CARE HOMES FOR OLDER PEOPLE
Elmbridge Residential Care Home 21 Elmbridge Road Gloucester Glos GL2 0NY Lead Inspector
Ms Gillian Goldfinch Unannounced Inspection 2:30 30 January 2006
th 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 Elmbridge Residential Care Home DS0000016432.V276980.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. Elmbridge Residential Care Home DS0000016432.V276980.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Elmbridge Residential Care Home Address 21 Elmbridge Road Gloucester Glos GL2 0NY 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) 01452 524147 Ms Caroline Ann Margaret O`Grady Ms Caroline Ann Margaret O`Grady Care Home 16 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (2), Old age, of places not falling within any other category (14) Elmbridge Residential Care Home DS0000016432.V276980.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: none Date of last inspection 18th October 2005 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 DS0000016432.V276980.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 2 hours on one day in January 2006. Six service users were spoken with and gave their views on the home; three care staff 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 recommendations made at the last inspection were followed up and records relating to service users care, staff training, complaints and fire safety were inspected. All comments received from service users and staff were highly complimentary of the home. What the service does well: What has improved since the last inspection? What they could do better:
Two recommendations were made and these related to accessing training for staff in the prevention of abuse and recording monitoring systems used in the Elmbridge Residential Care Home DS0000016432.V276980.R01.S.doc Version 5.1 Page 6 home. These recommendations have been carried forward from the previous inspection report, as they had not yet been acted upon. 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 DS0000016432.V276980.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Elmbridge Residential Care Home DS0000016432.V276980.R01.S.doc Version 5.1 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 the following standard(s): These Standards were not inspected during this inspection. EVIDENCE: Elmbridge Residential Care Home DS0000016432.V276980.R01.S.doc Version 5.1 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 the following standard(s): 11 Care and comfort are given to service users who are dying. EVIDENCE: The home has policies and procedures in place for handling dying and death. Staff spoken to confirmed that every effort is made to ascertain and record the wishes of each service user in relation to their death. The privacy ad dignity of the service user who is dying are maintained at all times. Service users are able to spend their final days in their own rooms, surrounded by their personal belongings, unless there are medical reasons to prevent this. Families and friends of a service user who is dying are able to stay with the service user for as long as they wish, so long as that is also the wish of the service user. Elmbridge Residential Care Home DS0000016432.V276980.R01.S.doc Version 5.1 Page 10 Palliative care and appropriate pain relief are accessed as necessary. Staff stated they have a positive and supportive relationship with the primary health care team. Service users told the inspector lots of very positive things about the Home – they like the staff very much and described them as caring and friendly. One person said ‘they are excellent’. Throughout the inspection staff were polite, patient and gentle with service users. Elmbridge Residential Care Home DS0000016432.V276980.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 inspected during this inspection. EVIDENCE: Elmbridge Residential Care Home DS0000016432.V276980.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): 16 The home has a clear complaints procedure. EVIDENCE: A complaints procedure was available in the home and the service users who were spoken to felt confident that the registered manager and staff would listen them to. A copy of the complaints procedure is provided to each service user and their representatives at the time of admission. There had been no complaints received by the home since the last inspection. Recommendation made at the last inspection for staff training to be accessed and provided in the ‘protection of vulnerable adults’ had not been implemented. This recommendation has been repeated in this report. Elmbridge Residential Care Home DS0000016432.V276980.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): These Standards were not inspected during this inspection. EVIDENCE: Elmbridge Residential Care Home DS0000016432.V276980.R01.S.doc Version 5.1 Page 14 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 inspected during this inspection. EVIDENCE: Elmbridge Residential Care Home DS0000016432.V276980.R01.S.doc Version 5.1 Page 15 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): 32 and 38 The management approach of the home creates a positive, open and inclusive atmosphere. Systems are in place to protect the health, safety and welfare of service users and staff. EVIDENCE: Feedback received from both service users and staff about the registered manager/provider, was without exception positive about open style of management. There were strategies in place for enabling service users, their representatives, staff and other stakeholders to express their view of the service offered and to
Elmbridge Residential Care Home DS0000016432.V276980.R01.S.doc Version 5.1 Page 16 influence the way in which the service is delivered. Questionnaires are sent to all interested parties on a regular basis. These are evaluated and acted upon by the provider. A suggestion box is located in the conservatory. Recommendation made at the last inspection for the medication systems used by staff to be audited, as part of the homes monitoring systems had not been implemented. This recommendation has been repeated in this report. Fire safety records were checked. These were being kept as required and were well maintained. Safety procedures were posted appropriately around the building. Elmbridge Residential Care Home DS0000016432.V276980.R01.S.doc Version 5.1 Page 17 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME 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 X 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X X X X X X X X 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 X 3 X X X X X 3 Elmbridge Residential Care Home DS0000016432.V276980.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation 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 OP18 OP33 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 DS0000016432.V276980.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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