Inspection on 08/01/07 for Elm Grove Nursing Home

This inspection was carried out on 8th January 2007.

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 27/02/06

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 8th January 2007 10:15 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.V323487.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. Elm Grove Nursing Home DS0000016431.V323487.R01.S.doc Version 5.2 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 Mrs Natalya James Care Home with Nursing 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.V323487.R01.S.doc Version 5.2 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 27th February 2006 Date of last inspection Brief Description of the Service: Elmgrove is part of the BUPA Care Homes Group and provides general nursing and personal care to persons over the age of 65 years. It also has a designated unit where those suffering from dementia can receive personal care. The Home is within a residential area of Cirencester Town and is near to several bus routes. There is a communal lounge and dining room in the main home with a designated space for activities. The dementia care unit has two communal areas consisting of lounge and dining areas. All bedrooms throughout the home have en suite facilities and are for single occupancy. The home as a whole has many adaptations designed to make daily living easier for the elderly person, however the dementia care unit has additional modifications which help the confused resident. The main home has a large garden and ample parking, as does the dementia care unit, although additional arrangements are in place here to meet the specific needs of this client group. The home has qualified nurses on duty 24 hours of the day and care staff receive specific training in the needs of those with dementia. Current care fees range from £500.00 to £720.00 per week. Neither the home’s Statement of Purpose or previous inspection report was on display, but can be obtained on request when visiting the home. Elm Grove Nursing Home DS0000016431.V323487.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by one inspector who was in the home between 10.15am and 20.15pm, therefore apart from residents both day and night staff were spoken to during the Inspector’s visit. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. The Commission for Social Care Inspection (CSCI) also received back 41 pre inspection surveys sent to residents and their relatives of which some information from these has been included in this report. As well as a selection of records relating to various aspects of care and the safe administration of medications, four residents’ care as well as their records were inspected in detail as part of a case tracking exercise. Arrangements for maintaining residents’ privacy and dignity were inspected and how these extend to allowing choices to be made and preferences to be met. Systems in place to ensure a varied and nutritional diet were inspected. Policies and procedures to ensure residents’ safety and protection from abuse were inspected, including how the home deals with complaints. The environment was inspected along with records that demonstrate that it is well maintained and equipment is serviced. Arrangements that help prevent infection were explored. All aspects relating to staffing were inspected, this included staff recruitment records, staff training and support records. Various management arrangements were inspected along with how the views of the residents and other visitors are sought and how these influence in what way the home improves its services. What the service does well: It is able to offer care to those with diverse needs which many residents and relatives feel is delivered well. Residents within the dementia care unit are recognised as individuals and given support and guidance to enable them to make choices despite their confused states of mind. The daily nutritional needs of all residents are very well planned and catered for. Elm Grove Nursing Home DS0000016431.V323487.R01.S.doc Version 5.2 Page 6 There are well-established arrangements with external healthcare professionals in order to meet residents’ specific health needs. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Elm Grove Nursing Home DS0000016431.V323487.R01.S.doc Version 5.2 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.V323487.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to provide the prospective resident/existing residents and visitors with information, which relates to the home and fees. Arrangements are in place to ensure that residents are only admitted once the home is sure their needs can be met. Residents benefit from living in a home where the staff have appropriate skills and or experience to meet their health and care needs. EVIDENCE: The home’s Statement of Purpose was updated when part of the home became a designated dementia care unit. The Inspector was informed that following this inspection this document would be returned to the entrance hall of the main house making it easily accessible to visitors. Elm Grove Nursing Home DS0000016431.V323487.R01.S.doc Version 5.2 Page 9 Consideration should be given to placing a copy also in the reception area of the dementia care unit as many visitors use this entrance and at the time of this inspection only an old version of this document was present. Each bedroom has a ‘welcome pack’ containing the home’s terms and conditions and complaint procedure including additional information. Representatives of the residents admitted to the dementia care unit are made aware of this information during the admission process. Additional information in the home included where to get advice on planning for care fees, a specific dementia care brochure, a guide for those short listing care homes and the