Inspection on 16/12/05 for Elm Lodge

This inspection was carried out on 16th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Elm Lodge 16/05/07

Elm Lodge 07/12/06

Elm Lodge 18/07/05

Elm Lodge 24/01/05

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Staveley Birk Leas Nursing Home

Carentan House

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

CARE HOMES FOR OLDER PEOPLE Elm Lodge Cluntergate Horbury Wakefield West Yorks WF4 5DB Lead Inspector Susan Vardaxi Unannounced Inspection 16th December 2005 08:15 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 Lodge DS0000062249.V274358.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 Lodge DS0000062249.V274358.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Elm Lodge Address Cluntergate Horbury Wakefield West Yorks WF4 5DB 01924 262420 01924 262420 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) Mrs Julie Mortimer Mr Philip Mortimer Lily Ann Wood Care Home 17 Category(ies) of Old age, not falling within any other category registration, with number (17), Physical disability over 65 years of age of places (17) Elm Lodge DS0000062249.V274358.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named service user with category DE (E) Date of last inspection 18th July 2005 Brief Description of the Service: Elm Lodge Care Home is registered to provide care for 17 Older People. It is located close to the centre of Horbury, Wakefield. The home is on the local bus route and all the local amenities are easily accessible. The home is set back in its own grounds and has a large walled garden with a lawn to the front and car parking space to the rear. The home provides a large communal lounge a small quiet room with a telephone for the service users use and a dining room. The local Health Centres support the home and provide health care as required. Elm Lodge DS0000062249.V274358.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on 16th December 2005 over a period of 6 hours. The inspection process included talks with service users, visitors, staff and the providers, a walk round the building and checking some records. What the service does well: What has improved since the last inspection? What they could do better: It was a matter for concern at the previous inspection that service users were being got up too early. Since then a strategy meeting has been held in November 2005 under Wakefield Metropolitan District Council’s Adult Protection Procedures in respect of four service users who are unable to make informed choices being got up at 6am. It was therefore concerning to find that 15 service users were up and dressed at 8:15 am on this occasion; four service users were up and dressed when day staff arrived on duty at 7am. Some other matters of concern that were raised by the owners at the strategy meeting are currently being investigated. The care plans need to be developed further and reviewed monthly. There are no menus, nutritional assessments have not been completed and some service users’ weights have not been checked. Elm Lodge DS0000062249.V274358.R01.S.doc Version 5.1 Page 6 Most service users are highly dependant and the current staffing levels are not sufficient to ensure that all service users’ needs will be met particularly at the peak times of the day. Current recruitment practices do not ensure service users safety. Some health and safety and fire issues were observed which need to be dealt with to ensure service users safety. 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 Lodge DS0000062249.V274358.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 Lodge DS0000062249.V274358.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): 3 Consideration needs to be given to the home’s category of registration, current service users’ needs, staff training and staffing levels before admitting service users who have cognitive impairments EVIDENCE: A service user’s pre admission assessment showed that they had a severe cognitive impairment and a diagnosis of dementia. The multi disciplinary assessment showed that residential care had been recommended. Elm Lodge DS0000062249.V274358.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): 7,8,9 Generally the records show that service users’ health needs are met, however there is a risk that some assessed needs will not be met appropriately due to shortfalls in the care planning and care plan reviews. EVIDENCE: The records of the times that service users get up had been had been crossed out on the care plans seen. The deputy manager said this was due to the recordings not being service user’s choices. The deputy said, “night staff get a service user up because they are at risk from falling”. The provider said that they are going to provide an alarm mat, which will alert staff when the service user is out of bed to prevent this. • A care plan did not include continence control and pressure area care. • A care plan had been provided by social services for a service user admitted 2 weeks before the inspection; no care plan had been completed by the home. • Some care plans had not been reviewed monthly. • Nutritional assessments had not been completed on the service users’ files checked. Elm Lodge DS0000062249.V274358.R01.S.doc Version 5.1 Page 10 • • Some service users had not been weighed; the deputy said they are unable to stand on the weighing scales. Some risk assessments had been completed and reviewed; manualhandling assessments had been completed. However some did not record the service users’ weight. Records of GP visits were seen on the file checked. Records were seen of medication refrigerator temperature checks, however the homely remedies review recommended at the last inspection had not been completed. Elm Lodge DS0000062249.V274358.