Inspection on 18/07/05 for Elm Lodge

This inspection was carried out on 18th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 16/12/05

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 WF4 5DB Lead Inspector Susan Vardaxi Unannounced 18 July 2005 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 Lodge J51J01_62249_Elm Lodge_v238381_180705.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Elm Lodge Address Cluntergate, Horbury Wakefield WF4 5DB 01924 262420 01924 262420 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) Mr & Mrs Mortimer Mrs Lily Wood Care Home - personal care only 17 Category(ies) of 17 x Older People over 65 registration, with number 17 x Physical disability - over 65 of places Elm Lodge J51J01_62249_Elm Lodge_v238381_180705.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Conditions of this registration are listed on the registration certificate displayed at the service Date of last inspection 24/01/2005 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 J51J01_62249_Elm Lodge_v238381_180705.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection which was completed over 6 hours and involved a walk round the building, talking with twelve service users, the providers, manager, four staff members and the inspection of some records. What the service does well: What has improved since the last inspection? The new owners have completed a programme of re decoration and replacement of carpets throughout the home, and new lounge chairs have been provided which are more suitable for older people. The owners visit the home to support the manager and have contact with service users and staff regularly. They are starting NVQ management training in September this year. An air conditioning machine had been provided for service users sitting in the lounge to help them to cope with the recent heat wave. The service users guide has been revised and produced in a large print format and the manager has developed the care plans, however further work is needed in care planning. Elm Lodge J51J01_62249_Elm Lodge_v238381_180705.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Elm Lodge J51J01_62249_Elm Lodge_v238381_180705.doc Version 1.40 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 Lodge J51J01_62249_Elm Lodge_v238381_180705.doc Version 1.40 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) 1,2,3,5, The pre admission arrangements are satisfactory and service users and their representatives are provided with accurate information about the service and facilities provided. EVIDENCE: The service users guide was seen and had been reviewed produced in larger print format. Contracts with the local authority, the home’s terms and conditions and records of pre admission assessment were seen. The manager said that relatives are able to visit the home prior to service users admission. Intermediate care is not provided. Elm Lodge J51J01_62249_Elm Lodge_v238381_180705.doc Version 1.40 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 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, risk assessment process and record keeping particularly where monitoring of the care delivered is required. EVIDENCE: Staff were observed interacting with service users and no incidents that could compromise their privacy and dignity were seen. Some progress had been made in the further development of the care plans however, however some care plans did not include, risk assessments and outcomes of the assessments for dietary needs, pressure area care or “confusion”. The care plans had been reviewed monthly, the daily notes did not include details of how and when the care needs had been met. There was no record of a nutritional assessment being completed when the records showed that a service user was not eating a balanced diet and fluid charts kept did not show that regular fluids had been given on two days. The need for a nursing needs assessment to be completed for a named service user was discussed with the manager at the time. Elm Lodge J51J01_62249_Elm Lodge_v238381_180705.doc Version 1.40 Page 10 Records were seen of GP, district nurse, community mental health intervention, chiropodist visits, however there was no record of the action taken when a GP had recommended that a service user should to be referred to the haematology department. The medication storage arrangements and records were checked and no problems were seen, the medication trolley was well organised. A new refrigerator had been provided however temperature checks had not been made. The records of homely remedies seen are not up to date. Elm Lodge J51J01_62249_Elm Lodge_v238381_180705.doc Version 1.40 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 The provision of activities, outings and for helping service users to maintain contact with family and the community are satisfactory. 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. The service users are satisfied with the meals provided, however due to staff not following the information in care plans there is a risk that an adequate diet will not always be taken. EVIDENCE: A records of the activities provided showed that service users are taken out for lunch to the local pub regularly, a representative from the local church visits regularly. A summer fayre is planned to take place in August. An activities organiser visits weekly; the manager said that three service users play chess and some service users read to staff. A postal book has been introduced to ensure that service users or their representatives receive their mail. Service users spoken with said that they have visitors. Elm Lodge J51J01_62249_Elm Lodge_v238381_180705.doc Version 1.40 Page 12 All service users were up and dressed, had their breakfast and most were asleep in the lounge, tables had been set for lunch and beds had been made when the inspection commenced at 8.40am. The manager said that she had arrived at the home early and had made the beds to help staff. There was no record in the care plans to show what time service users prefer to get up and go to bed and it could not be established with the service users spoken with what their preferences were as most are unable to make informed choices. The staff and manager said that night staff get most of the service users up. The service users were joined for lunch, the choice was meat pie or sausage with vegetables, and the dessert was fruit crumble or ice cream. The cook said that the provider is currently reviewing the menus. Some service users’ care plans had identified that encouragement was required to eat their meal, staff were observed throughout the meal and very little encouragement was offered and staff only asked the service user if they had finished their meal and the plate removed when there was quite a lot of meal still on the plate. The service users spoken with said that the meals are “OK” and “staff are good”. The home does not have a designated cook in the evenings and at weekends, the providers said that the manager and the providers assist with cooking and the post of weekend cook is being advertised. Elm Lodge J51J01_62249_Elm Lodge_v238381_180705.doc Version 1.40 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) 16,18 Unless staff are able to identify all forms of abuse and the procedure to follow in the event of abuse occurring there will a risk that abuse could be undetected. EVIDENCE: A complaint received by the Commission was discussed with the manager who