BUPA Magazine. The home’s inspection report written by the CSCI was not on display and only 9 relative surveys, out of 35 received back indicated that they were aware of this report. Consideration should be given on how to raise the profile of this report. An example of signed terms and conditions were seen for residents who are self-funding, including invoices that clearly showed what amount had been awarded for the Registered Nurse Care Contribution (RNCC). The administrator prefers to make an appointment with who ever is going to be responsible for the payment of fees on, or as near to the day of admission so that any queries can be answered and arrangements for an ‘in house’ account can be made. The invoices prepared for those receiving funding towards their care do not yet show what the RNCC amount is. This information is now required within the Care Home Regulations 2001. Monthly statements are also provided showing current balances and expenditure of individual personal monies. Receipts seen provide a paper trail for auditing purposes. These systems are very organised and well managed by the home’s administrator. Each resident has his or her needs assessed prior to admission. An alternative assessment format is used within the dementia care unit. Two such assessments were read and for a third resident this also included detailed information on the resident’s needs by an out of county funding authority. The staffs’ skills and knowledge base has been updated over the last year and includes subjects such as nutritional care, pressure relief, communication in palliative care and the use of syringe drivers. One staff member is qualified to do four-layer bandaging on leg ulcers. Six staff have attended BUPA’s 3 day dementia care training. This home does not provide designated rehabilitation care. Elm Grove Nursing Home DS0000016431.V323487.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Each resident has a written care plan and arrangements are in place to help care planning become more person centred. Residents and their relatives can be assured that healthcare needs will be met. The medication system is generally well organsied and is administered safely, therefore protecting residents from poor practice. The home’s philosopy is that all residents will be treated with respect and their privacy will be upheld; any identified shortfalls in this area are taken seriously in order to protect the resident. EVIDENCE: The written care plans for four residents were read in detail, one within the dementia care unit. These demonstrated that the home plan and record the care that is being given and generally review this on a monthly basis or sooner if required. Elm Grove Nursing Home DS0000016431.V323487.R01.S.doc Version 5.2 Page 11 There were some shortfalls where staff had not either signed the care plan or recorded in one resident’s case, their weight. Another resident would have been more than able to participate in the devising of her care plans but staff had not taken the opportunity to include her in this process. The care documentation for two residents recorded that there had been improvements in their health since admission. One had put weight on and another had been admitted with a pressure ulcer, which was healing well. BUPA are in the process of training all staff to use new paperwork that will encourage more individuality within the care plans. The staff in the home liaise with several external healthcare professionals in order to meet the residents’ healthcare needs. These include the General Practitioner, Community Nursing Team, Social Workers, Community Nutritionist, Continence Advisor, Chiropodist and Optician. Residents also attend hospital appointments or are sometimes visited by specialist Consultants. Residents have recently been reassessed for their continence aids. All relatives who responded to the pre inspection survey said they are kept informed of their relative’s health and of important issues that arise. The medication storage and administration system was inspected in the main house only. Correct arrangements were in place for the storage of medicines and completion of administration records. There were very few gaps noted. The supplying pharmacy checks the system regularly and a monthly ‘in house’ audit is carried out. A small supply of controlled medication was also checked and found to match the records being kept. The Inspector did note that qualified staff were not keeping the medication keys on their person but instead storing these in a non-secure place. This was pointed out to the Registered Manager immediately who assured the Inspector that this practice would cease. The Inspector noted that each resident was spoken to in a respectful manner and that staff knocked on bedroom doors before entering. This was particularly evident within the dementia care unit during the late afternoon, where staff related to residents in a very kind and considered manner even when the residents were repeating themselves or in one case, swearing at the staff member as part of their confused state. One member of the public who visits the home has informed the Inspector of staff behaviour that may suggest that residents are not always treated with respect. This concern has been forwarded to BUPA to investigate. Elm Grove Nursing Home DS0000016431.V323487.