Inspection on 18/10/05 for Elmbridge Residential Care Home

This inspection was carried out on 18th October 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Elmbridge Residential Care Home 21/08/09

Elmbridge Residential Care Home 30/04/07

Elmbridge Residential Care Home 30/01/06

Elmbridge Residential Care Home 14/03/05

Elmbridge Residential Care Home 12/10/04

Elmbridge Residential Care Home 24/02/04

Similar services:

Fairfields Country Rest Home

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

Stallcombe House

Belma

Hunters Care Centre

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

CARE HOMES FOR OLDER PEOPLE Elmbridge Residential Care Home 21 Elmbridge Road Gloucester GL2 0NY Lead Inspector Sharon Hayward-Wright Announced 18 October 2005, 09:30 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. Elmbridge Residential Care Home Version 1.40 D51_D03_16432_Elmbridge_v242866_181005_AI_Stage4.doc Page 3 SERVICE INFORMATION Name of service Elmbridge Residential Care Home Address 21 Elmbridge Road Gloucester GL2 0NY 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) 01452 524147 Ms Caroline OGrady Ms Caroline OGrady Care Home 16 Category(ies) of OP Old Age (14) registration, with number MD(E) Mental Disorder - over 65 (2) of places Elmbridge Residential Care Home Version 1.40 D51_D03_16432_Elmbridge_v242866_181005_AI_Stage4.doc Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 14/3/05 Brief Description of the Service: Elmbridge Residential Home provides personal care for sixteen older people. Within this number, the home can accommodate two service users with specific mental health needs. The accommodation is a converted two-storey older style house, which has been adapted and extended for its current use. Service users rooms are provided on two floors, fourteen of which provide single accommodation, with one shared room. One single room provides an en-suite facility, though each room has its own hand washbasin. Communal areas consist of a lounge, dining room and a conservatory, all of which are situated on the ground floor. A stair lift provides easy access from the ground to the first floor. All areas have a call bell system. Elmbridge Residential Care Home Version 1.40 D51_D03_16432_Elmbridge_v242866_181005_AI_Stage4.doc Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over 6 hours on one day in October 2005. Five service users were spoken with to gain their views on the home; the care of one service user was examined in detail and one staff member and visitor were also spoken to, as well as the Registered Manager/Provider. Staff were observed going about their duties and interacting with each other and service users. The requirements and recommendations made at the last inspection were followed up and records relating to the homes’ Statement of Purpose, Service Users Guide, service users care, duty rotas, staff training, complaints, activities, personnel files, quality assurance and servicing of equipment were inspected and a tour of the home took place with a number of service users rooms inspected. At this inspection the home were not given any requirements and only two recommendations. This is excellent and the staff should be commended on their hard work. All comments received from service users, staff and the visitor were highly complimentary of the home. What the service does well: Staff morale is high resulting in an enthusiastic workforce that works positively with service users to improve their whole quality of life. Recent investment has significantly improved the appearance of this home creating a comfortable and safe environment for those living there and visiting. There is a clear and consistent care planning system in place to adequately provide staff with the information they need to satisfactorily meet service users needs. The standard of the cleanliness in the home is excellent ensuring service users have a pleasant environment in which to live. Elmbridge Residential Care Home Version 1.40 D51_D03_16432_Elmbridge_v242866_181005_AI_Stage4.doc Page 6 Safe recruitment practices are in place ensuring service users are not put at unnecessary risk. Dietary needs of service users are catered for with a balanced and varied selection of food available that meets service users tastes. What has improved since the last inspection? 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. Elmbridge Residential Care Home Version 1.40 D51_D03_16432_Elmbridge_v242866_181005_AI_Stage4.doc 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 Elmbridge Residential Care Home D51_D03_16432_Elmbridge_v242866_181005_AI_Stage4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3 & 5 The home’s Statement of Purpose and Service Users Guide provides service users and prospective service users with details of the services provided, enabling an informed decision for those planning admission to this home. Prospective service users are not admitted to the home without an assessment of their needs being undertaken. Service users and/or their family where able are encouraged to visit the home prior to a decision being made to move in. EVIDENCE: The Registered Manager/Provider has not made any amendments to their Statement of Purpose and Service Users Guide and at previous inspections these guides meet the Care Homes Regulations. However the home is in the process of providing these guides transferred in to large print. The pre admission assessment for a recently admitted service users was seen and provided the home with the information needed to make a decision to whether they could meet their needs. This service user and their relative were very happy with the choice of home and both had viewed the home prior to the service user moving in. Elmbridge Residential Care Home D51_D03_16432_Elmbridge_v242866_181005_AI_Stage4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9 & 10 There is a clear and consistent care planning system in place to adequately provide staff with the information they need to satisfactorily meet service users needs. Health professionals’ are accessed for service users with an assessed need. Service users feel there are treated with dignity and respect. EVIDENCE: One service user was case