Inspection on 27/02/06 for Elm Grove Nursing Home

This inspection was carried out on 27th February 2006.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Elm Grove Nursing Home 10/12/08

Elm Grove Nursing Home 08/01/07

Elm Grove Nursing Home 24/03/05

Elm Grove Nursing Home 23/07/04

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 Elm Grove Nursing Home Somerford Road Cirencester Glos GL7 3HW Lead Inspector Mrs Janice Patrick Unannounced Inspection 10:00 27 February 2006 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 Elm Grove Nursing Home DS0000016431.V278277.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. Elm Grove Nursing Home DS0000016431.V278277.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Elm Grove Nursing Home Address Somerford Road Cirencester Glos GL7 3HW 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) 01285 653057 www.bupa.co.uk BUPA Care Homes (CFCHomes) Limited Ms Margot Holmes-Watkins Care Home 60 Category(ies) of Dementia - over 65 years of age (22), Old age, registration, with number not falling within any other category (38) of places Elm Grove Nursing Home DS0000016431.V278277.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. A designated person with two years proven experience in dementia care and staff supervision leads the day-to-day care within the Dementia Care Unit 14th September 2005 Date of last inspection Brief Description of the Service: Elmgrove is part of the BUPA Care Homes Group and provides nursing care for 38 older persons and personal care for 22 older persons within a separate dementia care unit. It is a well-managed and popular Care Home. The Home is within a residential area of Cirencester Town and has its own extensive gardens. The dementia care unit has its own enclosed garden area where residents can enjoy fresh air safely. All bedrooms have en suite facilities and are for single occupancy. The dementia care unit has some environmental adaptations, which are designed to help the confused resident in their daily living. Staff are trained to be skilled within the area they work and qualified nurses are on site at all times. Elm Grove Nursing Home DS0000016431.V278277.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out by one Inspector between the hours of 10am and 2.30pm. The General Manager and the Registered Manager were on duty including the newly appointed nurse responsible for the dementia care unit. Care documentation was inspected within the dementia care unit during this inspection. Five residents and two relatives were spoken with in the main house and one resident within the dementia care unit was spoken with. Their health care needs were discussed and their views on the care and services provided were sought. The Home’s infection control practice and general cleanliness was inspected. Staff training was discussed. Staff recruitment practice was inspected. The Home’s Quality Assurance arrangements were inspected. The arrangements in place for the safekeeping of residents’ personal monies were inspected. Some records pertaining to health and safety checks were seen. What the service does well: What has improved since the last inspection? The communal area within the main house has been redesigned to offer improved practical communal space. A member of staff with dementia care experience now manages the dementia care unit on a day-to-day basis. Care planning within this unit has improved and is beginning to reflect a ‘person centred’ approach to care. The management restructure over the site has now been completed and the Registered Manager is now registered with the Commission for Social Care Inspection (CSCI). Elm Grove Nursing Home DS0000016431.V278277.R01.S.doc Version 5.1 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. Elm Grove Nursing Home DS0000016431.V278277.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 Elm Grove Nursing Home DS0000016431.V278277.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): None of the standards above were inspected on this occasion. N/a EVIDENCE: N/a Elm Grove Nursing Home DS0000016431.V278277.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 & 10 Person centred care planning is now allowing individual needs to be identified and met. The health care needs of the residents are met, although staff need to ensure these are carried out with the dignity of the resident in mind at all times. EVIDENCE: The Inspector carried out a case tracking exercise on one resident within the dementia care unit. Written documentation corresponded with the actual support that was being given. It also identified areas of need, which the resident did not have insight of. The conversation between the Inspector and resident demonstrated that the resident did lack insight in several areas. When staff were observed talking to her they maintained her dignity and self worth without being patronising or dismissive. This resident appeared very much in a state of ‘well being’. Other interactions between staff and residents were observed which included appropriate use of affection and touch. The Inspector also witnessed a member of staff talking with a resident who was very confused. Although the content of Elm Grove Nursing Home DS0000016431.V278277.R01.S.doc Version 5.1 Page 10 what the resident was saying appeared to be disjointed this was listened to actively and in a respectful manner by the carer. Within the main house comments from residents and relatives about the staff’s attitude and approach towards residents was positive. Another situation witnessed by the Inspector was not so positive. This involved two care staff approaching a very frail resident who was unable to move independently out of a chair, start to recline her electronic chair without telling her and proceed to talk over her. This unusual event for this home was reported back to the Manager who will be speaking with the two staff involved. Elm Grove Nursing Home DS0000016431.V278277.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, 13 & 14 Residents benefit from living in a home that encourages them to make their own decisions and keep some control within their individual lives. The homes visiting policy encourages visitors at any time. EVIDENCE: One resident within the dementia care unit was asked how she makes choices for herself. She had been a very independent individual and although she has little insight into her capabilities as they are now, she clearly feels she is in control and making her own choices. She demonstrated a good sense of ‘well being’ and clearly liked the staff who are unobtrusively supporting her decision making. An example of this is her control over her personal money held within the ‘in house’ account. On a weekly basis she is helped to the administrator’s office to withdraw an amount of money, held on her behalf. This resident informed the Inspector that she manages her account and all her finances as she has always done so. In fact arrangements are in place through a Power of Attorney, but she is able to retain her dignity by making her own withdrawal ‘in house’. Other residents were observed to be asked where they would like to go, where they would like to sit, who they wished to sit next to and what they wanted to do next. One resident used to be a great bridge player and although not really able to play