Inspection on 21/11/05 for Ellerslie

This inspection was carried out on 21st November 2005.

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

Ellerslie 29/09/09

Ellerslie 11/12/08

Ellerslie 16/06/08

Ellerslie 19/06/07

Ellerslie 14/07/06

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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Ellerslie 108 Albert Road Pittville Cheltenham Glos GL52 3JB Lead Inspector Mrs Eleanor Fox Unannounced Inspection 09:40 21 . November 2005 st 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.V266916.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Ellerslie DS0000064584.V266916.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Ellerslie Address 108 Albert Road Pittville Cheltenham Glos GL52 3JB 01242 514384 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.V266916.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th June 2005 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 residents 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 the residents. 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 majority of the property, the exception being the top floor of the Home. There has still been no progress in providing suitable facilities for the residents accommodated in this part of the building. The comfortable 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 residents at weekends. The attractive private gardens are easily accessible and may be enjoyed by the residents in warm weather; they are well protected from the busy main road by tall mature trees. Adequate parking is provided for staff and visitors. Ellerslie DS0000064584.V266916.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector undertook this unannounced inspection over a period of six hours. During the day she talked to six of the residents, read their care records, visited their bedrooms and observed some of the care, which was given to them. The inspector also spoke with two visitors and some members of staff, and looked at a selection of recruitment records and other documents, which were available in the home on that day. Comments and views of some of the people who met the inspector have been reflected in this report. Finally, the inspector talked to the Manager, who was on duty for part of the day and who was most cooperative in providing information as requested. What the service does well: What has improved since the last inspection? Following the successful recruitment and reorganisation of the duties of existing staff, the Home now provides more consistent staffing and improved communications between each shift. One resident did comment that, “There don’t seem to be so many different faces looking after us now.” There has also been some progress in improving the decorative state of the Home although further work is still required. Ellerslie DS0000064584.V266916.R01.S.doc Version 5.0 Page 6 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. Ellerslie DS0000064584.V266916.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Ellerslie DS0000064584.V266916.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 3 A thorough assessment process plus the provision of detailed information about the Home enables prospective residents to make an informed decision regarding their admission and gives them assurance that their needs will be met. EVIDENCE: Following the takeover of management responsibility by the Orders of St. John Care Trust, residents who are privately funded are now provided with a revised copy of the terms and conditions for admission to the Home. The new documentation for social services funded residents is being prepared and will be issued shortly. In the meantime, these residents are provided with a copy of the ‘Accommodation Charter’ so that they are aware of the necessary information when they are admitted to Ellerslie. This document complies with the requirements. A comprehensive assessment of each resident’s care needs is undertaken prior to their admission to the Home. The completed documentation is retained for use during the admission processes. A staff nurse visited a patient in hospital Ellerslie DS0000064584.V266916.R01.S.doc Version 5.0 Page 9 on this day; she had the benefit of a very detailed questionnaire to assist her to ensure that all the prospective residents’ care needs were considered. Ellerslie DS0000064584.V266916.R01.S.doc Version 5.0 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 the following standard(s): 7, 8, 9 and 11 The care planning systems in place still do not adequately provide the staff with the information they require to care for all the residents’ needs. Medication systems also require improvement to ensure that residents are not put at any risk of potential errors. Residents receive attentive care when they reach the end of their lives. EVIDENCE: In July, a new care planning system was introduced in the Home. However, it has now been decided that this documentation will be discontinued and an alternative will be utilised. As a result, in the six records selected for close scrutiny on this day, it was observed that most of the documentation was incomplete. Each resident had had an assessment of care needs; some containing appropriate details, others with only minimal information. In the majority of cases, there had been no recent reviews of this information. Where specific care plans had been prepared, those seen on this visit had not been reviewed recently and did not reflect the residents’ current conditions. Even personal care records had not been completed, suggesting that one person had not had a bowel movement for over a month and had only been Ellerslie DS0000064584.V266916.R01.S.doc Version 5.0 Page 11 washed twice in October. Observation of and discussion with this person showed that she was receiving regular and appropriate care. Some risk assessments had been completed but were also not reviewed in a timely fashion and did not reflect current conditions. A carer commented that, for the time being, all information and instructions were recorded in the daily records although even these