Inspection on 09/05/05 for Elm House

This inspection was carried out on 9th May 2005.

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 House 09/05/06

Elm House 29/11/05

Elm House 18/10/04

Elm House 07/05/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Elm House 76 Pillory Street Nantwich Cheshire CW5 5SS Lead Inspector Val Flannery Unannounced 9 May 2005 09:00 th 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 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 House F51 F01 S6502 Elm House V225660 Elm House 090505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Elm House Address 76 Pillory Street Nantwich Cheshire CW5 5SS 01270 624428 01270 510241 joan.grocott@clsgroup.org.uk CLS Care Services Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Care Home Only (PC) 37 Category(ies) of Old age, not falling within any category (OP) 37 registration, with number of places Elm House F51 F01 S6502 Elm House V225660 Elm House 090505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 18th October 2004 Brief Description of the Service: Elm House provides care and accommodation for thirty seven older people. Located in Nantwich it is close to the town centre and other local amenities such as shops, pub and train station. The lay out of the two-storey building is such that there are two passenger lifts to the separate first floors. There are a variety of aids and adaptions around the building to help those residents with mobility problems. All the bedrooms are single and contain handwashing facilities, one room has an en-suite toilet. Staff are on duty twenty four hours a day to deliver care to the residents. Elm House F51 F01 S6502 Elm House V225660 Elm House 090505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over seven hours. One hour was spent planning the inspection, this included reading the previous inspection reports and reviewing the service history for the home. During the inspection nine service users, three relatives, four staff plus the manager and a visitor to the home were spoken with. A partial tour of the building was carried out, four resident and other records were seen. What the service does well: What has improved since the last inspection? Elm House F51 F01 S6502 Elm House V225660 Elm House 090505 Stage 4.doc Version 1.30 Page 6 The improved statement of purpose and service user guide will inform residents of the service offered by the home. The redecoration of the corridors will improve the internal appearance of the home. 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 House F51 F01 S6502 Elm House V225660 Elm House 090505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Elm House F51 F01 S6502 Elm House V225660 Elm House 090505 Stage 4.doc Version 1.30 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 standard(s) 1/2/3/4/5/ The statement of purpose/service user guide provides residents with the information to make an informed choice about the home. The admission procedure includes a pre-assessment of residents needs, this ensures the home can meet these needs EVIDENCE: Residents and relatives confirmed that they had received information about the home prior to moving in. CLS Care Services have recently updated the statement of purpose and service user guide to the home, a copy of which was on display in the entrance area. Copies of contracts, both for privately and local authority funded residents, were seen during the visit. Two personal care files for residents who have recently moved into the home were seen. They showed that pre-admission assessments were carried out by staff from the home. Residents ,and relatives, said that the home continues to meet their assessed care needs. They also confirmed that they were able to visit the home before making a decision about moving in. Elm House F51 F01 S6502 Elm House V225660 Elm House 090505 Stage 4.doc Version 1.30 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 standard(s) 7/8/9/10 The residents’ health and social care needs are set out in their plans of care. Residents are treated with respect and their privacy is upheld. EVIDENCE: Residents and relatives confirmed that their health and personal care needs were discussed with staff before admission. They also confirmed that any changes on how their needs are to be met are discussed with them. A number of residents said they had seen their plans of care. Personal information on individual residents is kept on their Personal Files. The Care Needs Initial Assessment document seen was not signed by the staff member carrying out the assessment (See Recommendation Number 1) Plans of care showed that residents receive visits from doctors, district nurses and other health professions. A separate record is kept of the reason for, and outcome of, these visits. A sample of the record of medication administered to residents was seen. The records were signed by staff. Satisfactory arrangements were observed for the administration of medication to residents by staff. Elm House F51 F01 S6502 Elm House V225660 Elm House 090505 Stage 4.doc Version 1.30 Page 10 Seven residents spoken with said that staff treat them with respect and dignity and that their right to privacy is upheld. Residents gave examples of this which included knocking on bedroom doors, closing doors when bathing/using the toilet, discussing their private affairs in their bedrooms and being consulted on their care needs. Elm House F51 F01 S6502 Elm House V225660 Elm House 090505 Stage 4.doc Version 1.30 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 standard(s) 12/13/14/15/ Residents are offered a lifestyle that matches their expectations. They are enabled to exercise choice and control over their daily lives. A choice of meals is made available which offer variety and are well presented. EVIDENCE: The residents spoken with said that staff support and encourage them to exercise choice over their daily lives. This includes when they get up/go to bed, where they have their meals, preferences over bathing/using the toilet, who they mix with socially and where they receive visitors. Relatives spoken with said they are able to visit the home as they wish and are able to see the residents in private. Residents said they are offered a choice of good meals which are well presented. They also said that mealtimes are flexible to accommodate individual residents preferences. During the visit a member of kitchen staff was observed asking residents what they wanted for dinner. The menus showed that residents are offered three choices for each meal. The home does not currently have an activities co-ordinator. At the moment