Inspection on 06/09/07 for Elm View Nursing Home

This inspection was carried out on 6th September 2007.

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 06/03/06

Elm View Nursing Home 30/06/05

Elm View Nursing Home 12/10/04

Elm View Nursing Home 02/04/04

Similar services:

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Snydale Care Home

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 View Nursing Home 2 Elm View Huddersfield Road Halifax West Yorkshire HX3 0AE Lead Inspector Paula McCloy Key Unannounced Inspection 6 September 2007 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 Elm View Nursing Home DS0000001050.V339153.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Elm View Nursing Home DS0000001050.V339153.R01.S.doc Version 5.2 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 vacant post Care Home 27 Category(ies) of Old age, not falling within any other category registration, with number (27) of places Elm View Nursing Home DS0000001050.V339153.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Can accommodate one named service user under 65 years of age Date of last inspection 13th September 2006 Brief Description of the Service: Elm View cares for people over the age of 65 years. The home provides both personal care and nursing care. 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 that people can use in nice weather. The current weekly charges at the home range from £331 - £443 per week. Additional charges are made for hairdressing and chiropody. Elm View Nursing Home DS0000001050.V339153.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The last inspection of the home took place on 13 September 2006. We have visited the home since then. This visit took place on 8 August 2007 to look at a complaint that had been made about staff working long hours and night staff sleeping on duty. This inspection was carried out to assess the quality of care provided to people living at the home. I carried out the inspection over one day and spent approximately 6 hours in the home. During the visit I spoke to 4 people who live in the home, 4 staff and the deputy manager. I observed care staff delivering care, looked at various records and looked around the home. The home completed a self-assessment form and the information provided has been used in this report. Comment cards were sent to 1 person living at the home, 8 relatives, 4 GPs and 7 social workers; these cards provide an opportunity for people to share their views of the service with us. Information received in this way is shared with the home without identifying who has provided it. One person living at the home, six relatives and two social workers wrote to us with their comments. Their comments received have been used in this report. What the service does well: Anyone thinking of moving into the home is properly assessed before they are offered a place. This means that staff are sure they can meet that person’s needs before they move in. Relatives that completed a survey said that that they are kept up to date regarding their relatives’ well being and that the home meets the needs of their relatives. Elm View Nursing Home DS0000001050.V339153.R01.S.doc Version 5.2 Page 6 Relatives are made to feel welcome when they visit. The meals at the home are very good, offering choice and variety. The staff are well trained and there are enough staff on duty to meet people’s needs. People living in the home and their relatives like the staff and say that they are kind and caring. One relative said ‘the staff do a good job and are very nice. My relative likes them and they seem to attend to his needs.’ The home is kept clean and tidy. What has improved since the last inspection? What they could do better: Staff need to make sure that people living in the home and anyone thinking of moving in get a copy of the service users guide. This will make sure that people have all of the information they need about the service offered at Elm View. Staff need to make sure that they take action to reduce or eliminate any identified risks to people living in the home. This will mean that people are kept safe and receive the right care. Activities need to be provided that keep people living in the home stimulated. The owners must make sure that the adult protection procedures are followed. This will make sure that people living in the home are kept safe. Elm View Nursing Home DS0000001050.V339153.R01.S.doc Version 5.2 Page 7 The owners must appoint a registered manager. This will make sure that there is someone taking responsibility for the running of the home. The owners need to introduce a quality assurance system. This will make sure that people living in the home and their relatives are able to give their comments about the way the home is run. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Elm View Nursing Home DS0000001050.V339153.R01.S.doc Version 5.2 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 Elm View Nursing Home DS0000001050.V339153.