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a home where staff acknowledge and try to support where possible residents’ individual choices and preferences. Links with family, friends and the community are encouraged in order to enhance the residents’ quality of life. Arrangements are in place to ensure the provision of activities that help meet individual social, recreational, cultural and religious needs. Residents are provided with a varied and balanced diet, which is devised to meet everyone’s’ needs. EVIDENCE: Residents say they are able to make choices about how they spend their day, but for many this can be difficult due to their high levels of dependency and ill health. Residents can choose whether they stay in their bedrooms or socialise in the communal rooms. Elm Grove Nursing Home DS0000016431.V323487.R01.S.doc Version 5.2 Page 13 There is a very motivated activities co-ordinator who will invite residents to take part in activities, if they choose not to then this is not a problem. The coordinator carries out one to one visits to several residents who prefer to remain in their bedrooms. Relatives and friends are free to visit as they wish, one visitor said she is always made welcome and usually visits her relative in his bedroom where he prefers to spend his time, although staff explained that he has to be taken to the lounge area to be observed because he is prone to wandering near the staircase. The Inspector did make comment on the possibility of a ground floor bedroom for this resident. The resident’s relative brings in specific activities for her relative to do. It was noted that a talking book machine was in the bedroom but apparently this is difficult to use, as it has to be very loud for the resident to hear. A communion service is held regularly in the home and specific and individual faiths are respected. Residents within the dementia unit were observed to be moving around freely and being asked simple questions such as where they would like to sit and what they felt like doing. Some required more guidance than others. Four residents were observed in the lower lounge enjoying a favourite programme on the television. A daily choice of food is available and the head chef confirmed that an alternative could always be cooked in addition to these. This was seen at teatime for one resident. Another resident commented that she would prefer a certain type of cereal; this had been brought in by the kitchen but unfortunately had never been offered to her by the care staff. The Registered Manager was going to make sure that she was offered this at breakfast. BUPA have devised menus and systems that provide the elderly person with a balanced diet. Arrangements are in place to ensure that these are adhered to and recorded. A new initiative has started which enables ‘light bites’ to be available at any time of the day, also during the night. The head chef explained the many ways he uses to get additional calories into foods for the very frail or overly active residents. Most residents spoken to in the dining room thought the food was good. One resident said, “ the soup is always excellent”. The home must ensure that any alternative food provided, other than the planned choices on the menu, are recorded for that individual. Elm Grove Nursing Home DS0000016431.V323487.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A robust complaints procedure gives complainants reassurance that their complaints/concerns will be investigated fully. Although the home has policies and procedures in place that relate to the protection of vulnerable adults, staff awareness and the general profile of this subject needs to raising within the home to increase the protection to older residents. EVIDENCE: Although this outcome group has been assessed as ‘adequate’ there are areas of the Protection of Vulnerable Adults that require serious consideration. BUPA have policies and robust procedures for dealing with complaints and have fairly recently reviewed their policy and procedures for the Protection of Vulnerable Adults (POVA). One complaint has been received by the home since the last inspection. This was not related to care and has been resolved. Within the same week of this inspection some concerns were raised anonymously with the CSCI. A senior member of BUPA’s staff will investigate these and report their findings to the CSCI. An additional concern was raised via a relative survey and will also be investigated. Elm Grove Nursing Home DS0000016431.V323487.R01.S.doc Version 5.2 Page 15 The home’s complaint procedure is located on the wall in the entrance hall and is within the ‘welcome pack’ in each bedroom. There is a leaflet ‘alerters guide’ which relates to elderly abuse, the protection of vulnerable adults and who to contact in the event of an allegation or situation on the notice board in the dementia care unit. There was nothing prominent relating to this in the main house, although information on ‘whistle blowing’ is in the staff room. The Registered Manager has completed a company course on abuse within dementia care and will be the ‘link’ person on this subject for the home; the plan being that staff will receive a talk and information on this subject. There are other policies and procedures and practices taking place that help to protect vulnerable adults. However records show that three staff members attended training on abuse issues and confidentiality in June 2006 and six staff have attended the complete 3 day dementia training via BUPA where the subject is discussed. This is not a lot of staff out of a total of 47 care staff and the general profile on the subject needs lifting. Two night staff spoken to had not received any training on this subject. Consideration should also be given to senior staff attending the Protection of Vulnerable Adult training, which is provided by the Adult Protection Team as this gives a countywide perspective on the subject and explains to the attendee how and when other agencies become involved. Elm Grove Nursing Home DS0000016431.V323487.R01.S.doc Version 5.2 Page 16 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, 21, 22, 24, 25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This is a well maintained home offering comfortable, warm and well ventilated accommodation which in places has been adapted to