Inspection on 16/05/07 for Elm Lodge

This inspection was carried out on 16th May 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 Lodge 07/12/06

Elm Lodge 16/12/05

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 Key Unannounced Inspection 16th May 2007 09:30 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.V332546.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 Lodge DS0000062249.V332546.R01.S.doc Version 5.2 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 vacant post 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.V332546.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named service user with category DE (E) Date of last inspection 7th December 2006 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. The fees charged in May 2007 were from £380 hairdressing & chiropody are charged in addition to the fees. The provider makes information about the service to enquirers when initial enquiries are made and of the Commissions role in the service user guide. Elm Lodge DS0000062249.V332546.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit to the home on 16th May over 7 hours commencing at 9:am. The visit included talking with the people who live at the home, four relatives, two staff, the providers and manager. Some records were inspected and a tour of the building completed. Some surveys forms were sent to people living at the home, their relatives and GPs to record their views of the service. At the time of this visit fourteen were completed and returned to the Commission and overall comments about the service were positive. The inspector would like to thank everyone who participated with the overall inspection process for their co-operation. The current manager was appointed at the home in April 2006, her application to be registered is currently being processed, and within the report she is referred to as the acting manager. What the service does well: What has improved since the last inspection? Elm Lodge DS0000062249.V332546.R01.S.doc Version 5.2 Page 6 The care plans seen had been developed to a good standard which will ensure needs are met. Observations of people’s abilities during the inspection and information seen on people’s records showed that care plans had been generated according to people’s need. A menu has been developed and further development has occurred in respect of monitoring and identifying nutrition since the provider has taken over the weekday cooks duties. Staff files seen showed that recruitment checks had been completed appropriately since the last visit, which will ensure people are protected. The providers had sent confirmation to the Commission that action required at the last visit in respect of health and safety matters had been completed to ensure people are safe. 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 Lodge DS0000062249.V332546.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 Lodge DS0000062249.V332546.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): 3,6 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People are provided with information about the service, pre admission assessments are completed and information is recorded appropriately. Intermediate care is not provided EVIDENCE: The records for two people admitted to the home since the last visit seen showed that pre admission assessments are completed. Twelve comment cards completed by people living at the home showed that they had received a contract and enough information about the service before they moved into the home. A local authority contract had been provided for one person, however a copy of the homes contract/ terms and conditions. Elm Lodge DS0000062249.V332546.R01.S.doc Version 5.2 Page 9 This was discussed with the provider who said this would be arranged. The records showed that pre admission assessments are completed and letters had been sent to the people confirming the home can meet their needs. Elm Lodge DS0000062249.V332546.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 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The arrangements for meeting people’s health, personal and social care needs are satisfactory. Information in respect of people’s health, personal and social care needs are generated from assessed needs and included in their individual care plans. People are treated with respect and their privacy and dignity are protected. EVIDENCE: Some care plans were seen had been completed and stored electronically which the provider said made it easier to access and to keep people’s record up to date. The care plans had been developed further and were to a very good standard, needs were clearly identified, the objectives and action to be taken by staff Elm Lodge DS0000062249.V332546.R01.S.doc Version 5.2 Page 11 were included and clearly written. They had been generated from assessed needs and reviewed to ensure needs are met. Risk assessments had been completed and some discussion occurred with the provider regarding obtaining information in respect of the use of lifting equipment for one person. The provider said she would contact a physiotherapist for further guidance. One person who had been ill and on bed rest at the last visit was seen to be very comfortable and sitting in the lounge. The manager said their condition had improved. Pressure relieving equipment was in use. Some records of weights were seen and weight gains noted, nutritional assessments had been completed and risks recorded which would help to prevent pressure sores occurring. Generally relatives comments about the service provided were positive, a relative who was overall satisfied with the care felt they would like to be kept more informed about changes in a person’s needs. This was discussed with the providers at the visit who said they would arrange a meeting to discuss any issues with them. A visitor said their relative “had greatly improved since they had been admitted to the home”. GPs and district nurses visit the home when needed. Twelve comment cards received from the people who live at the home considered the medical support to be satisfactory. Two GPs had completed surveys; they had not received any complaints and were generally satisfied