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 5 (standard 6 does not apply) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People are assessed before they move in to make sure that the home can meet their needs. They can visit to see if they think the service is suitable for them. People are not given up-to-date and accurate information about the service. EVIDENCE: The home only has one copy of the service user guide, which is kept in the office. Staff must make sure that they have copies of this document available to give to people living in the home or to anyone thinking of moving in. This will make sure that people have all of the information they need about the service Elm View provides. There is a brochure available that contains some information about the home, however, it does not have all of the details that are required and some of the information is not accurate. For example it Elm View Nursing Home DS0000001050.V339153.R01.S.doc Version 5.2 Page 10 states that activities staff are employed to keep people stimulated. There are no activities staff currently working at the home. It also states that there are programmes and aids designed to cure incontinence, which is misleading. The home’s admission procedures are good. Individual records are kept for people living at the home. The records for one of the people who had moved into the home recently showed that staff had completed the necessary assessment before she was admitted. This means that staff are sure they can meet people’s needs before they move into the home. Staff said that they encourage people to come and have a look around the home, although sometimes the relatives do this. This gives people the opportunity to see the home for themselves and decide if it is suitable for them. The home does not provide intermediate care. Elm View Nursing Home DS0000001050.V339153.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Care plans are not kept up to date and do not accurately reflect the care that people need. This means that people may not always receive the care they require. Risks to people are identified but not always acted upon, which means that people’s care is not being managed and monitored properly. EVIDENCE: I looked in detail at three care plans. There were care plans in place for people that gave staff information about what they needed to do in order to meet that person’s needs. Staff are reviewing the care plans on a monthly basis, but there was no evidence that people using the service or their relatives were involved in these reviews. It is important that people are involved in these reviews so they or their relatives have the opportunity to discuss the care and support that is being provided. Although staff are reviewing the care plans two of the care plans I looked at were not up to date. For example one stated that a person was being nursed in bed, but she was up and sat in the lounge all Elm View Nursing Home DS0000001050.V339153.R01.S.doc Version 5.2 Page 12 day. Another stated the person wore a leg brace, but the daily records showed that when she went to an out patients appointment at the beginning of August 2007 that this was no longer needed. Staff are completing all of the necessary risk assessments but they are not always using this information effectively. For example one person’s nutritional risk assessment identified that she is at high risk of malnutrition. In her care plan it states that she needs a high fat and high protein diet. When I asked staff about this they said that she was just on a pureed diet. Another person had also been assessed as being at high risk of malnutrition. She had only been weighed twice, once in April 2007 and again in July 2007. She had lost 6lbs during this period and has not been weighed since. In January 2007 one person has been assessed as being at risk of developing pressure sores. Staff did not put any measures in place in order to minimise this risk. This person has since developed a pressure sore. Although he now has a specialist bed and mattress in place staff need to consider carefully if this could have been avoided if pressure reliving equipment had been put in place following the initial assessment. Staff also need to put in place repositioning charts and food intake diaries for those people who have been identified as being at risk. This will make sure that the nursing staff can monitor people’s progress properly and report accurately about their progress. Moving and handling plans are in place for people who require assistance. These are clear and are followed by staff. This means that people living in the home and staff are not at risk of any injury from poor practice. The one person living in the home, who completed a survey, confirmed that they get the right care and support and the medical help he needs. The six relatives that completed a survey said that that they are kept up to date regarding their relatives well being and that the home meets the needs of their relatives. One relative said ‘when I visit mum always seems happy enough, clean and nicely dressed. Staff always seem happy and caring and willing to do anything that might be asked of them. I am happy and content with the overall care mum gets.’ Two relatives said that ‘staff look after people very well.’ One social worker said that ‘staff appear to have a good grasp of peoples needs.’ ‘Individual care plans appear to reflect resident’s needs. Staff appear to consider relatives opinions and act accordingly i.e. calling a GP if there are concerns from the family.’ People’s general health care needs are being met. There was clear evidence in the care plans of people being seen by GPs, tissue viability nurses and other Elm View Nursing Home DS0000001050.V339153.R01.S.doc Version 5.2 Page 13 health care professionals. During my visit one person was unwell. Staff contacted her GP straight away and he visited and prescribed treatment. Staff need to make sure that they write the details of visits by health care professional on the relevant sheet in the care plan. Sometimes details are just being written on the daily records. This makes it difficult to find out quickly when people were last seen and what advice was given. For example on one of the care plans I looked at I only found out that one person had been seen by a GP and dentist from reading all of her daily records from July 2007. Generally the medication system is well managed, this means that people get their medication at the right times. Staff need to make sure that medication is booked in consistently. There was one person whose medication had been received but not booked in on the medication record. Also there were a few occasions where staff had not signed the medication administration record to show that the tablets had been given or entered a reason why they had been omitted. The acting manager needs to monitor the medication system to make sure staff are following the home’s medication procedures. Elm View Nursing Home DS0000001050.V339153.