said that the home had been unable to meet a service user’s needs following their admission. She said that this was due to full details of the service user’s needs not being given at the time of the pre admission assessment. The manager said that no complaints had been made to the home. The training records showed that Adult Protection training is needed. Elm Lodge J51J01_62249_Elm Lodge_v238381_180705.doc Version 1.40 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 clean well-maintained and pleasant environment for service users to live in. EVIDENCE: The home was seen to be well maintained, decorated and cleaned to a good standard. New carpets have been fitted in nearly all areas of the home, and new chairs provided in the lounges. Lounge chairs have been placed in the front entrance and a suggestion box is now available for service users and visitors use. There is an adequate number of toilets and bathrooms, soap dispensers and disposable hand towels had been fitted since the last inspection in those seen. Bath hoists and lifting equipment was seen in rooms throughout the home. The manager said that there are plans to replace the dining furniture. Elm Lodge J51J01_62249_Elm Lodge_v238381_180705.doc Version 1.40 Page 15 The laundry room was clean, however issues in respect of Health and Safety and infection control were seen and have been addressed fully to in standard 38 of the report. The window and patio doors in the bedroom on the top floor can not be opened therefore there is no ventilation in the room` All bedrooms seen were clean and service users’ possessions helped to make them homely and personal. Elm Lodge J51J01_62249_Elm Lodge_v238381_180705.doc Version 1.40 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) 27,28,29,30 Appropriate training is provided, however given that care staff duties do not only involve providing personal care it is considered that there are not enough care staff on duty during the waking hours to ensure that service users needs will be fully met. EVIDENCE: The staff rosters were seen and showed that there is two care staff on duty during the waking hours and two staff on duty at night. The home employs a domestic assistant, however care staff have responsibility for washing clothing, serving and preparing the evening meal and administering medications. The manager and providers said that they help with the evening and weekend meals. Many of the service users have high dependency needs, one service user requires two to assist her and some service users need encouragement and assistance to eat their meal. The manager said that she helps care staff when needed. Staff spoken with said that they manage however they are busy sometimes. The manager said that there has not been any staff recruitment since the last inspection. Staff files showed that induction programmes are completed. Some staff are doing Infection control training. Staff spoken with said that they had completed mandatory training, the deputy manager has NVQ level 3 and the manager said that all staff are registered to do NVQ level 2. Elm Lodge J51J01_62249_Elm Lodge_v238381_180705.doc Version 1.40 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) 31,32,38 The management are committed to training. More attention to health and safety, infection control and fire prevention issues is needed to ensure service users safety at all times. EVIDENCE: The manager has the NVQ level4 management and registered mangers qualification. The deputy manager is doing NVQ 4 training. The providers visit the home every other day, however they do not send copies of monthly-unannounced visit reports to the Commission. They said that they are due to start NVQ level 4 management training in September 2005. The staff spoken with said they do not have copies of the General Social Care Council’s Code of Practice. Elm Lodge J51J01_62249_Elm Lodge_v238381_180705.doc Version 1.40 Page 18 There were some Health and Safety issues observed during this visit, there is no ventilation in the bedroom of the first floor, a window catch was broken in a bedroom. The uneven floor in the area across the door opening to the dining area, which could cause service users to fall, had not been attended to as required at the last inspection. The manager said that the fire officer had visited and approved the locks on bedroom doors. A service user’s bedroom door was seen to be wedged open. A build up of dust was seen at the back of the washing machines and dryer. Vacuum cleaners were stored in the laundry room and the waste bin is not foot operated. The training records showed that manual handling training had been provided however updates are needed. Elm Lodge J51J01_62249_Elm Lodge_v238381_180705.doc Version 1.40 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 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 2 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 1 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 1 3 1 x x x x x 1 Elm Lodge J51J01_62249_Elm Lodge_v238381_180705.doc Version 1.40 Page 20 YES 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 OP7 Regulation 15(1) 13(4) 13(1)(b) 17(1)(o) Requirement Care plans must include all assessed needs. Risk assessments must be completed. The registered person must ensure that a GPs recommendation for a service user to be referred to hospital has been actioned. Nuitritional assessments must be completed A nursing needs assessment must be requested for a named service user. Adult Protection training must be provided for all staff. There must be sufficient staff on duty to reflect the number and needs of service users and the layout of the home The registered person must undertake monthly unannounced visits to the home and provide a report to the manager and the Commission. The registered person must ensure that immediate action is taken to comply with the health and safety requirements in this standard. Timescale for action 18th July 2005 & Ongoing 18th July 2005. 2. OP8 3. 4. OP18 OP27 13(6) 18(1) 30 September 2005 18th July 2005 18th July 2004 & Monthly. 18th July 2005 5. OP32 26(3)(4) 6. OP38 13(4) Elm Lodge J51J01_62249_Elm Lodge_v238381_180705.doc Version 1.40 Page 21 A risk assessment must be completed and appropriate action taken to ensure service users are not at risk from falling due to the uneven floor across the door leading into the dining room. Previous timescale of 24th January 2005 not met. 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. Refer to Standard OP9 Good Practice Recommendations The temperature of the medication refridgerator should be checked regularly and records kept. The homely medication remedies should be reviewed with the GP. Advocacy arrangements should be made for service users who are unable to make informed choices. The times that service users get up and go to be should be established and recorded in their care plans. Staff should follow the care plans and where needed provide encourgement and assistance at meal times to ensure an adequate and nuitritious diet is provided. Staff and service users should be made aware of the General Social Care Councils Code of Practice. 2. OP14 3. 4. OP15 OP32 Elm Lodge J51J01_62249_Elm Lodge_v238381_180705.doc Version 1.40 Page 22 Commission for Social Care Inspection Parkview 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 J51J01_62249_Elm Lodge_v238381_180705.doc Version 1.40 Page 23 - 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!