secure to prevent any risks to people who use the service. The home must make sure that all the required recruitment checks are undertaken as listed in this Regulation prior to the new worker starting work at the home. This will help to reduce any risks to people who use the service. Each applicant for a post at Ellerslie must provide a full employment history so that this may be checked, if necessary. Time scale of the 31/07/07 was not met. 01/10/08 7. OP18 22(8) 8. OP19 16(J) 01/10/08 9. OP26 16(k) 17/06/08 10. OP19 13(4c) 17/06/08 11. OP29 19 01/10/08 12. OP29 Schedule 2.6 01/10/08 Ellerslie DS0000064584.V364418.R01.S.doc Version 5.2 Page 29 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. Refer to Standard OP8 OP9 Good Practice Recommendations The home should consider using wound mapping or photographs to enable them to monitor the progress of wounds or pressure sores. Care plans should reflect what choices people who live in the home are given about how their medicines are administered and their consent to the way in which nurses administer their medicines. Where consent is not possible because of lacking capacity records should be made of the agreement that the way in which medicines are administered is in the best interests of that particular person. The home should review the format their menus are printed in to make sure all people who use the service can read them. All staff should attend the ‘alerters’ guide training provided by the local council. The home should obtain copies of the ‘alerters’ guide and display them around the home. The home should review the process of leaving clothes in areas around the home for care staff to put away. This makes the home look untidy and does not create a good impression when they are still waiting to be put away late in the afternoon. 3. 4. 5. 6. OP15 OP18 OP18 OP26 Ellerslie DS0000064584.V364418.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Ellerslie DS0000064584.V364418.R01.S.doc Version 5.2 Page 31 - 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. 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