make the daily lives of those that use it a little easier. Residents are free to bring in their own personal possessions to help them settle and feel at home. Residents have the benefit of living in a safe and clean home. EVIDENCE: A tour of the building was carried out and all areas appeared generally well maintained. The Registered Manager explained that BUPA has planned extensive refurbishment for the home and she is hopeful that this may commence this year. Elm Grove Nursing Home DS0000016431.V323487.R01.S.doc Version 5.2 Page 17 During this inspection it was noted that all carpets in the upstairs corridors within the dementia care unit have been replaced. Several bedrooms throughout the home have also been re-carpeted. A downstairs assisted shower room has been added in the dementia care wing and a new bath with a Jacuzzi has been installed in the main house. One part of the home has been fitted with new boilers. The home has many new fire doors, meeting updated fire requirements and the home’s fire risk assessment. Several bedrooms on the first floor have new windows. There has been new dining room furniture and new televisions in the main communal lounges. All bedrooms are furnished to the minimum standard with co-ordinating soft furnishings and vary in how personalised the resident or their family have made them thereafter. One resident’s relative has included some adaptations in her relative’s room that help him move around safely even though he has limited sight. The home itself, should be considering these adaptations when admitting a resident with visual impairment. All areas of the home seemed clean and there were no offensive odours. There are systems in place that compliment good infection control practice. Staff were observed washing their hands or using the alcohol gel available. They also wore appropriate protective clothing when carrying out certain care tasks or when serving food. The laundry was not inspected on this occasion but the Inspector was told that the floor covering has been renewed. Elm Grove Nursing Home DS0000016431.V323487.R01.S.doc Version 5.2 Page 18 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are adequate staff in number and enough experienced staff to meet the needs of the residents. Some staff are trained appropriately although the home would benefit in increasing the number of staff trained formally in care. Recruitment processes are generally robust and help protect vulnerable residents, although checks must be more organised to ensure no one individual is employed before all the requirements are in place. EVIDENCE: The Registered Manager confirmed that each area of the home has adequate staff on duty to meet the needs of the residents. Qualified nurses are on duty within the main house 24 hours of the day and although the dementia care unit is registered to provide ‘personal care’ only, a qualified nurse is on duty in this unit for up to 4 shifts a week. Other times the unit is managed by a senior care assistant, with dementia care experience, as was the situation at the time of this inspection. Over the last year there have been several changes of staff within the dementia care unit and a settling down period has pursued as the client group has changed from predominantly general care to dementia care. The Elm Grove Nursing Home DS0000016431.V323487.R01.S.doc Version 5.2 Page 19 Registered Manager says this is settling as more staff are receiving appropriate training and experience. Staff do rotate within the home as the home’s staffing is worked out as one site, not two separate units. Staff with dementia care training and experience tend to work more often in the dementia care unit. There are still some residents in the dementia care unit who have not been formally diagnosed with dementia but who either have chosen not to move or do require a fair degree of supervision because of their confusion. The home has some vacancies on the domestic team at present and the laundry is staffed 7 days a week. The kitchen is staffed throughout the day and early evening; therefore care staff do not carry out any food preparation. There is a designated breakfast waitress. The home also has a fulltime administrator, housekeeper and maintenance person. According to the pre inspection information compiled by the home it is currently just under the national minimum standard for numbers of care staff holding the National Vocational Award (NVQ) in care or an equivalent. This is an ever-moving target for the home as staff come and go however, 4 staff are about to commence this training at Level’s 2 & 3. The home adheres to set recruitment procedures and all staff are cleared by the Criminal Records Bureau (CRB) and/or the Protection of Vulnerable Adult (POVA) list prior to working in the home. Two satisfactory references are required along with various other requirements. The records for two new staff were inspected. A shortfall was identified in two additional staff records and for various reasons the CRB clearance was not present. This was to be looked into immediately by the administrator. All staff are provided with a formal induction training, care staff receive a more in-depth induction which is care related. Mandatory training at this stage includes fire awareness, safe moving and handling, food hygiene and health and safety. A selection of records seen indicated that full induction trainings had been completed. The member of staff’s mentor closely monitors this period of time and an appraisal system is in place. Elm Grove Nursing Home DS0000016431.V323487.R01.S.doc Version 5.2 Page 20 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, 32, 33, 35, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from living in a home that is managed by a person able to carry out the task, who is approachable and which has systems