tracked as the other service users have been case tracked at previous inspections and no issues have been highlighted with care plans. This provided evidence that the care provided to this service user was current. The care plans are reviewed monthly. Moving and handling assessments are undertaken and risk assessments for the risk of scalding from hot water and burns from the radiators. Evidence was seen of health professionals’ involvement in service users care and the Community Nurse was visiting to administer flu jabs on the day of the Elmbridge Residential Care Home D51_D03_16432_Elmbridge_v242866_181005_AI_Stage4.doc Version 1.40 Page 10 inspection. Service users are able to register with a GP of their choice from the attachment area. The requirements from the Commission for Social Care Inspection Pharmacy inspector were followed up, following a recent visit. The home has addressed all of these. Records of medication received, administered and returned to the local pharmacy were seen. The home has reviewed the position and storage arrangements of the medication to meet the Care Homes Regulations. One member of staff was observed administering medication and was following the correct procedure. The home has arranged some medication training for staff that is due to start next week with assistance from a local college. Service users confirmed the staff maintain their privacy and dignity and examples given were knocking on their door prior to entering, addressing them by their preferred form of address. Elmbridge Residential Care Home D51_D03_16432_Elmbridge_v242866_181005_AI_Stage4.doc Version 1.40 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 & 15 The homes activities programme offers service users some opportunity to satisfy their interests and needs. Links with the local community are encouraged and maintained and visiting to the home is flexible to meet the needs of service users families and friends. Dietary needs of service users are catered for with a balanced and varied selection of food available that meets service users tastes. EVIDENCE: The home has an activities board for staff to write down planned activities by outside entertainers or activities undertaken by them. The Registered Manager/Provider has encouraged the staff to start undertaking activities with service users and this was observed during the inspection. Service users said they have a choice as to whether they participate in the activities provided. A number of service users attend day centres and one service user was at a day centre during the inspection. Service users and a visitor to the home confirmed that visiting is flexible and the visitor said they are always made to feel very welcome in the home and offered a drink. Service users personal possessions were seen in their rooms and each room is individualised. Service users spoken with said they are able to make choices over their daily lives. Elmbridge Residential Care Home D51_D03_16432_Elmbridge_v242866_181005_AI_Stage4.doc Version 1.40 Page 12 Lunchtime was observed; staff offered assistance discreetly and service users were given time to enjoy and eat their meal. A number of service users after lunch all said how much they enjoyed the meal. The menu is displayed on the notice board in the dining room, however two service users were not sure what would happen if they didn’t like what was on the menu, as they always liked what is provided. The Registered Manager said the staff are aware of service users likes and dislikes and provide alternatives. Hot drinks are offered at regular intervals and cold drinks are provided in the dining room at all times for service users. Bowls of fresh fruit and sweets are provided in the lounge and dining room. The kitchen and associated records were not inspected. Elmbridge Residential Care Home D51_D03_16432_Elmbridge_v242866_181005_AI_Stage4.doc Version 1.40 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 & 18 Arrangements are in place to protect service users from abuse. The home has a complaints system in place if service users or their relatives need to complain. EVIDENCE: The home has not received any complaints and their complaints procedure has been inspected at previous inspections and meets the Care Homes Regulations. Service users and the visitor spoken with said they would approach the Registered Manager/Provider if they had any concerns. The Registered Manager/Provider said they have regularly discussions on the prevention of abuse at staff meetings but has not provided any specific training. The Registered Manager/Provider is considering purchasing some training material to assist the staff and it is recommended that training be accessed. The Registered Manager/Provider is aware of POVA and the procedure that may need to be followed if an allegation is ever made. The Care Homes Association provides the home’s policies and procedures. Elmbridge Residential Care Home D51_D03_16432_Elmbridge_v242866_181005_AI_Stage4.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20 & 26 Recent investment has improved the appearance of this home creating a comfortable and safe environment for those living there and visiting. EVIDENCE: The home has recently redecorated a number of rooms to include the downstairs assisted bathroom, dining room and lounge. Further redecoration is planned. Service users and the visitor all commented on the redecoration and new furniture in the lounge saying how much it has improved the environment. The home is well maintained with plans in place to address any areas that need attention. The communal areas consist of a lounge, dining room and conservatory. The outside gardens are well maintained and service users said they have enjoyed sitting out in the warm weather. A separate area is provided for service users that wish to smoke. Elmbridge Residential Care Home D51_D03_16432_Elmbridge_v242866_181005_AI_Stage4.doc Version 1.40 Page 15 The home was cleaned to high standards and no odours were present on the day of the inspection. A number of service users and the visitor commented on how the staff always maintained these high standards. The Registered Manager is looking to access infection control training for staff. The laundry