Inspection on 05/07/05 for Elm Royd Nursing Home

This inspection was carried out on 5th 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 Royd Nursing Home 18/06/08

Elm Royd Nursing Home 19/06/07

Elm Royd Nursing Home 23/05/06

Elm Royd Nursing Home 13/01/06

Similar services:

Snydale Care Home

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Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Elm Royd Nursing Home Brighouse Wood Lane Brighouse West Yorkshire HD6 2AL Lead Inspector Liz Cuddington Announced 5 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 Royd Nursing Home J52J01_s61813_Elm Royd_v228416_050705.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Elm Royd Nursing Home Address Brighouse Wood Lane Brighouse HD6 2AL 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) 01484 714549 01484 711400 Philip Bennett (Elmroyd) Ltd Mr Edward Bazunu Care Home with Nursing 45 Category(ies) of 45 x Older People (over 65 years) registration, with number of places Elm Royd Nursing Home J52J01_s61813_Elm Royd_v228416_050705.doc Version 1.30 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 30 November 2004 Brief Description of the Service: Elm Royd Care Home offers nursing care, personal care and accommodation for up to 45 people over 65 years of age. This includes 5 places registered for intermediate care as well as 1 place for an adult with a disability under 65 years of age. The private bedrooms consist of 31 single rooms, 22 of which have en suite facilities, and 7 twin rooms. The home is located in a residential area of Brighouse just a short distance from the town centre and near to the bus routes between Brighouse, Elland and Halifax. Elm Royd Nursing Home J52J01_s61813_Elm Royd_v228416_050705.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. There have been some improvements since the last inspection of Elm Royd in November 2004, although not all the requirements and recommendations have been addressed. During the inspection the management showed they were keen to improve the services and facilities at the home. While there are some areas for serious concern, in particular the medication administration and kitchen hygiene, the healthcare needs of service users and the general standard of cleanliness and maintenance in the home was good. Thanks go to the service users, the staff and the management for their time, welcome and hospitality during the inspection. Also the time given by the people to complete pre-inspection comment cards is much appreciated. Their views are a very valuable source of information. What the service does well: What has improved since the last inspection? The Service Users’ Guide has been improved and contains all the necessary information. It is now well laid out and easy to read. The provision of suitable activities appears to have improved. The complaints handling system is now in place to make sure any complaints are properly dealt with and recorded. Fire drills are now being carried out regularly. The rotas showed that the staffing levels in the home are now sufficient to meet the needs of the service users. There seemed to be an improvement in meeting the training needs of staff, although the absence of the training coordinator meant it was difficult to get a full picture. Elm Royd Nursing Home J52J01_s61813_Elm Royd_v228416_050705.doc Version 1.30 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 Royd Nursing Home J52J01_s61813_Elm Royd_v228416_050705.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Elm Royd Nursing Home J52J01_s61813_Elm Royd_v228416_050705.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 & 3 The pre-admission assessments, needed to make sure that the home are able to properly care for the people who go to live there, were satisfactory. The new Service Users’ Guide has been produced with thought about the people who are to read it. EVIDENCE: The new Service Users’ Guide has been produced in an attractive, well laid out format using a larger than average print size, making it easy to read. Evidence showed that when new service users are admitted to Elm Royd they have had an assessment to determine their individual health and care needs. The facilities for providing intermediate care were not inspected at this visit. However a plan of care for a service user receiving intermediate care was examined which showed a full assessment of needs, planned work with the service user, a record of progress and a projected discharge date. Elm Royd Nursing Home J52J01_s61813_Elm Royd_v228416_050705.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 & 9 The individual plans contain a lot of the information needed but there were gaps, including missing risk assessments, which need to be dealt with to make sure the plans accurately show how a person’s needs are to be met. The general and specialist healthcare needs of individuals are properly looked after. The way medicines were being stored and administered was unsafe, inaccurate and therefore unacceptable. EVIDENCE: The individual plans of care which were seen contained most of the information needed to provide the proper care for each person. Where specialist needs are involved there was not always sufficient information detailing how the care was to be delivered. The daily records reflected how the needs of each individual had been met and care plans are reviewed monthly. The manager said that the home was carrying out a thorough review of all the plans of care and was contacting the service users families, inviting them to call in and discuss the plan with the service user and the relevant staff. Elm Royd Nursing Home J52J01_s61813_Elm Royd_v228416_050705.doc Version 1.30 Page 10 Individual health care