activities are organised by staff when they have time. The manager confirmed that the post of activities co-ordinator is to be advertised as soon as possible. Elm House F51 F01 S6502 Elm House V225660 Elm House 090505 Stage 4.doc Version 1.30 Page 12 A number of residents commented that they miss the planned programme of activities. Elm House F51 F01 S6502 Elm House V225660 Elm House 090505 Stage 4.doc Version 1.30 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 standard(s) 16/17 Satisfactory arrangements are in place to respond to complaints and adult protection issues. The procedures enable residents, relatives and others to raise concerns with the home and other agencies. EVIDENCE: Residents, relatives and others spoken with said they are made aware of how to raise complaints and concerns. They said they are comfortable about discussing issues/worries with the manager and staff, these are taken seriously and acted upon. A complaints procedure is on display and includes details on how to contact CSCI. The complaints record showed that the home received a complaint in January ’05 from a resident. This was resolved to the satisfaction of the resident. CSCI have not received any complaints about the home. An Adult Protection Procedure has been provided by CLS Care Services which includes the government guidelines ‘No Secrets’. A copy of the procedure is kept in the home. Elm House F51 F01 S6502 Elm House V225660 Elm House 090505 Stage 4.doc Version 1.30 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 standard(s) 19/20/21/22/23/24/25/26/ The home provides a comfortable and safe standard of accommodation for the residents. All the bedrooms are single which, with the communal areas, match the residents expectations. EVIDENCE: The home provides a well-maintained, safe environment for the residents. One large dining/lounge, one small dining room and four lounges are provided on the ground floor with one lounge on each of the separate first floors. Outdoor areas include open front garden and a secure garden to the rear of the home which are well maintained. Residents said they have access to the gardens as they wish. The down stairs corridors have recently been reredecorated, the upstairs corridors are to be re-decorated in the coming weeks. All the bedrooms are single and have hand-washing facilities. One bedroom has an en-suite toilet. Residents said they are happy with the standard of decoration and furnishings in their bedrooms. The home provides four bathrooms, one shower and 12 toilets that are close to bedrooms and communal areas. Lifting/mobility equipment and grab rails are provided for Elm House F51 F01 S6502 Elm House V225660 Elm House 090505 Stage 4.doc Version 1.30 Page 15 service users who may have mobility problems. One of the lounges has a hearing loop for service users with hearing difficulties. Residents and relatives said the home was always clean, comfortable and free from unpleasent odours. The floor boards on the corridor of the first floor (upper annexe) are very noisy when walked on (See Recommendation Number 2) Elm House F51 F01 S6502 Elm House V225660 Elm House 090505 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27/28/30 Staff are employed in sufficient numbers to meet residents’ assessed needs. Training is provided for care staff which ensures that are competent to care for the residents. EVIDENCE: The staffing rota showed that there is one care team leader and three care assistants on duty during the day and one care team leader and one care assistant on duty during the night. Support staff including a cook, kitchen assistant and domestics are also employed in sufficient numbers. Residents commented that staff ‘are caring and understanding’, also that they ‘come quickly when you pres the care call bell’. The relatives said that from what they have seen when visiting the home ‘staff cannot do enough for residents’. One relative said that ‘staff are very patient in difficult circumstances’. The manager said that four care staff have NVQ Level 2/3 in caring and that a further eight care staff are working to gain the qualification. A list was seen of the training provided by CLS Care Services for all staff. Elm House F51 F01 S6502 Elm House V225660 Elm House 090505 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31/32/36/38 The home is managed efficiently and is run in the best interests of the residents. The manager offers leadership and supervision to staff that ensures residents assessed care needs are met. EVIDENCE: Although an application to register the current manager has been received by CSCI this has been withdrawn as the manager will be leaving CLS Care Services at the end of May 2005. The current manager has been employed as a manager with CLS since 1991. She has obtained qualifications and has attended training required for the dayto-day running of the home. Residents, relatives and staff expressed concern over the changes in the management team as they feel the current manager ‘is excellent and knows her job’. Residents also said that she is always available to speak to them and ‘ sort out any problems’. Elm House F51 F01 S6502 Elm House V225660 Elm House 090505 Stage 4.doc Version 1.30 Page 18 Staff commented that the manager is supportive and offers guidance/supervision on ensuring residents needs are met. The tour of the building showed that health and safety issues are addressed. On the 14/2/05 an officer from Cheshire Fire Service carried out an inspection of the home. A number of requirements were identified, these have been addressed by the home. Elm House F51 F01 S6502 Elm House V225660 Elm House 090505 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 x x x 3 x 3 Elm House F51 F01 S6502 Elm House V225660 Elm House 090505 Stage 4.doc Version 1.30 Page 20 NO Are there any outstanding requirements from the last inspection? 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 Regulation NONE Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 7 19 Good Practice Recommendations Staff to sign prospective residents Care Needs initial Assesment. Maintenance work to be carried out on the noisy floorboards. Elm House F51 F01 S6502 Elm House V225660 Elm House 090505 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection Unit D, Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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 House F51 F01 S6502 Elm House V225660 Elm House 090505 Stage 4.doc Version 1.30 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. 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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