with the overall care. Some medication records and medications in stock were checked and a substantial improvement since the last visit was observed and some staff training has occurred. The balances of some tablets and one person’s medication in sachets were checked and were found to be accurate. Some hand written entries had not been signed by the person making the entry and countersigned to confirm the details to confirm that the details were correct. The controlled medication records were seen and had been completed appropriately. The medication trolley was clean and well organised. The date of opening had not been written onto the labels for some eye drops and bottles of aperients however, the manager said that these are renewed on a monthly basis and would not be used after the end of the monthly cycle. Elm Lodge DS0000062249.V332546.R01.S.doc Version 5.2 Page 12 Medication refrigerator temperatures had been taken, however not on a daily basis to ensure that medications are stored at the recommended temperatures The interaction between staff and the people living at the home was observed, and the people were spoken to respectfully. A screen was in place in a shared room and there are two sittings for meals to give privacy to people who need staff assistance to eat their meal. Elm Lodge DS0000062249.V332546.R01.S.doc Version 5.2 Page 13 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 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The arrangements for meeting people’s social needs and maintaining links with family and friends are generally satisfactory, however opportunities for outings would further enhance this. The people are satisfied with the provision of meals. EVIDENCE: People’s social needs were clearly set out in the care plans seen. People spoken with said they enjoyed the entertainers who visit, surveys showed that they are generally satisfied with the activities, however one person considered more outings were needed. The provider agreed with this as only one outing had been arranged and said this would be improved in future. One person was reading a newspaper, another spoken with said “staff chat with them and sit with them if they feel a bit down. Social activities and the encouragement needed to participate was seen in care plans. Elm Lodge DS0000062249.V332546.R01.S.doc Version 5.2 Page 14 Information received prior to the visit states religious services are held and tapes from Wakefield Talking Library are provided. Surveys views about the provision of activities varied on the surveys received. Those spoken with during the visit made very positive comments about the service and the providers, manager and staff. People spoken with said they could receive visitors in their bedrooms to give privacy to their visits. Some people’s records seen showed that advocacy arrangements have been made. The people spoken with said they could get up and go to bed when they want to. A provider said she had taken over the cook’s duties when the weekday post became vacant and is enjoying this. She said she has completed a food hygiene course. A new menu has been developed since the last visit. The meal was taken in the dining room with some people who needed staff to assist them. The meal was sausage, mashed potato and a selection of vegetables and was well cooked and presented. A choice of pudding was available and people spoken with said they enjoyed the meal. Staff were observed assisting people appropriately, one member of staff showed sensitivity toward the person they were assisting, the food was offered to them at their pace and the whole process unrushed. Relatives completing the survey views varied regarding the provision of meals, one said, “the quality of food falls short”. Elm Lodge DS0000062249.V332546.R01.S.doc Version 5.2 Page 15 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 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People living at the home and their relatives are aware of how to make a complaint should the need arise. EVIDENCE: A relative spoken with said they had read the complaints procedure displayed on the homes notice board and comment cards completed by people living at the home, and relatives, showed that they would know how to make a complaint. One visitor spoken with said they “could knock on the provider’s door anytime and would feel able to complain” however this had not been necessary. The manager said safeguarding training was ongoing. Staff records seen held certificates for staff who had completed the training. Elm Lodge DS0000062249.V332546.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): 19,24,25,26 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People at the home live in a clean and comfortable environment that is decorated and maintained to a good standard. EVIDENCE: During a walk round the home is was seen that the home was cleaned to a good standard and no unpleasant odours were noted. The provider has contacted the fire officer to arrange a meeting to clarify some issues in respect of the emergency lighting. He said his five-year development plan is to be reviewed to ensure all work that he has identified is completed and information provided on the provider’s monthly report to the Commission states that accredited maintenance contractors complete maintenance work. Communal toilets/bathrooms seen were clean and tidy. Elm Lodge DS0000062249.V332546.R01.S.doc Version 5.2 Page 17 Mobile hoists and bath seats were seen and information provided on the pre inspection questionnaire shows that service checks had been completed to ensure they are safe. The lounges were light, clean and tidy. The manager said new dining room furniture had been ordered. Through discussion with some people sitting in the lounges it was established that not everyone could was use the emergency call point. This was observed at the last visit and discussed fully with the providers again at this visit. The provider said that a new emergency call system was to be installed on receipt of the local authority grant expected in June 2007. The provider said that until then alert mats currently used in bedrooms would be placed under lounge chair cushions to alert staff to