in place that acknowledge their views/opinions on the service provided. Residents can be reassured that arrangements are in place to protect their personal monies. There are shortfalls in the staff supervision system, which allow for potential opportunities of poor practice or practice through ignorance to take place and go unchecked. Generally residents live in a home that ensures their safety. EVIDENCE: Elm Grove Nursing Home DS0000016431.V323487.R01.S.doc Version 5.2 Page 21 The general manager carries out the overall management of the site. There is also a Registered Manager who is registered with the Commission. They are both well supported by the Deputy Manager. All are registered nurses and the Registered Manager has a further qualification in the care of those with dementia. Being a BUPA care home there are regular meetings held with all levels of staff and the heads of various departments. These are minuted and each area is responsible for improving the service given by their department. BUPA has several initiatives that encourage and recognise staff commitment and ideas. The home follows a quality assurance system that helps the home meet the corporate aims and objectives. This particular system has been in place for several years now and is an ongoing piece of work within the home over a year. Audits for nutrition, medication and care plans have been particularly targeted by BUPA recently. Questionnaires are also sent to residents and relatives for feedback on the care and services provided. Additional audits are carried out on a monthly basis. No personal monies are kept in the home, although the records of individual amounts held in a central account are kept. These were not inspected on this occasion, however are audited by BUPA. Statements of current balances and expenditure are forwarded monthly to the resident or person with Power of Attorney, examples of which were seen. Receipts for chiropody and hairdressing were seen for services carried out on the day of this inspection. A record of the dates that day staff received supervision was seen and most were up to date. Night staff are not receiving regular formal supervision at present although the Registered Manager is aware of this and needs to organise how this can be achieved. The Managers ensure that the health and safety of residents and staff is maintained by providing training and making sure that various safety checks are carried out. Moving and handling training is given to all staff. Nine staff were due to attend a training session soon and senior staff confirmed that new staff do not carry out moving and handling techniques unsupervised. There was an example of a new member of staff being supervised by a mentor throughout the day of this inspection. Nine new staff required a full fire lecture, which was due the day after this inspection. One member of staff is due to undertake a trainers course on managing challenging behaviour/violence and will cascade this information back to the rest of the staff. Elm Grove Nursing Home DS0000016431.V323487.R01.S.doc Version 5.2 Page 22 There is one member of staff currently up to date in first aid, although some staff have applied for the 2007 course and the subject is discussed in the induction training the home must increase the number of staff trained in first aid to adequately protect residents. Two night care staff confirmed they have received moving and handling training and fire training in the last year. One confirmed he had attended several trainings another said it was difficult to attend many of the trainings provided during the day hours. Records pertaining to safety checks and servicing were inspected. Elm Grove Nursing Home DS0000016431.V323487.R01.S.doc Version 5.2 Page 23 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 3 2 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 N/A DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X 3 3 X 3 3 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 4 X 3 2 X 3 Elm Grove Nursing Home DS0000016431.V323487.R01.S.doc Version 5.2 Page 24 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. Standard OP2 Regulation 5A 5(b) Requirement The Registered Persons shall provide the service user with a statement that shows the amount being contributed with respect to the Registered Nurse Care Contribution (RNCC) irrespective of how the fees are being funded. The Registered Person must by means of training staff and or other measures prevent service users from being abused or harmed. The Registered Person must ensure that all staff who work in the Care Home have been cleared by the a Criminal Record Bureau (CRB) and the Protection of Vulnerable Adults (POVA) list in order to protect service users. The Registered Person must ensure all staff receive adequate supervision, this requirement is with particular reference to the night staff. Timescale for action 31/03/07 2. OP18 13 (6) 31/03/07 3. OP29 19 01/03/07 4. OP36 18 (2) 31/03/07 Elm Grove Nursing Home DS0000016431.V323487.R01.S.doc Version 5.2 Page 25 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP1 OP18 OP38 Good Practice Recommendations Consideration should be given to placing a current Statement of Purpose in the reception area of the dementia care wing. Consideration should be given to senior staff within the home attending the Protection of Vulnerable Adult training provided by the county’s Adult Protection Team. Consideration should be given to increasing the numbers of staff qualified in First Aid. Elm Grove Nursing Home DS0000016431.V323487.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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 Elm Grove Nursing Home DS0000016431.V323487.R01.S.doc Version 5.2 Page 27 - 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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