Inspection on 10/10/05 for Elmfield House

This inspection was carried out on 10th 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

Elmfield House 04/06/09

Elmfield House 26/06/07

Elmfield House 16/01/06

Elmfield House 21/10/04

Elmfield House 11/05/04

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

CARE HOMES FOR OLDER PEOPLE Elmfield House Elmfield House Church Lane Bisley Surrey GU24 9ED Lead Inspector Christine Bowman Unannounced Inspection 10th October 2005 11:00 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 Elmfield House DS0000013637.V257437.R01.S.doc Version 5.0 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. Elmfield House DS0000013637.V257437.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Elmfield House Address Elmfield House Church Lane Bisley Surrey GU24 9ED 01483 489522 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) Mrs Linda Ann Marsh Mr Alex James Findlay Mrs Linda Ann Marsh Care Home 10 Category(ies) of Dementia - over 65 years of age (3), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (3), Old age, not falling within any other category (10) Elmfield House DS0000013637.V257437.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The age/age range of the persons to be accommodated will be: OVER 65 YEARS OF AGE Of the 10 Residents accommodated up to 3 may fall within the category DE(E) or MD(E) 21st October 2004 Date of last inspection Brief Description of the Service: Elmfield House is a care home providing a service for up to ten service users in the category of older persons. A specified number may have a mental disorder or dementia. The home is located on the village green in Bisley and consists of a large detached property, which has been extensively improved to provide suitable accommodation for its residents. In the vicinity of the home are a selection of shops, the village post office and a public house. The home is well presented and the environment is well maintained. The service is appropriate for individuals with a high level of mobility and independence. Elmfield House DS0000013637.V257437.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which started at 11.00 a.m. and took five hours to complete. Initially there were two members of staff working with the residents and the manager, who had been on call on the previous evening, was available to be interviewed later in the day. A partial tour of the premises, which included all the communal areas, and two of the resident’s bedrooms, took place, and two residents were interviewed at length. Other residents were spoken with briefly and the two members of staff were interviewed. The home was in good decorative order and well adapted to the needs of the client group. The residents spoken to were happy to be living there and very satisfied with the service provided. The staff were cheerful, competent and attentive to the needs of the residents. As part of the inspection process The Statement of Purpose, the Service User Pack, records, policies, care plans and staff personnel files were viewed. The manager, the staff and the residents were all very helpful throughout. What the service does well: What has improved since the last inspection? Elmfield House DS0000013637.V257437.R01.S.doc Version 5.0 Page 6 The manager and a senior carer have attended The Surrey Multi-Agency Adult Protection Procedures and have also been trained as trainers so that they can cascade the information to the rest of the staff. The manager has reviewed the staffing matrix and under the guidance from the Residential Forum, ensures there are always two members of staff on duty. 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. Elmfield House DS0000013637.V257437.R01.S.doc Version 5.0 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 Elmfield House DS0000013637.V257437.R01.S.doc Version 5.0 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): 1&3. Some well-written information regarding the home, which is presented effectively is available to inform potential residents but more detail is required to improve their ability to make a decision about the ability of the home to meet their needs. A full care needs assessment of potential residents must be completed prior to them moving into the home to ensure their needs can be met there. EVIDENCE: The home provides a Statement of Purpose, which includes some of the required information under Schedule 1 of The Care Homes Regulations 2001 (Amended 2002, 2003 and 2004) and is written in a friendly and inclusive manner. In order for prospective clients to make a more informed choice, The Statement of Purpose should be reviewed and contain more specific information as required. Elmfield House DS0000013637.V257437.R01.S.doc Version 5.0 Page 9 The Service User Pack contains a well-presented leaflet printed on high quality card with a print of the home on the front, photographs of the interior and exterior of the home throughout and a map showing the location of the home in relation to Bisley village. It offers more information than the Statement of Purpose. Neither of these documents gives the address and telephone number of the CSCI local office and The Statement of Purpose refers to the NCSC. A reference is made to the complaints procedure but it is not summarised. The complaints procedure is included in the Service User Pack. Referrals to the home are from a