people who may wander and prevent the risk of falling. Some running hot water temperatures were tested with the provider and were generally around 43 degrees centigrade, the ground floor bathroom temperature reading was 47 degrees centigrade, the provider adjusted the thermostat control valve straight away to ensure a safe and comfortable bath was provided. Records were seen of regular temperature checks completed by the provider who said he regulates temperatures immediately if needed. Bedrooms seen were clean and tidy, one wardrobe was slightly tilted and the Commission has been informed since the visit the wardrobe has been removed from the room and destroyed. The laundry room was seen and was clean and tidy. The provider said he would contact environmental services regarding enclosing the water tanks stored in the room as the environment is open and dust collects on the tank covers which are difficult to clean. Work has been completed on the electrics throughout the home following the 5 year check The provider said he was expecting the pass certificate in the next few days. Elm Lodge DS0000062249.V332546.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 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The staffing arrangements and provision of training are adequate at the time of the visit however to ensure needs are always met and people are safe regular reviews of staffing arrangements are needed. EVIDENCE: Information provided by relatives on the surveys received showed that their view varied regarding staffing levels, one felt levels could be improved. However people at the home spoken with did not have any concerns and generally they felt there were enough staff on duty. The night staffing arrangements and the need for regular reviews of night staffing levels were discussed with the providers as accident records showed eight falls had occurred in the night since the last visit. The providers said that night staff check the people hourly and record their visits on the homes computers. The providers said they did not have any concerns about night staffing levels. They said that they visit the home at night and have on occasion worked at night and had not considered there to be any problems regarding the number of staff on duty. The providers agreed to keep night staffing levels under review. Elm Lodge DS0000062249.V332546.R01.S.doc Version 5.2 Page 19 Information provided on the pre inspection questionnaire states that 58 of staff have NVQ qualifications. The files for two staff recruited since the last visit were checked and application forms had been completed, CRB and POVA first checks had been completed and two references obtained to ensure people are protected. Information provided on the pre inspection questionnaire and on staff files seen shows that training was provided at the time of staff induction and staff training and updates are provided on a regular basis. Elm Lodge DS0000062249.V332546.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): 31,33,35,38 People who use this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The providers and the manager work to ensure that the home and the health and safety of the people living at the home are protected. EVIDENCE: The Commission has received an application for the manager to be registered, as required at the last visit, and this is currently being processed. Elm Lodge DS0000062249.V332546.R01.S.doc Version 5.2 Page 21 The home has completed a survey of the service and the outcomes were positive. The provider provides the Commission with a copy of the reports of his monthly-unannounced visits to the home as required by regulation. There was general satisfaction at the way the home is run. A member of staff spoken with said “the providers are 150 for the people who live at the home, nothing is too much trouble”. A visitor said they felt “the atmosphere had improved” another said, “The providers are caring”. “Provider always gives a straight forward answer”. The provider said staff meetings and meetings with people living at the home are held. Some personal allowance records and cash held were checked and no discrepancies seen. Some of the homes monitoring systems records were seen at the visit and information had also been provided on the pre inspection questionnaire and were satisfactory. The fire records seen showed that fire system checks had been completed and two fire drills had occurred as required at the last visit. One of the providers is waiting to complete training by the fire service that will enable them to cascade fire training throughout the staff team. The provider said the fire office had approved the use of the clothesline pulley system located in the laundry. The gas certificate dated 13 April 2007 shows that a new boiler should be budgeted for, as one will need replacing. Confirmation had been received from the providers that requirements made at the last visit in respect of health and safety issues had been completed. Elm Lodge DS0000062249.V332546.R01.S.doc Version 5.2 Page 22 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 2 3 X X 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 Standard No Score 16 3 17 3 18 3 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 3 3 X X 3 Elm Lodge DS0000062249.V332546.R01.S.doc Version 5.2 Page 23 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. Standard Regulation 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 OP2 OP9 Good Practice Recommendations All people admitted to the home should be provided with a copy of the homes terms and conditions. To improve medication practices for people living in the home: • Hand written entries made on medication records should be signed by the person making the entry and countersigned by a member of staff to confirm the details to confirm that the details are correct.. • Medication refrigerator temperatures should be checked and recorded daily to ensure medications are being stored at the correct temperatures. Elm Lodge DS0000062249.V332546.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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 Lodge DS0000062249.V332546.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!