was inspected and the washing machine used has a sluicing facility. The home does not have a sluice. Chemicals covered by COSHH regulations are stored in a locked cupboard. Elmbridge Residential Care Home D51_D03_16432_Elmbridge_v242866_181005_AI_Stage4.doc Version 1.40 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 & 30 Staff morale is high resulting in an enthusiastic workforce that works positively with service users to improve their whole quality of life. Recruitment practices in the home support and protect service users. Training is provided for staff to assist in ensuring they are competent to undertake their job roles. EVIDENCE: The off duty for the home was seen as evidence of staffing levels. On an early shift there are three care staff on a Monday to Friday and two at weekends. On a late shift the home has two care staff. Night shift consists of one waking and one sleep in care staff. The Registered Manager or another member of staff covers a shift from 8am to 6pm except on a Monday or Tuesday. The care staff undertake additional duties to include, domestic tasks, laundry and cooking. The majority of staff have been working at the home for a number of years resulting in consistency for service users. Because of this the staff demonstrated a very good understanding of the service users needs and service users felt they have developed good relationships with the staff. All service users spoken with and the visitor all spoke highly of the staff saying nothing was too much trouble for them and they are very good. None of the staff have NVQ 2 training, however the Registered Manager said she is having difficulty accessing NVQ placements. Elmbridge Residential Care Home D51_D03_16432_Elmbridge_v242866_181005_AI_Stage4.doc Version 1.40 Page 17 One new member of staff is due to start at the home and their personnel file was examined. All the correct information was present and the Registered Manager is going to obtain a photograph when they start work. The home is still waiting for Criminal Records Bureau Disclosure, however the POVA check is in place. The home has a set induction programme with a booklet designed by an outside company to meet the recommendations of the National Training Organisation. An experienced supervisor will be allocated to the new staff member when they start at the home and records maintained as evidence. A number of staff training files were seen as evidence of ongoing training, this includes fire, first aid, moving and handling and food and hygiene. Elmbridge Residential Care Home D51_D03_16432_Elmbridge_v242866_181005_AI_Stage4.doc Version 1.40 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 35, 36 & 38 Service users, staff and a visitor all praised the Registered Manager/Provider saying she is of good character and able to discharge her responsibilities fully. The home has systems in place to gain the views of service users and relatives, but it is recommended that monitoring systems used by the home be recorded. Procedures in the home ensure that service users’ monies are safeguarded. Staff are appropriately supervised to ensure the needs of the service users are met. The health, safety and welfare of service users and staff are promoted and protected. Elmbridge Residential Care Home D51_D03_16432_Elmbridge_v242866_181005_AI_Stage4.doc Version 1.40 Page 19 EVIDENCE: The management of the home has not changed and the Registered Manager/Provider said she participates in the same training as the care staff. Service users, staff and the visitor all said they find the Registered Manager/Provider very approachable. The results from last year’s questionnaires were seen and the Registered Manager/Provider said she has just sent out new ones for this year and is waiting for them to be returned. A suggestions box is situated in the conservatory. Monitoring of the home is continuous as the Registered Manager/Provider is in day-to-day control of the home but she is going to record some of her findings. It is recommended that the auditing of medication systems used by the staff be undertaken as part of this process. The Care Homes Association provides the home with policies and procedure and they ensure they are updated with any new legislation. The home’s business and financial plan was seen. Service users’ monies were checked and the appropriate records and receipts are maintained and they are stored in a secure facility. Staff supervision was inspected and the Registered Manager/Provider said the staff have agreed that group supervision works best, however staff said they are able to see the Registered Manager/Provider at any time individually should they need to. Records were seen of these sessions as they are undertaken as part of staff meetings. Evidence as seen of servicing of equipment, boilers, fire equipment, water temperatures and Legionella testing. This information was also documented in the pre-inspection questionnaire. Elmbridge Residential Care Home D51_D03_16432_Elmbridge_v242866_181005_AI_Stage4.doc Version 1.40 Page 20 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 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 3 COMPLAINTS AND PROTECTION 4 3 x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 3 3 x 3 3 x 3 Elmbridge Residential Care Home D51_D03_16432_Elmbridge_v242866_181005_AI_Stage4.doc Version 1.40 Page 21 No 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 Regulation None Requirement Timescale for action 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 18 33 Good Practice Recommendations The home should access training for staff in the prevention of abuse. The home should audit the medication systems used by the staff as part of their monitoring systems and maintain records of this. Elmbridge Residential Care Home D51_D03_16432_Elmbridge_v242866_181005_AI_Stage4.doc Version 1.40 Page 22 Commission for Social Care Inspection Unit 1210 Lansdowne Court Gloucester Business Park Braockworth Gloucester GL3 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 Elmbridge Residential Care Home D51_D03_16432_Elmbridge_v242866_181005_AI_Stage4.doc Version 1.40 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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