Inspection on 19/08/05 for Elm Lodge Care Home

This inspection was carried out on 19th August 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 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 Care Home 03/04/07

Elm Lodge Care Home 10/04/06

Elm Lodge Care Home 18/01/06

Elm Lodge Care Home 16/03/05

Elm Lodge Care Home 21/07/04

Elm Lodge Care Home 25/03/04

Similar services:

Cheaney Court Care Home

Chater Lodge

Conifer Lodge

Egerton Lodge Care Home

Edenhurst Care Home

Ernehale Lodge Care Home

Ecton Brook House

Cherry Trees @ Hazel Hill

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

CARE HOMES FOR OLDER PEOPLE Elm Lodge Care Home Stand Road Newbold Chesterfield Derbyshire, S41 8SL Lead Inspector Ray Coonan Unannounced 19 August 2005 10:00 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 Care Home C52 C02 S2054 Elm Lodge V243231 190805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Elm Lodge Care Home Address Stand Road, Newbold, Chesterfield, Derbyshire, S41 8SJ 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) 01246 456747 Amocura Limited Margaret Berry Care Home 40 Category(ies) of Old age (40), including 20 places in the category registration, with number of Dementia, DE. of places Elm Lodge Care Home C52 C02 S2054 Elm Lodge V243231 190805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 16/3/05 Brief Description of the Service: Elm Lodge is a purpose built care home located in a quiet close in a residential area of Chesterfield. Accommodation for 40 elderly people is spread over 2 floors and all rooms are single. The first floor of the premises is utilised as a specific unit for up to 20 residents whose primary care needs are related to dementia. The Home is appropriately resourced with assisted bathing and toilet facilities, including showers. There are also lounge and dining room facilities on both floors. A passenger lift is installed for the use of residents and there is an alarm call system fitted throughout the Home. A garden/sitting area is located at the rear of the building, which is accessible to residents, and a further small sitting area has been developed at the front of the Home. Elm Lodge Care Home C52 C02 S2054 Elm Lodge V243231 190805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over a period of four and a half hours on the 19th August. The first part of the visit was specifically focussed on the ground floor environment as the Home are looking to also use this floor for residents who have Dementia as their primary care need, as well as the first floor. The proprietors have applied to vary their current registration accordingly. Recommendations and requirements regarding this proposed change in the Home’s services have been sent to the proprietors separately. Other parts of the environment were viewed during the inspection as well as a variety of documentation such as care plans, staff files, staffing rotas and policies and procedures. There was also the opportunity to speak with several residents and staff. The Home’s manager, Margaret Berry, was present throughout the inspection visit, as was the proprietors’ representative, Maureen French. What the service does well: What has improved since the last inspection? A small garden and sitting area has been developed at the front of the Home and security improved at the rear. Elm Lodge Care Home C52 C02 S2054 Elm Lodge V243231 190805 Stage 4.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 Care Home C52 C02 S2054 Elm Lodge V243231 190805 Stage 4.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 Care Home C52 C02 S2054 Elm Lodge V243231 190805 Stage 4.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) This section was not assessed during this inspection. EVIDENCE: Elm Lodge Care Home C52 C02 S2054 Elm Lodge V243231 190805 Stage 4.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 and 8. The Home assesses the needs of residents in a thorough manner and plans individual care clearly and responsively. The health needs of residents are actively monitored and promoted. EVIDENCE: A sample of several working care plans was examined and these were in good order. Individual needs were appropriately assessed and care instructions clearly laid out for staff. Daily reports were up to date and plans were evaluated on a regular basis. A range of relevant risk assessments were seen and the Home develops a Risk Taking Action Plan for each resident. Service users or the representatives signed their agreement to the care plan. Care plans showed that the general health needs of residents were suitably promoted at the Home and a range of relevant assessments was initiated. Records of medical appointments were maintained on resident files and these demonstrated that an appropriate range of community health services were accessed such as G.P. and nursing services and also dentist, audiology, optician, and chiropody. Specialist input was also obtained, such as geriatrician and falls clinic. The Home had specialist equipment to assist in the Elm Lodge Care Home C52 C02 S2054 Elm Lodge V243231 190805 Stage 4.doc Version 1.40 Page 10 maintenance of skin integrity. Care plan files showed that residents’ physical and emotional needs were monitored regularly. Elm Lodge Care Home C52 C02 S2054 Elm Lodge V243231 190805 Stage 4.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 Activities continue to be developed in line with assessed needs though a more focussed, specialised and coordinated level of input had yet to be fully established for the Home as a whole. EVIDENCE: Currently the manager has taken lead responsibility for the development of activities at the Home and has established a specific programme for those residents on the first floor unit. However, it was stated that this programme was not implemented in a structured way. Records were kept of residents’ social interests and needs. The situation with the 9 residents on the ground floor was somewhat transitory, given that several had already left, and others were in the process of arranging to move or were being reassessed. It was mentioned that the Home had not arranged any outings this year. Elm Lodge Care Home C52 C02 S2054 Elm Lodge V243231 190805 Stage 4.doc Version 1.40 Page 12 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 and18 Service users interests and welfare were protected by a systematic approach to facilitating complaints and developing awareness of abuse issues. EVIDENCE: There had been no formal complaints since the last inspection. The Home had a satisfactory complaints policy that was made accessible to residents and visitors. Appropriate records