Inspection on 06/03/06 for Elm View Nursing Home

This inspection was carried out on 6th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Elm View Nursing Home 24/09/08

Elm View Nursing Home 28/03/08

Elm View Nursing Home 06/09/07

Elm View Nursing Home 30/06/05

Elm View Nursing Home 12/10/04

Elm View Nursing Home 02/04/04

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

CARE HOMES FOR OLDER PEOPLE Elm View Nursing Home 2 Elm View Huddersfield Road Halifax West Yorkshire HX3 0AE Lead Inspector Paula McCloy Unannounced Inspection 6th March 2006 09:20 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 DS0000001050.V285876.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000001050.V285876.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Elm View Nursing Home Address 2 Elm View Huddersfield Road Halifax West Yorkshire HX3 0AE 01422 362538 01422 362538 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) Mr Philip Bentley Mrs Barbara Bentley Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places DS0000001050.V285876.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th June 2005 Brief Description of the Service: Elm View cares for service users over the age of 65 years. The home provides both personal care and nursing care to male and female service users. The home is a converted property and provides accommodation over three floors. Single and double bedrooms are available. There is a lounge/dining room on the ground floor and a separate quiet lounge. Each floor is accessed by a passenger lift. Elm View is situated on the main Huddersfield Rd about a mile from Halifax town centre. There is a small car park and on street parking close to the home. At the rear of the car park there is a small, garden seating area, for use by service users. DS0000001050.V285876.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Over an inspection year from April until March, care homes have a minimum of two inspections; these may be announced or unannounced. This was the second unannounced inspection of this home; the first inspection was also unannounced and took place in June 2005. There were three requirements made following this visit. One requirement about the management of the medication system remains outstanding. There have been no further visits to the home until this unannounced inspection. One inspector carried out the inspection and spent approximately six hours in the home. Inspection reports can be obtained form the Commission for Social Care Inspection web site at www.csci.org.uk The purpose of this inspection was to assess the home against a predetermined selection of the National Minimum Standards for Older People and to check what progress had been made on meeting the requirements from the last inspection. The methods used in this inspection included discussions with 3 residents, 2 relatives and 5 members of staff and management, examination of records, and a tour of the home. What the service does well: Residents look well cared for. Residents spoke well of staff and they felt they were kind and caring. Residents said that the food is good and that they are asked about their preferences. There are enough staff on duty to make sure residents are cared for properly. Residents’ bedrooms are very personal. DS0000001050.V285876.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: The medication system needs to be better managed to make sure the records are accurate and that residents have got their medication at the right time. Some areas of the home need redecorating to bring them up to standard. There is only one of the four bathrooms that is used on a regular basis. The owners need to look at how the other bathrooms can be improved so that they can be used by residents. There is very little storage space in the home and bathrooms are being used to store various pieces of equipment. Proper storage space needs to be found so that toilets and baths are safely accessible to residents. A registered manager needs to be appointed so that the service continues to develop. DS0000001050.V285876.R01.S.doc Version 5.1 Page 7 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. DS0000001050.V285876.R01.S.doc Version 5.1 Page 8 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 DS0000001050.V285876.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed during this visit; please see the last inspection report dated 30 June 2005. EVIDENCE: DS0000001050.V285876.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 The medication system is not well managed and is leaving residents at risk of not receiving their medication. EVIDENCE: The medication system is poorly managed. Nurses are not signing the medication administration records contemporaneously. There were a number of residents who have been prescribed antibiotics recently. Nurses have been signing the medication records to acknowledge they have given medication after the course of medication has finished. For example one resident was prescribed 15 antibiotic tablets. Staff have signed for these 20 times. They have signed for 5 tablets that were not in existence. The acting manager is aware of this problem and has arranged medication training for all of the nursing staff. DS0000001050.V285876.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed during this visit; please see the last inspection report dated 30 June 2005. EVIDENCE: DS0000001050.V285876.R01.S.doc Version 5.1 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 the following standard(s): These standards were not assessed during this visit; please see the last inspection report dated 30 June 2005. EVIDENCE: DS0000001050.V285876.R01.S.doc Version 5.1 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 the following standard(s): 19, 20, 21, 22, 23, 24, 25 & 26 The home is generally well maintained, but a redecoration programme needs to be implemented as some bedrooms are looking a little shabby. The bathing facilities also need to be improved so that residents have a choice of facilities EVIDENCE: Elm View is situated on Huddersfield Road in Halifax. The town centre is easily accessible by car or public transport. There is a small car park to the front of the building. The most recent environmental health inspection made two recommendations, which staff are in the process of addressing. The home complies with the fire authority’s requirements. There is one quiet lounge and one lounge / dining room on the ground floor. These rooms are comfortably furnished with two televisions in the lounge / diner for residents entertainment. On the day of the inspection the hairdresser was using the quiet