anymore, informed the Inspector that she had held a bridge Elm Grove Nursing Home DS0000016431.V278277.R01.S.doc Version 5.1 Page 12 evening recently. The Inspector later found out that staff were aware of this person’s past social history and included her and four other residents in a game of cards one evening. Some of the residents in this unit had enjoyed going to the main home to have coffee and ‘make things’. ‘Great fun’ it was described by one resident. Another resident in the main home confirmed that she is able to take herself to bed when she chooses and said that the food ‘would be hard to beat’. Another resident who is dependant on staff to help her, said that the staff know when she likes to go to bed and they usually come for her then. A frail resident that was very deaf and almost blind said people can be around her all day but at times she feels very lonely. Several residents enjoyed the activities that are held. An ad hoc quiz was being held after lunch on the day of this inspection. One resident said it happens quite often ‘keeps the grey matter ticking over’. All the residents spoken to confirmed that their family and friends could visit when they choose. Visitors also confirmed this to be so and that they were always made welcome. One visitor said that she visits at varying times of the day and the welcome has always been the same. Elm Grove Nursing Home DS0000016431.V278277.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): None of the above standards were inspected. N/A EVIDENCE: N/A Elm Grove Nursing Home DS0000016431.V278277.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): 20 & 26 The communal lounge offers a comfortable and safe place for residents to sit. Residents benefit from living in a clean home that has good infection control awareness. EVIDENCE: The furniture in the main lounge has been rearranged in order to offer small areas of grouped seating, but which staff can access easily with moving and handling equipment. There is now space for those with Zimmer frames to walk directly up to their chair a sit down. Residents that are very frail and who require larger recliner chairs and more attention are in another part of the lounge over looking the garden. The large lounge has been subtly divided in order to offer this group of residents a little more privacy. One dining room table has remained within the lounge area as a particular group of residents enjoy sitting together for meals. One of these residents in particular does not like going to the dining room. Elm Grove Nursing Home DS0000016431.V278277.R01.S.doc Version 5.1 Page 15 The home looks clean and was free from offensive odours. 21 staff members have signed up to undertake the next wave of training in Infection Control. Aprons and gloves were seen being worn appropriately. Alcohol Gel is available at different points in the home for staff to use on their hands. Several times the Inspector observed staff coming in to the nurses’ office to wash their hands. Elm Grove Nursing Home DS0000016431.V278277.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 & 29 Residents benefit from being cared for by appropriately trained staff, who have been recruited well. EVIDENCE: The percentage of staff holding the National Vocational Award (NVQ) in Care is above the 50 required by the National Minimum Standards (NMS). An audit list was provided showing the current training status of each member of staff. Arrangements are in place within BUPA for this training and all staff are expected to undertake the NVQ Award. A recent improvement has been made to how an individual can submit their course work that should speed up the period of time it takes to complete a unit. An assessor visits the home fortnightly to work alongside the candidates. One carer has obtained her Level 2 and is in the process of doing Level 3; she wishes then to use this as entry to her nurse training. The staff files of three new recruits were inspected. All the criteria had been met except for one file, which was missing a photograph. Elm Grove Nursing Home DS0000016431.V278277.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): 33, 35 & 38 Arrangements are in place to ensure the home is run in the best interest of the residents. Residents can be assured that their personal monies are protected. The health and safety of the residents and staff working in the home is generally safe guarded. EVIDENCE: The home fulfils the criteria set by BUPA as well as the NMS by ensuring that an extensive quality assurance and auditing system is maintained. Care planning and staff education have been two of the audits carried out recently by external auditors. Care plans are also more rigorously audited ‘in house’ since the last inspection. The Inspector was shown BUPA’s 2005 Audit Report of which some of the information was collated from the spring and autumn satisfaction surveys. Elm Grove Nursing Home DS0000016431.V278277.R01.S.doc Version 5.1 Page 18 An example of the letter that summarises the findings and which is sent to each resident or relative was seen. The Manager will be meeting with her heads of departments and going through each area within the report in order to see where and how improvements, if needed, can be made. The usual arrangements are in place regarding residents’ personal monies. The home only holds a small cash float. Most residents have an ‘in house’ account, which is electronically maintained. This is currently held in a non-interest bearing account, separate from the business finances of the home. The safe guarding of how one resident’s money is spent on her behalf was discussed. The correct steps, of questioning this with her Power of Attorney have been carried out and a letter to this affect from the home Manager was seen during this inspection. The home records many health and safety checks carried out on a weekly and monthly basis. On this occasion these could not be accessed, although records pertaining to the checking on a monthly basis of the fire fighting equipment and emergency lighting had no entries for January or February 2006. The Fire Officer who is due to return in April 06 to follow up minor requirements has recently inspected the home. A fire risk assessment has been completed (17/01/06). It was minor actions on this that will be checked again by the Fire Officer in April. Elm Grove Nursing Home DS0000016431.V278277.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X 3 X X X X X 3 STAFFING Standard No Score 27 X 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 4 X 3 X X 2 Elm Grove Nursing Home DS0000016431.V278277.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP10 OP38 Regulation 12(4)(a) 17 Schedule 4 (14) Requirement The Registered Manager must ensure that each staff member treats all residents with dignity. The Registered Manager must ensure that records are maintained according to the home’s individual policy, on the checking of fire equipment. Timescale for action 31/05/06 31/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Elm Grove Nursing Home DS0000016431.V278277.R01.S.doc Version 5.1 Page 21 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 Elm Grove Nursing Home DS0000016431.V278277.R01.S.doc Version 5.1 Page 22 - 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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