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Social activities are provided consistently or on an individual basis to keep people stimulated. Relatives are made to feel welcome and can visit at any time. The meals are very good offering choice and variety. EVIDENCE: Two out of the three care plans I looked at had lots of information about people’s preferred routines, likes and dislikes, interests, life history and religious needs. This information needs to be used to develop social care plans for each person. This will make sure that people’s individual social needs are met. Elm View Nursing Home DS0000001050.V339153.R01.S.doc Version 5.2 Page 15 Although the brochure states that the home employs activities staff to stimulate people, this is not the case. Staff do have time to spend with people living in the home, but they need training in how to provide stimulating and interesting activities on either an individual or group basis. The one person living in the home that completed a survey said ‘that there were never any activities taking place.’ One relative said that ‘more entertainment would improve the service.’ Relatives said that they are made to feel welcome when they visit. One said ‘when visiting, we always get a good greeting.’ And another said ‘it is nice to know that when relatives telephone the home from away they are able to talk to Mum.’ The meals at the home are very good. There is a wide choice at breakfast time and choices available for all of the other meals. During the week there is a dining room assistant on duty. She has a really good knowledge of people’s likes and dislikes and their individual dietary needs. She talks to the cook about what people like and the menus are changed accordingly. For example on the day of my visit one person had asked if they could have trifle at tea time instead of banana custard. People living in the home, relatives and staff all said that the food was really good. The lunchtime meal was observed. The meal was nicely presented, everyone was served in a timely way and those people who needed assistance were supported appropriately. Elm View Nursing Home DS0000001050.V339153.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Complaints and adult protection issues have not been dealt with appropriately, which means people at the home are not protected. EVIDENCE: The complaints procedure is on display in the dining room, however, this needs to be updated with the new contact details for the Commission for Social Care Inspection. The one person living in the home that completed a survey said that they knew about the complaints procedure and who to speak to if they were unhappy about anything. They also said that staff listen to them and act on what they say. All six relatives that completed a survey said that they knew about the complaints procedure and that if they had raised any concerns these had been dealt with appropriately. One social worker suggested that the home has a suggestion box so that relatives can pass an opinion without giving a name. One relative she had contact with was too nervous to talk to staff and some ‘niggles’ were left to be dealt with at the review.’ Elm View Nursing Home DS0000001050.V339153.R01.S.doc Version 5.2 Page 17 The Commission for Social Care Inspection have received three complaints about the home since the last inspection. Two of these were sent to the owner to investigate. The most recent complaint was about night staff sleeping on duty and staff working long hours was looked at during an inspection visit in August. Complaints are not being dealt with properly by the owners. For example part of the complaint that was sent to them in October 2006 was about staff working long hours. This was the subject of another complaint in August 2007. Staff at the home had also told the owners about night staff sleeping on duty. No action was taken until the Commission for Social Care Inspection looked at this complaint. The deputy manager booked an agency care assistant for night duty. Someone from the home telephoned the agency and cancelled this carer. This has been reported to the owners but to date, they have taken no action. The owners must find out who cancelled the shift and take the necessary disciplinary action as this could have left people living at the home at risk. All of the staff I spoke to were able to talk about what they would do if they felt there were any practices in the home that were not in the best interests of the people living there. This should mean that people are kept safe and protected. However, when staff have reported issues to the owners they have not taken appropriate action and this is leaving people at risk. Elm View Nursing Home DS0000001050.V339153.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People live in a clean, safe, comfortable, well maintained home. 