needs were detailed in the plans. A number of people were seen to be using pressure relieving cushions on their chairs and pressure relieving mattresses on their beds. Psychological health needs were also seen to be properly handled, including bringing in specialist healthcare professionals where necessary. The way medications were stored and administered at Elm Royd was seen to be unsafe and not in accordance with the guidelines of the The Royal Pharmaceutical Society, although the storage and recording systems for controlled drugs were seen to be correct. The movable cabinets containing medicines in daily use were locked but then left in the corridor, instead of being securely stored or attached to the wall when not in use. During the inspection a more secure cupboard for storing stock medication was being built. Medicines must be stored securely at all times. The nurses who administer medicines had not always signed the Medicines Administration Record (MAR) sheet to show when each dose had been accepted and sometimes there was just a tick instead of the nurse’s initials. There was no ‘brought forward’ system to enable an accurate count of all medicines to be kept. One service user had several packs of one type of medication; one pack had the name of the person it was prescribed for scratched out and this person’s name written on instead. According to the signed MAR sheets the person whose name had been scratched out was also receiving this medication, but no other packs were found prescribed for that individual. The Royal Pharmaceutical Society guidelines says the Medicines Act 1968 ‘clearly defines that medicines must only be administered to the person for whom they have been prescribed, labelled and supplied’. Elm Royd Nursing Home J52J01_s61813_Elm Royd_v228416_050705.doc Version 1.30 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 & 15 The social profile and preferences of each individual need to be noted in their personal plan and any wishes regarding religious observance noted and followed through. EVIDENCE: On the day of the inspection there was musical entertainment in the main lounge. The activities available are recorded and notices displayed. The manager said that as part of the review process all the individual plans of care would, if the service user agrees, include a social profile. There was no information seen about supporting people to continue with religious observance. There are two lunchtime sittings and there seemed to be some choice about which sitting to attend. The menus included a choice of two main courses at lunchtime and a selection of dishes at teatime. Discussions were held with the chef about providing for special diets. Elm Royd Nursing Home J52J01_s61813_Elm Royd_v228416_050705.doc Version 1.30 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, 17 & 18 There are now satisfactory procedures for handling complaints, prevention of abuse and for enabling service users to participate in the election processes. Information about advocacy services should be kept at the home and made available to service users and relatives. EVIDENCE: The complaints record book is now in place showing the nature of any complaints and the remedies, also how the home responds to complaints. Service users receive postal voting forms if they wish to participate in elections. When discussing availability of advocacy services the manager said that information would be obtained if needed. Some of the staff at the home have undertaken adult protection training and the manager said that more training sessions were planned. Elm Royd Nursing Home J52J01_s61813_Elm Royd_v228416_050705.doc Version 1.30 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, 22, 24, 25 & 26 The house and grounds are clean and generally well maintained with plans for improvements underway. The bedroom doors should all have locks fitted to give service users a choice and shared rooms need to have privacy screening available. A more suitable storage space should be found for keeping wheelchairs and other equipment. EVIDENCE: Maintenance of the house and grounds was seen to be carried out during the inspection. During a tour of the house one of the bathrooms seen was waiting to have a new bath hoist fitted so that it can be used again. Moving and handling equipment and wheelchairs were being stored in bathrooms and corridors. Not all wheelchairs were fitted with the footplates, which are essential for the safety of the person using the wheelchair. The bedroom doors do not all have locks fitted; the manager said that this is part of the handyman’s routine maintenance programme. One twin room did not have privacy screening. Elm Royd Nursing Home J52J01_s61813_Elm Royd_v228416_050705.doc Version 1.30 Page 14 The heating, lighting and ventilation in the house appeared to be satisfactory. The bedroom and communal areas of the home were clean and hygienic. The laundry floor is to be made impervious and more hygienic as soon as a new screed has been laid to level the floor. Elm Royd Nursing Home J52J01_s61813_Elm Royd_v228416_050705.doc Version 1.30 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, 28, 29 & 30 The staff files need to be completed as soon as possible and all basic and mandatory training updated, with appropriate records. More staff need to complete NVQ level 2 in care in order to meet the standard. EVIDENCE: The rotas showed staffing levels sufficient to meet the needs of the service users. At present only three care staff have achieved NVQ level 2 in care and one of them is now working towards NVQ level 3. The manager said that another eight members of staff were working towards NVQ level 2. When the new owners took over Elm Royd all the