variety of sources including General Practitioners, district nurses, social care managers and locally from the village. One resident, who lived in the village before moving into the home used to ride her bicycle until three years ago and she is now ninety six years old. She was pleased to be placed so close to her old haunts even though she can no longer use her bicycle. The manager stated that she assesses the care needs of potential residents prior to admission, but the assessment form states that the questions on the Assessment of Care Needs form are to be directed at the resident concerned during the admission. Elmfield House DS0000013637.V257437.R01.S.doc Version 5.0 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): 7&8 Residents’ care plans set out their health, personal and social care needs to inform those who care for them and ensure their needs are met. The home ensures access to health care services as required by residents. EVIDENCE: The manager stated that the care plan is compiled a month after the resident has moved into the home to allow for any adjustments from the care needs assessment, which is revisited fortnightly. Care plans viewed showed that for those residents with mental health needs, cognitive ability had been assessed and one resident, who had a poor memory, had been to visit the home at a regular time and for the same number of hours for a week before moving in so the change of environment would not be frightening to her. Care plans had been signed and dated and contained all the information required including a photograph of the resident, personal details and there was evidence of sixmonthly reviews having taken place. Elmfield House DS0000013637.V257437.R01.S.doc Version 5.0 Page 11 One resident interviewed stated that she had suffered from bronchitis recently and had been visited by her GP. She said the staff called the GP for her but she did have access to a telephone to use in private should she wish to call the GP herself. A member of staff spoke of two resident who had moved to nursing care since the last inspection. An ambulance had been called when one of the residents was having difficulty breathing and she had recently passed away in the nursing home. The other ex resident was fine and being visited by a resident who was her friend, the resident stated. The ex resident’s niece takes her in a wheelchair to make the visit. Care plans showed that nutritional screening took place on admission and that weight records were kept. Elmfield House DS0000013637.V257437.R01.S.doc Version 5.0 Page 12 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): 13&15 The home actively encourages residents to maintain links with family, friends and the community and seeks to ensure residents are fulfilled in their social and community contacts. Residents are satisfied by the presentation, content and frequency of the meals they are served and that they can choose the location. EVIDENCE: From discussions with residents it was clear that relatives and friends were encouraged to visit. One resident spoke of her young nephew being welcomed and another of being taken out by her relatives. Some of the residents fondly mentioned the home’s cat, which had a bed in the conservatory and was fast asleep in the summerhouse, and of the manager’s small dog, which makes regular visits. Most of the residents had family connections or friends who visited, the manager stated. One resident loves to hear the birds in the garden and doesn’t mind spending her money on birdseed to encourage them. A resident, who had only been at the home for a few months, mentioned how nice it was to have made friends with some of the other residents. The manager was mindful of the fact that for some residents there was no possibility of visiting their relatives at Christmas time, and she endeavours to make it a family occasion by sharing Christmas, including her grandchildren, with the remaining residents. A resident, who had lived at the home for many years, appreciated this connection. Elmfield House DS0000013637.V257437.R01.S.doc Version 5.0 Page 13 Some links with the local community were discussed with the manager, stated that the residents enjoyed a good view of the fireworks from the comfort of their own home on bonfire night and that everyone looks forward to the annual Strawberry Fair on the green with Morris dancers, stalls and fun events such as the ‘Duck Race’. Some residents attend the local church but the day centre, which is just across the green and which some residents had accessed when they were living in their own homes, costs £30 per day and a carer must accompany any resident, who wishes to attend. The three weekly rotating menus were seen and they were varied. Residents spoken with said that they enjoyed the food and this was confirmed at lunchtime, when all the residents partook of a hot and nutritious meal together around the dining room table. The manager confirmed that staff do not cook meals or deal with food until they have attended a course on food hygiene. One resident stated that she really enjoyed having her breakfast in bed and getting up in a leisurely fashion. When asked about having the choice of making a drink or a snack for herself, a resident was quite clear that she did not want this choice and that the staff asked her frequently if she would like a hot drink. Elmfield House