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 home has met the requirements made by both the fire authority and environmental health. Since the last inspection in September 2006 the home has been redecorated and bedrooms have new curtains and duvet covers. Elm View Nursing Home DS0000001050.V339153.R01.S.doc Version 5.2 Page 19 The kitchen was inspected by environmental health in January 2007 and was awarded 4 stars for hygiene. Since that inspection the kitchen has also been redecorated. There are four bathrooms in the home, but only the assisted bathroom on the ground floor is used. Staff told me that one of the bathrooms on the second floor is going to be made into a shower room. This will improve the facilities for people and give them a choice of either a bath or shower. On the day of my visit the hot water to the ground floor bathroom was too hot. It was running at 64°C. The hot water should run at 43°C. The deputy manager telephoned the contractors to visit that day to sort the problem out. When I looked at some of the bedrooms there were problems with two of the windows. In one bedroom on the first floor the tilt and turn window could be fully opened. This is dangerous and a restrictor must be fitted. In another bedroom the bottom of the double glazed unit was full of condensation. This means that the person occupying this room cannot enjoy the view from her window. The person living at the home that completed a survey said that the home was always kept fresh and clean. Relatives also said the home was kept clean. The laundry is in the basement and is suitably equipped for the size of the home. There is no access to the basement by the passenger lift. This means that the laundry assistant is carrying large baskets of laundry up and down the stairs. A risk assessment needs to be completed regarding this to make sure that the laundry staff are safe doing this. Infection control procedures are in place and there have been no outbreaks of any infectious diseases since the last inspection. Elm View Nursing Home DS0000001050.V339153.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. There are enough staff on duty to meet the needs of people living in the home. Staff are well trained and competent to do their job. EVIDENCE: At the time of the inspection there were 20 people living at the home. The duty rotas were examined. These show that during the day there is one nurse on duty with four care assistants. At night there is one nurse and two care assistants on duty. There is cook, domestic and laundry assistant cover during the day. During the week there is also a dining room assistant who takes responsibility for serving breakfast and lunch. Staff said that at the current time the numbers of staff on duty were adequate to meet people’s needs. One relative said ‘staff are always very polite and they go to mum, whenever she needs them. There is always a member of staff in the lounge to make sure people are alright.’ When I visited the home on 8 August 2007 to look at a complaint about staff working long hours I found that some staff were regularly working 50 – 70 hrs Elm View Nursing Home DS0000001050.V339153.R01.S.doc Version 5.2 Page 21 per week. We wrote to the owners about this because it is not safe practice to have staff working long hours and leaves people living at the home at risk of being cared for by tired, overworked staff who are unable to offer the best care and support. The owners told us that this had happened because of sickness and holidays and that no one working in the home had a contract for more that 45 hours per week. We agreed that two new care assistants could start work at the home as they had been checked against the protection of vulnerable adults register as long as they worked with an existing member of staff until their full criminal records bureau check was received. We also told the owners that agency staff must be used if necessary. On this visit the duty rotas showed that some care staff are still being rostered to work between 51 – 65 hours per week and one of the ancillary staff is being rostered to work between 66-74 hours per week. We will be arranging a meeting with the owners about the management of the rota. I looked at the recruitment files for the two newest members of care staff. One contained the necessary checks and references. The second file only contained one written reference. It is very important that before staff start working in the home that all of the necessary checks are made. This will make sure that staff are suitable and safe to work with older people. There are 82 of the care staff who have completed their NVQ(National Vocational Qualification) level 2 training in care. This means that staff are competent to do the job. People living in the home said that they liked the staff and that they were kind and caring. It wasn’t possible to establish what training each individual member of staff had completed and if their training was up to date. This information needs to be available in a way that makes it easy to check when staff need to update their training and what training they still require. Elm View Nursing Home DS0000001050.V339153.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home is not being managed properly. There is no registered manager and no one taking overall responsibility for the service. People living in the home and their relatives need to be consulted about the way the home is managed. This will make sure that the home is run in the best interests of the people living there. EVIDENCE: The home is not being managed properly. There has been no registered manager at the home since October 2004. One of the nursing staff has been Elm View Nursing Home DS0000001050.V339153.R01.S.doc Version 5.2 Page 23 the acting manager since that time, but has no legal responsibility for the home as she is not registered with the Commission for Social Care Inspection. At the inspection in September 2006 she was going to apply for registration but this hasn’t happened. The acting manager works as the nurse on duty most of the time. The rotas show that she only has one day a week when she has time off the rota to undertake any management tasks. A registered manager must be appointed, who works supernumerary to the rota, so that issues raised in this report are dealt with. There are no formal quality assurance systems in place or formal systems for consulting residents and their relatives about how the home is managed. One of the owners undertakes monthly visits to the home and as part