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): 14,15 Advocacy arrangements are needed to ensure that service users’ choices and preferences regarding all aspects of their care are fully established, recorded and monitored particularly for those who are unable to make informed choices. EVIDENCE: Concerns had been raised with the manager at the previous inspection when all service users were up and dressed and all beds made at 8.40am. The providers have since visited the home at 6am to check on the times that staff get service users up prior to this inspection and found four service users up and dressed. A referral was made for this to be investigated under Wakefield Metropolitan District Council’s Adult Protection Procedures. At this inspection there were 15 service users seen up and dressed at 8:15am. The deputy manager said four service users were up and dressed when she arrived on duty at 7am. She confirmed that the service users were unable to make informed choices. She said night staff got a service user up before 7am as the service user was at risk from falling. Some service users were having breakfast; others were sleeping in the chairs in the lounge. The cook said that service users have fresh fruit daily. There were provisions in the food stores and refrigerators. The providers said that tinned meat is Elm Lodge DS0000062249.V274358.R01.S.doc Version 5.1 Page 12 used to make pies only. A record of meals provided was seen, however the cook said that she does not have a menu. The cook had made 2 chocolate sponge cakes and some homemade scones were seen. A record of service users “likes and dislikes” regarding food was displayed. Elm Lodge DS0000062249.V274358.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): 17,18 The providers deal with allegations of abuse appropriately, however they need to ensure that staff are fully aware of their duty under the Whistleblowing policy and that staff recruitment procedures ensure service users are protected. EVIDENCE: The providers said that all service users are registered on the electoral register. Allegations of abuse are currently being investigated under Wakefield Adult Protection Procedures. The registered persons who visit the home daily have taken appropriate action to ensure service users are protected. The staff had acted appropriately in reporting concerns to the manager. However they did not inform the providers when they were aware that no action was being taken. A staff file seen showed that they had commenced employment without a CRB and POVA 1st check being completed. Elm Lodge DS0000062249.V274358.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): The home is generally clean and well decorated, however delays in general maintenance could affect service users’ health and safety. EVIDENCE: The standard of cleanliness in the communal areas and service users’ bedrooms was generally good. There is no ventilation in the bedroom on the top floor; this was required at the last inspection. The provider said that he had received a quote for the work to be completed. The laundry room was clean and tidy, however the buildup of dust had not been removed from under the washing machine as required at the last inspection and a lounge chair was stored in the room. Elm Lodge DS0000062249.V274358.R01.S.doc Version 5.1 Page 15 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 There are not enough care staff on duty during the waking hours to ensure that service users needs, preferences and choices will be fully met. Staff recruitment does not always ensure that service users are protected. EVIDENCE: The staff rosters seen showed that: • 2 carers are on duty from 7am to 10am, an extra carer is rostered from 10am to 5pm Monday to Thursday. • 2 carers are rostered from 2pm to 9pm • 2 carers work the night duty. The providers said that care staff prepare and serve the evening meal as cooks only work late afternoon at the weekend. Most of the service users have high dependency needs; some service users need encouragement and assistance to eat their meal. A staff file seen showed that a satisfactory CRB check and POVA first check had not been completed prior to them starting work. A reference received was not satisfactory. Elm Lodge DS0000062249.V274358.R01.S.doc Version 5.1 Page 16 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): 