staff files were missing. They are in the process of updating staff records and most of those examined had completed Criminal Records Bureau (CRB) checks, others were waiting for them to be returned. Staff are currently completing work profiles and training records. The manager said that all staff were to receive basic training to provide a good baseline knowledge assessment. A notice had been posted reminding all staff of the need to undertake or update their mandatory training. Elm Royd Nursing Home J52J01_s61813_Elm Royd_v228416_050705.doc Version 1.30 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) 31, 35, 36, 37 & 38 The manager needs to complete his management qualification without further delay. All care and nursing staff should receive a minimum of six formal supervision sessions with their line manager each year. Confidential records must be securely stored in accordance with the Data Protection Act 1998. The kitchen was not in as clean and well maintained a condition as it should be to promote good food hygiene standards. EVIDENCE: The manager said that he is currently completing further professional training and plans to start his management course in January 2006. Elm Royd Nursing Home J52J01_s61813_Elm Royd_v228416_050705.doc Version 1.30 Page 17 The care and nursing staff are not yet receiving formal, one to one supervision with their line manager. On the day of the inspection service users personal records were not being securely stored and the Medicines Administration Record sheets were seen left on top of the medicine cabinets in the main hallway. The manager said that new storage was to be built to keep confidential records secure. The records showed that fire drills are now being held twice a year and some staff have been designated as fire marshals. However during the inspection doors were seen to be wedged open, which is not good practice when considering fire safety. Risk assessments are being carried out covering safe working practices within the home. As part of the home’s improvement plans the fire exit doors are to be connected to the nurse call system. Infection control measures were seen to be in place. During the afternoon the kitchen was inspected. The two refrigerators and two deep freezers were seen to be in a poor condition and the freezers were iced up. As soon as this was mentioned to the management replacement refrigerators and deep freezers were ordered. Food packages stored in the freezers had not been re-sealed after opening. They should also be labelled with the date the package was opened, to enable proper stock rotation. The records showed refrigerator and freezer temperatures were being recorded daily, although the thermometers were covered in ice making them difficult to read. The kitchen cleaning record was not being kept up to date and the kitchen was not as clean as it should be. Frying pans filled with dirty oil were found on top of the cooker. One new work surface had been fitted but the kitchen would benefit from some refurbishment. Elm Royd Nursing Home J52J01_s61813_Elm Royd_v228416_050705.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x 2 x 2 3 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 2 3 2 x x x 3 2 1 1 Elm Royd Nursing Home J52J01_s61813_Elm Royd_v228416_050705.doc Version 1.30 Page 19 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 OP 9 Regulation 13(2) Requirement The administration and storage of all medications must be carried out in accordance with the guidance from the Royal Pharmaceutical Society. All care staff must receive six individual supervision sessions per year. All confidential information relating to service users and staff must be securely stored at all times, in accordance with the requirements of the Data Protection Act 1998. The kitchen and its equipment must be maintained in a hygienic condition. Timescale for action 30/09/05 2. 3. OP 36 OP 37 18(2) 17(1)(b) 30/09/05 30/09/05 4. OP 38 16(2)(j) 31/08/05 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 OP 7 OP 12 Good Practice Recommendations The individual plans of care need to be reviewed to ensure they fully reflect the current needs of the person concerned. The individual plans would benefit from including a social J52J01_s61813_Elm Royd_v228416_050705.doc Version 1.30 Page 20 Elm Royd Nursing Home 3. 4. OP 17 OP 22 5. 6. 7. 8. 9. 10. 11. 12. OP 24 OP 26 OP 28 OP 29 OP 30 OP 30 OP 31 OP 38 profile. Information about advocacy services should be available for service users and their families. The large upstairs bathroom should have a new hoist fitted to make the bath usable. Suitable storage facilities for wheelchairs and other equipment should be found. All wheelchairs need to have their footplates attached. The programme for fitting locks to the remaining bedroom doors needs to be completed. The laundry floor needs to be made impermeable. A minimum of 50 of all care staff should have completed NVQ 2 in care by the end of 2005. The home needs to complete the updating of all staff files with minimal delay. All new staff should receive appropriate induction training. The manager should ensure that all staff receive up to 3 days paid training each year and that staff training records are kept up to date. The registered manager should complete NVQ 4 in management. Doors should not be wedged open as this constitutes a fire hazard. Elm Royd Nursing Home J52J01_s61813_Elm Royd_v228416_050705.doc Version 1.30 Page 21 Commission for Social Care Inspection 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 Royd Nursing Home J52J01_s61813_Elm Royd_v228416_050705.doc Version 1.30 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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