did not give full details and guidance to provide holistic care to the residents. Numerous ‘Post it’ notes are attached to records and to medication administration sheets. Although containing important information, these are very unstable and could lead to confusion and possible errors. It was recorded that the tissue viability nurse had visited one person and the ‘Dressings’ care plan reflected the advice, which had been given. It was documented that another person suffering from diabetes, must have the blood sugar results recorded daily. This had been done meticulously for one week and then left for eight days despite fluctuating levels. Another person was due to have blood sugar levels assessed weekly but nothing had been recorded since 3.11.05. These issues are now being addressed. Medications are stored securely and appear to be administered as directed. However, there were three examples where handwritten drugs had no signature or counter-signature. One person was seriously ill but appeared to be receiving appropriate and attentive care. She was lying peacefully in her clean bed, she was being turned two hourly, her mouth was moist and fresh and members of staff were observed visiting the room regularly. Her family were fully aware of her deteriorating condition and one person was heard to deal with an enquiry in a sympathetic and informative manner. Ellerslie DS0000064584.V266916.R01.S.doc Version 5.0 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 the following standard(s): 12 and 14 Residents are facilitated to exercise choice in their daily lives, including taking part in social activities, if they wish. EVIDENCE: There are lists of a variety of activities to suit the needs of the residents displayed on the notice board in the Home. Different carers are delegated to lead these sessions on each day and they differ from week to week. The Home continues to have the benefit of a fully equipped sensory room, which some of the residents do find beneficial. However, as on the previous visit, any residents not choosing to remain in their bedrooms sat quietly in one of the sitting rooms, a few watching television or talking to a visitor. Later in the afternoon two people did do some painting with a carer. No other diversionary activity was organised on this day. Residents are given the opportunity to exercise choice in what they will eat and how they will spend their day, within their capabilities. One gentleman was overheard commenting at 10.00 am that he had enjoyed his ‘lie in’ and was now ready for his cooked breakfast. Later in the morning he confirmed that he was happily settled in the Home. Ellerslie DS0000064584.V266916.R01.S.doc Version 5.0 Page 13 Ellerslie DS0000064584.V266916.R01.S.doc Version 5.0 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 the following standard(s): 16 and 18 The Company’s policies and procedures are fully implemented, giving residents the assurances that they may expect to live in a safe environment and that any concerns they raise will be addressed in a timely manner. EVIDENCE: There have been no formal complaints received in the Home since the last inspection. The clearly detailed complaints policy is readily available to residents, their visitors and staff working at the Home. One visitor agreed that she was aware of the procedures to follow if she had any problems. The only time that her family had had a concern about the home, the issue was addressed and resolved promptly. The Home has full policies relating to all forms of abuse. These have recently been reviewed following the takeover by The Orders of St John Care Trust. Members of staff receive timely training on these issues. It was observed that applicants interviewed for employment at the Home are questioned on their knowledge and understanding of this subject. Ellerslie DS0000064584.V266916.R01.S.doc Version 5.0 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 the following standard(s): 19, 21, 23 and 26 Urgent investment is required to create a comfortable and homely environment for residents living at Ellerslie. EVIDENCE: An additional handyman has now been appointed to the Home. He is gradually addressing some of the outstanding decorative issues. Despite some improvement, there are still many areas of this Home which appear worn and ‘tired looking’. The carpet in the main sitting room has been replaced but the windowsill in Room 26 still requires repair, as does the ceiling in Room 10. The toilet roll holder in the Ladies toilet close to Room 10 also requires replacement or repair. There are plans to upgrade the bathroom facilities on the first floor but there are still no adequate bathing or toilet facilities for the residents accommodated on the top floor of the Home. This issue will now be subject to regulatory enforcement action. Ellerslie DS0000064584.V266916.R01.S.doc Version 5.0 Page 16 Bedrooms are of differing sizes and provide adequate dimensions to meet the residents’ needs. However, there are inadequate curtains provided in Room 20 to allow sufficient privacy to both the ladies in that bedroom. Although the laundry room was unattended on this occasion, all the machines were in use and there were a number of skips awaiting attention. It was observed that clean laundry had been left in a heap on top of equipment next to a skip full of soiled articles, creating a serious health and safety risk. There was evidence of an offensive odour on the ground floor corridor, there was no improvement in the situation throughout the day. The remainder of the Home was reasonably clean. Ellerslie DS0000064584.V266916.R01.S.doc Version 5.0 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 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): 27, 29 and 30 Residents receive care from a stable competent workforce but improved recruitment practice would help to ensure that residents are fully protected. EVIDENCE: On this occasion there were twenty-eight residents living in the Home, one of whom was seriously ill. The majority of people appeared to require high dependency care. All the staff