31,33,35,38. A manager should be recruited to ensure the home is managed effectively. Health and safety issues need to be addressed to ensure service users are not at risk. EVIDENCE: The home does not have a registered manager; the providers are at the home on most days. Records of staff and service users meetings were seen. The uneven floor in the area across the door opening to the dining area had been attended to as required at the last inspection. However there was still a slight slope, which could affect service users who use Zimmer frames. Elm Lodge DS0000062249.V274358.R01.S.doc Version 5.1 Page 17 A service user’s bedroom door located on the top floor was seen to be wedged open with a sock. A build up of dust was seen at the back of the washing machines and dryer. The kitchen was seen and the area around the wall oven was not clean, some tiles are cracked and some drinking mugs stained and scored. The lounge chair seen in the service user’s bedroom located on the top floor must be checked to establish if it is fire retardant. The providers said that they are planning to have training so that they can provide manual handling to staff. Elm Lodge DS0000062249.V274358.R01.S.doc Version 5.1 Page 18 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 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 1 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 1 X X X X X X 1 1 STAFFING Standard No Score 27 1 28 X 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 1 Elm Lodge DS0000062249.V274358.R01.S.doc Version 5.1 Page 19 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 OP3 Regulation 14(1) Requirement The registered person must ensure that service users are only admitted to the home whose needs are within the category of registration. Care plans must include all assessed needs. Previous timescale of 18 July 2005 not met. Care Plans must be reviewed at least monthly or when changes in need are identified Nutritional assessments must be completed Previous timescale of 18 July 2005 not met. Weighing scales must be provided that service users can sit on to ensure all service users are weighed. Homely medication remedies must be confirmed with the GP to ensure that they can be administered safely with prescribed medications. Timescale for action 06/01/06 2 OP7 15(1)15(2 )(b) 31/01/06 3. OP8 13(1)(b) 17(1)(o) 31/03/06 4 OP9 13(2) 31/01/06 Elm Lodge DS0000062249.V274358.R01.S.doc Version 5.1 Page 20 5 OP14 12(2) Advocacy arrangements must be made for service users who are unable to make informed choices. The times that service users get up and go to bed must be established, respected and recorded in their care plans. Previous timescale of 18 July 2005 not met. Adult Protection training must be provided for all staff. Previous timescale of 30 September 2005 not met. 31/01/06 6 OP18 13(6)12(1 )(a) 31/01/06 7 OP25 23(2) 8 OP26 16) 2)(j) 9. OP27 18(1) 10 OP38 13(4)23(4 c i v12(1) All staff must be made aware of the Whistleblowing policy and of their duty to report abuse under the policy. Care Standards Act 2000 82(1)(2) The registered person must ensure that the names of staff dismissed from employment following allegations of abuse are referred to the Secretary of State for inclusion of the POVA list. The bedroom located on the top 31/01/06 floor of the home must have adequate ventilation. Previous timescale of 18 July 2005 not met. The areas around the wall oven 31/01/06 in the kitchen must be cleaned, cracked wall tiles and stained and scored crockery replaced. There must be sufficient care 06/01/05 staff on duty to reflect the number and needs of service users and the layout of the home. Previous timescale of 18 July 2005 not met. The registered person must ensure that immediate action is taken to comply with the health DS0000062249.V274358.R01.S.doc Version 5.1 Page 21 Elm Lodge and safety requirements in this standard. 06/01/06 • The lounge chair in the bedroom on the first floor of the home must be fire retardant. • Fire doors must not be wedged open. • The areas behind and under the washing machines and dryers must be kept free of dust to prevent the risk of fire occurring. • The registered persons must confirm in writing to the Commission and the fire service when the recommendations made in the fire officer’s report dated 28th January 2005 have been completed. • A record of service users’ weight must be included on the manual handling assessment records. • A risk assessment must be completed and action taken to prevent falls when accessing the dining room due to the decline in the floor level. 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 OP15 OP31 Good Practice Recommendations The registered person should provide a rotating menu. A manager should be recruited. Elm Lodge DS0000062249.V274358.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 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 Lodge DS0000062249.V274358.R01.S.doc Version 5.1 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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