of his visits talks to residents, relatives and staff about the service provided. Written reports of these visits are available at the home. Looking at these visits the owner is not following up some important issues. For example part of the complaint that was sent to him in October 2006 was about people being put to bed too early. On his visit to the home in December 2006 he wrote that he could not talk to people living in the home because they were all in bed at 9pm. One of the staff told me that one of the night nurses liked everyone in bed early. The owner should have checked why everyone was in bed at such an early time. The acting manager does hold money on behalf of residents. The records examined were well maintained and accurate. The deputy manager is a moving and handling facilitator and is responsible for making sure that all staff have up to date training. The fire alarm test records were up to date and new staff have received fire safety training. The service records for the fire alarm system, gas and nurse call system were all seen and were up to date. Staff said that the lift and hoists had all been serviced recently but the records of these services could not be found in the file. Elm View Nursing Home DS0000001050.V339153.R01.S.doc Version 5.2 Page 24 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 2 X 3 3 X x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 3 X X 3 Elm View Nursing Home DS0000001050.V339153.R01.S.doc Version 5.2 Page 25 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 OP1 Regulation 5 Requirement An up to date ‘service users guide’ that contains all of the required information must be available to all of the people living in the home and to anyone thinking of moving in. This will make sure that people have all of the information they need about Elm View and the service they provide. Previous timescale of 31/10/06 not met) Timescale for action 30/11/07 2 OP7 15 3. OP7 15 Staff must make sure that care 14/10/07 plans are kept up to date. This will make sure that people’s changing needs are met. 14/10/07 Staff must make sure that all of the available information about a resident is considered at the monthly reviews. Staff must also involve people and / or their relatives in the reviews. This will make sure that people are consulted about the care and support they receive. Previous timescale of 30/11/06 not met) Elm View Nursing Home DS0000001050.V339153.R01.S.doc Version 5.2 Page 26 4 OP7 13 5 OP9 17 6 OP12 16 7 OP16 17 Staff must make sure that they use the risk assessments properly and take appropriate action to demonstrate how they will reduce those risks. This will make sure that people are kept safe. Staff must make sure that medication is booked in and that the medication administration records are signed properly. This will make sure that people get their medication. Individual and group activities must be provided. This will make sure that people are kept mentally active and stimulated. The owners must make sure that any complaint that is made is thoroughly investigated and appropriate action taken to resolve the complaint. This will make sure that any problems are sorted out. 14/10/07 14/10/07 30/11/07 14/10/07 8 OP18 12 9. OP21 23 The owners must make sure that 14/10/07 the adult protection procedures are followed and any allegations of abuse are reported. This will make sure that people living in the home are kept safe. The bathing facilities in the home 31/12/07 must be reviewed and an action plan submitted to show how the owners intend to make bathing or shower facilities more accessible to residents. (Previous timescale of 12/05/06 & 30/11/06not met) The owners must investigate the allegations about night staff sleeping and send a full report to the Commission for Social Care Inspection. This must be done to make sure that people living DS0000001050.V339153.R01.S.doc 10 OP27 18 14/10/07 Elm View Nursing Home Version 5.2 Page 27 11 OP27 18 12 OP29 19 13. OP31 9 in the home are being cared for properly. (previous timescale of 24/08/07 not met) The owners must make sure that staff are competent to work their shift. They must take into consideration the number of hours that staff are working to make sure that individual members of staff are not too tired to fully carry out their role. This will make sure that people living in the home are care for properly by staff. (previous timescale of 24/08/07 not met) The owners must make sure that all of the necessary checks are made on new staff before they start working in the home. This will make sure that staff are suitable and safe to work with older people. A permanent manager for the home must be appointed and registered with the Commission for Social Care Inspection. This will make sure that the home is being run properly.(Previous timescale of 30/05/06 & 31/12/06 not met) 14/10/07 14/10/07 31/12/07 14. OP33 24 A quality assurance system must be introduced. This will make sure that people living in the home and their relatives are consulted about the service that is being provided. (Previous timescale of 30/06/06 & 30/11/06 not met) 31/12/07 Elm View Nursing Home DS0000001050.V339153.R01.S.doc Version 5.2 Page 28 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 OP26 OP30 Good Practice Recommendations A risk assessment needs to be completed about how laundry is carried to and from the basement. This will make sure that staff are completing this task safely. Staff training records must be brought up to date. When this is done it will be easy to establish what additional training staff need. Elm View Nursing Home DS0000001050.V339153.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Elm View Nursing Home DS0000001050.V339153.R01.S.doc Version 5.2 Page 30 - 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. 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