lounge as her salon. Whilst this may not be ideal it was providing a social occasion for those residents having their hair done. DS0000001050.V285876.R01.S.doc Version 5.1 Page 14 The bedroom accommodation is spread over three floors. There are 13 single bedrooms, 3 of which have en suite toilets and 7 double bedrooms, 3 of which have en suite facilities. The bedrooms have all been personalised with various pictures, ornaments and pieces of resident’s own furniture. The bedrooms all have a lockable drawer and emergency call bell. Some of the rooms are in need of redecoration to bring them up to standard. Although there are locks on the bedroom doors these are not in use as they are mortice locks and do not meet the requirements of the fire authority. These locks need to be replaced with locks of a ‘single action’ type, which will allow residents to leave the room without the use of a key. There are four assisted bathrooms in total. The bathroom that is used most is the one on the ground floor. The other bathrooms are small and their usage is limited. The owners need to look at improving the bathing facilities to make them more appropriate to the needs of residents. There is a problem at the home with storing items of equipment. Hoists, linen trolleys, linen skips etc. are being stored in the bathrooms, making them hazardous and inaccessible to residents. All of the bedrooms have an opening window, with the exception of a double bedroom on the first floor. The window in this room opens on to the fire exit and the fire authority require that this window remains permanently closed. On the second floor there are ‘tilt and turn’ windows. These are only restricted from fully opening by the position of the curtain rail. These windows need to be locked in a way that only allows them to ‘tilt’ so that residents are not put at risk. The laundry and kitchen are both located in the basement. These facilities are appropriately equipped for the size of the home. The home was clean and mostly odour free. The stale smell that was evident in the entrance hall has been eliminated. The television lounge did smell of stale urine as did two bedrooms. The carpets in these rooms need to be cleaned regularly in order to eliminate the smell. DS0000001050.V285876.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed during this visit; please see the last inspection report dated 30 June 2005. EVIDENCE: DS0000001050.V285876.R01.S.doc Version 5.1 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 The owners need to recruit a permanent manager to lead the staff team and to develop the service. Some improvements need to be made to make sure that equipment in the home is maintained in a safe condition. EVIDENCE: There is no registered manager at the home. The previous manager left approximately 18 months ago. A new manager was recruited in June 2005 but did not take up the post. The deputy manager has been the acting manager for this period. The deputy manager is doing a good job of running the home on a day to day basis, but does not have the time to develop the service further. There are no formal quality assurance systems in place or formal systems for consulting residents and their relatives about how the home is managed. The DS0000001050.V285876.R01.S.doc Version 5.1 Page 17 owners are required to complete monthly visits to the home and to write a report about their findings. The last copy of such a report available in the home was for April 2005. The acting manager does hold residents’ money for safekeeping. Individual records are maintained and receipts are obtained for any purchases made. In order to keep a check that no arithmetical errors have been made on the sheets, it would be useful if the sheets were reconciled on a regular basis. Staff receive moving and handling, food hygiene, fire safety, first aid and infection control training. The fire alarms are only being tested monthly, these test need to be completed every week. Fire drills/practices are held and more fire training has been booked. The test records for the small electrical appliances were available and up to date. There were some test certificates that were not available and some service reports that were overdue. DS0000001050.V285876.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 3 1 1 3 2 2 2 STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 3 X X 2 DS0000001050.V285876.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13 Requirement All medication received into the home must be booked in. The date, amount of medication and the signature of the member of staff taking receipt must be recorded on the medication administration record. (outstanding requirement from 30.6.05. Previous timescale of 14.7.05 not met) Staff must sign the medication records contemporaneously (at the time the medication is given) The bathing facilities in the home must be reviewed and an action plan submitted to show how the owners intend to make bathing or shower facilities more accessible to residents. The owners must consult with the fire authority regarding the suitability of the bedroom door locks. A redecoration programme for the home must be drawn up and implemented. The ‘tilt an turn’ windows must be restricted so that they are only operable in ‘tilt’ mode to DS0000001050.V285876.R01.S.doc Timescale for action 15/03/06 2 3 OP9 OP21 13 23 15/03/06 12/05/06 4 OP24 12 31/03/06 5 6 OP19 OP25 23 23 14/04/06 31/03/06 Version 5.1 Page 20 7 8 OP26 OP31 16 9 9 10 OP33 OP33 24 26 11 OP38 23 12 OP38 13 residents. The odour of stale urine must be eradicated from the lounge and identified bedrooms. A permanent manager for the home must be appointed and registered with the Commission for Social Care Inspection A quality assurance system must be introduced. The owners must completed monthly visits on a regular basis and ensure that copies of their reports are available at the home and that a copy is forwarded to the Commission for Social Care Inspection. The fire alarm system must be tested on a weekly basis and records of these tests maintained. Copies of the following test/maintenance certificates must be forwarded to the Commission for Social Care Inspection; Electrical wiring certificate Landlords Gas Safety Certificate Hoist service reports 30/03/06 30/05/06 30/06/06 30/03/06 24/03/06 30/03/06 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 OP22 Good Practice Recommendations Suitable storage areas need to be identified, so that equipment is not stored in bathrooms. DS0000001050.V285876.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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