were fully occupied attending to residents’ care needs. Observation of the duty rota sheets showed that there were was normally a trained nurse with five carers on duty each morning; a nurse and four carers each evening and a nurse with two carers overnight. Although it has not been possible to recruit a deputy manager, as yet, there is now improved continuity of senior staff at Ellerslie. One visitor did comment that it is often difficult to find a carer when required although she was quite satisfied with the care her relative was receiving. The personnel records relating to all four members of staff employed since May were seen on this visit. Careful recruitment procedures are normally followed when employing new members of staff at the Home. All the required criminal record screening is undertaken before the member of staff joins the team but information about their full employment history plus the reasons for any gaps in employment is not yet obtained in every case; the application form only requests details of the previous ten years and even this was not clear in one example. In addition, only one reference had been obtained for three of the employees. The additional information is now being obtained. Ellerslie DS0000064584.V266916.R01.S.doc Version 5.0 Page 18 Full records are maintained of all the training undertaken in the Home. These indicated that almost every member of staff had attended all the required mandatory training and, if any gaps had been identified, arrangements made to address the issue. Additional training needs are also addressed as required. Ellerslie DS0000064584.V266916.R01.S.doc Version 5.0 Page 19 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): 33, 37 and 38 The consistent implementation of robust management systems would ensure that the health, safety and welfare of the residents would be safeguarded. EVIDENCE: There are a number of auditing processes undertaken at the Home. In July, each resident and/or family member was requested to complete a satisfaction questionnaire by the Orders of St John Care Trust. The Manager has not been made aware of any results of this survey. Residents’ satisfaction with meals provided, complaints, accidents and general quality of the provision of care is all monitored monthly. A quality improvement report has not been provided for the Home in the last twelve months, as is required. The majority of records seen on this occasion were maintained correctly and stored securely. It was confirmed that residents might have access to their Ellerslie DS0000064584.V266916.R01.S.doc Version 5.0 Page 20 records if they wish. However, there were no photographs provided for at least two people. There is still a need to employ agency and relief staff and the photographs are required to assist identification. Members of staff continue to attend mandatory health and safety training as required. However, during a tour of the building, it was observed that cleaning materials had been left unsecured in the cleaners’ room. In addition there was no restrictor on the window of the toilet on the first floor mezzanine. Maintenance of equipment was not addressed on this occasion; this was satisfactory at the inspection in May. The Home has had a recent visit from the Fire Department leading to enforcement action. The identified issues are being addressed and it is anticipated that the necessary action will be completed within the specified time frame. Ellerslie DS0000064584.V266916.R01.S.doc Version 5.0 Page 21 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 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 x 1 x 2 x x 2 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 2 x x x 2 2 Ellerslie DS0000064584.V266916.R01.S.doc Version 5.0 Page 22 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(1) Requirement A written plan must be prepared detailing how the service users needs in respect of his health and welfare are to be met (Time scale 31/7/05 not met). Risk assessments must be undertaken, documented and reviewed for each resident where there are identified concerns. Evidence must be provided that residents receive where necessary, treatment, advice and other services from staff in the Home and other healthcare professionals. The person making the record in the drug administration documentation must sign any handwritten amendments (Time scale 30/6/05 not met). Decorative and maintenance requirements identified under Standard 19 must be addressed (previous time scales 28.2.05 and 31.8.05 not fully met) An assisted bathroom or shower facility, and accessible toilet must be provided on the upper floor of the building (previous DS0000064584.V266916.R01.S.doc Timescale for action 31/01/06 2 OP7 13(4b and c) 13(1b) 01/12/05 3 OP8 31/12/05 4 OP9 13(2) 01/12/05 5 OP19 23(2b) 31/12/05 6 OP21 23(2j) 05/02/06 Ellerslie Version 5.0 Page 23 7 OP23 16(2c) 8 9 OP26 OP29 16(2k) Sched. 2 10 11 12 OP33 OP37 OP38 24(2) Sched. 3.2 13(4) timescales 31.3.05 and 31.8.05 not met) The Home must provide adequate curtains in Room 20 to allow both the occupants adequate privacy. The Home must be kept free from offensive odours Each employee must provide a full employment history plus a satisfactory explanation for any gaps in employment. Two written references must also be obtained A quality improvement report must be provided for the home A photograph must be provided for each resident The Home must be kept free from any avoidable risks to the health and safety of the residents, particularly in relation to cleaning materials and unrestricted windows. 31/01/06 01/12/05 01/12/05 31/01/06 31/12/05 01/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7OP9 Good Practice Recommendations It is strongly recommended that the practice of using ‘post it’ notes should be discontinued to ensure that important information is not mislaid. Ellerslie DS0000064584.V266916.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Ellerslie DS0000064584.V266916.R01.S.doc Version 5.0 Page 25 - 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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