were maintained with clear procedures for investigation. There had been no complaints made direct to the commission. The Home had relevant policies in place regarding protection including local interagency protocols for dealing with abuse referrals. Staff spoken to had an awareness of adult protection issues from their NVQ training and confirmed that several had now attended further training from Derbyshire Social Services, which was part of an ongoing programme. Elm Lodge Care Home C52 C02 S2054 Elm Lodge V243231 190805 Stage 4.doc Version 1.40 Page 13 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 and 26. An overall safe and comfortable environment was provided for residents with suitable aids and adaptations fitted to assist mobility around the Home. The premises were generally clean and well maintained, internally and externally. The Home was generally suitably furnished and pleasantly decorated, though several lounge areas were in need of freshening up. EVIDENCE: The Home is purpose built and located in a small cul-de-sac in a residential area with access to local amenities. The Home was generally well maintained internally and externally and was clean and hygienic. General furnishing, fixtures and fittings were satisfactory though the décor in some parts of the Home such as lounge areas was starting to look a little ‘tired’ and in need of repainting. It was stated that the carpet in the upstairs dining area is to be replaced. Elm Lodge Care Home C52 C02 S2054 Elm Lodge V243231 190805 Stage 4.doc Version 1.40 Page 14 Differing colour schemes for the corridor areas on both floors had been developed in order to assist residents’ orientation and there had also been increased use of signing on the first floor. There were satisfactorily maintained and accessible garden/sitting areas to the rear of the building and new fencing had been put up in this area. Plans to develop another sitting area at the front had now been implemented. Garden areas immediately outside bedrooms at the side of the building remained in need of clearance and improvement. Several bedrooms were viewed and these were comfortably furnished, pleasantly decorated and personalised by residents. Residents are able to have their own door keys, however, it was noticeable that there were many instances of bedroom doors being left wide open, whether residents were in their room in bed or somewhere else in the building. Bathroom, shower room and toilet areas were well maintained and clean. In addition to fixed hoists in bathing areas the Home has 2 portable hoists. In general suitable aids and adaptations were in place throughout the Home including loop systems to assist residents with hearing impairments. Lighting, heating and ventilation systems were satisfactory and many parts of the Home had good views and natural light. Elm Lodge Care Home C52 C02 S2054 Elm Lodge V243231 190805 Stage 4.doc Version 1.40 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 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, 29 and 30 Service users benefited from the Home’s active and organised approach to meeting staff training needs. However, their interests could be better protected by some improvements in recruitment practices. EVIDENCE: The Home maintained satisfactory staffing numbers commensurate with occupancy levels, which had been reduced to 29 at the time of the inspection, with only 9 residents on the ground floor. A sample of staff files were examined and these were in good general order containing interview records, references, signed contracts, confidentiality agreements and relevant training records, including induction. However, there were examples of only one written reference on file and gaps in employment records not being followed up. There was evidence of a systematic approach to staff development with individual training records maintained and regular provision of mandatory care courses together with regular input on more specialised areas such as protection and working with dementia. The provider organisation had their own training resources but external training services were also used. Staff spoken to confirmed that they received a good range of training opportunities, but did mention that they would like the dementia awareness support to be provided on an ongoing basis. Elm Lodge Care Home C52 C02 S2054 Elm Lodge V243231 190805 Stage 4.doc Version 1.40 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 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) 33 There is a organised approach to ensuring that services meet the needs of residents. EVIDENCE: The Home’s annual development plan was displayed near the entrance area as was comments from the last resident/carer questionnaire. Regular audits and quality checks on all aspects of the running of the Home are made by the proprietors’ representative and records of meetings with the manager are maintained appropriately. Elm Lodge Care Home C52 C02 S2054 Elm Lodge V243231 190805 Stage 4.doc Version 1.40 Page 17 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 x x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 x COMPLAINTS AND PROTECTION 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 2 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 x x 3 x x x x x Elm Lodge Care Home C52 C02 S2054 Elm Lodge V243231 190805 Stage 4.doc Version 1.40 Page 18 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. 2. 3. Standard 19 19 29 Regulation 23 23 19 Requirement A programme for redecoration must be developed and implemented. The garden area immediately outside bedrooms at the side of the buiding must be tidied up. 2 written references must be kept on staff files and any gaps in employment properly investigated. The Home must review its practice for keeping bedroom doors open and ensure that that the privacy, dignity, and security of residents is fully taken into account. Timescale for action 30/9/05 30/9/05 30/9/05 4. 24 12 30/9/05 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 12 30 Good Practice Recommendations The Home should keep the development of specialised activities under review and look to provide a more focussed approach. The Home should consider ways to provide ongoing training in dementia care for staff. C52 C02 S2054 Elm Lodge V243231 190805 Stage 4.doc Version 1.40 Page 19 Elm Lodge Care Home Elm Lodge Care Home C52 C02 S2054 Elm Lodge V243231 190805 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection South Point Cardinal Square Nottingham Road Derby. DE1 3QT 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. 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