DS0000013637.V257437.R01.S.doc Version 5.0 Page 14 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&17 The open culture within the home encourages residents to make their feelings known. The complaints procedure needs to be modified to give a clear timescale for responding to complainants and residents need to be made aware of the fact that they can contact the CSCI local office at any time they wish. Staff training in the protection of vulnerable adults safeguards residents from abuse and informs the staff of the correct procedures should an incident occur. EVIDENCE: The complaints procedure was simple, clear and appropriate to those using the service. It did not however give any actual timescales or allow for the complainant to contact the CSCI local office at any time throughout the complaints procedure. Residents meetings were conducted at the home and the minutes were displayed on the notice board in the conservatory, demonstrating an open culture where residents were encouraged to make their views known. The residents interviewed stated they would feel comfortable speaking to the manager should they wish to complain about anything at the home. There was a log for recording complaints and compliments, which contained many letters of gratitude from relatives of residents but no complaints, had been recorded. Since the last inspection, the manager and a senior carer had attended The Surrey Multi-Agency Vulnerable Adults Procedures training and had also completed the training for trainers course so that they could in turn train the staff, the manager stated. Elmfield House DS0000013637.V257437.R01.S.doc Version 5.0 Page 15 There had been one Vulnerable Adult Procedure investigation since the last inspection, which had been instigated by the home to protect one of the residents. Elmfield House DS0000013637.V257437.R01.S.doc Version 5.0 Page 16 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): 19,20,24 The continuous attention to the maintenance of the environment provides the residents with a comfortable and safe home. The domestic nature of the furnishings and attention to detail create a homely and relaxing atmosphere for the residents. Resident’s bedrooms are comfortable, private and contain the resident’s own possessions according to their wishes. EVIDENCE: The home was well maintained and provided a homely and comfortable living environment. The terrace to the rear of the building, which was accessible through double French windows from the conservatory, was clean and a member of staff stated that at this time of the year when the leaves are falling, it is jet washed frequently to prevent slip hazards. The communal areas, which included the sitting room, dining room and conservatory inside and the terrace and summerhouse outside, contained domestic style furnishings and lighting. There was a large flat screen television with video recorder and DVD player in the sitting room, a bookshelf full of books, games, videos and a fish tank. In the conservatory were a number of pot plants, which were cared for by one of Elmfield House DS0000013637.V257437.R01.S.doc Version 5.0 Page 17 the residents, a member of staff stated. There were framed photographs on the walls of residents and ornaments displayed on shelves giving the home a genuine ‘home from home’ experience as described in The Statement of Purpose. Two residents allowed their rooms to be viewed. The rooms contained all the required furnishings and one resident stated that everything in her room belonged to her. The en suite consisted of a toilet facility in the actual bedroom, which the resident stated she was quite happy about. Elmfield House DS0000013637.V257437.R01.S.doc Version 5.0 Page 18 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): 29&30 The home’s recruitment procedures safeguard the residents and a structured induction and foundation training instructs newly recruited staff in all aspects of their role in caring for the residents. The Criminal Records Bureau check number should be recorded on the staff personnel files to verify the fact that they have been received for the protection of the residents. EVIDENCE: The staff personnel files inspected contained the required documentation but the Criminal Records Bureau number was not recorded. The manager stated that these documents were securely stored separately. The files would benefit from binding and a more orderly presentation. There was evidence of a structured induction in line with The Skills for Care syllabus having taken place and being signed off by the manager and the member of staff. Foundation training was recorded covering the mandatory subjects. It was noted that a member of staff who started working in September 2004 had not received food hygiene training until August 2005, but as there are always at least two staff on duty at any one time, this may not have been a problem. Elmfield House DS0000013637.V257437.R01.S.doc Version 5.0 Page 19 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): 31,32&36 The manager is experienced, provides competent leadership and promotes an open and inclusive ethos within the home so residents are comfortable in expressing their views. Staff supervision on a regular basis ensures they are supported to give their support in turn to the residents. EVIDENCE: The manager has many years of experience of leadership and one resident, who had lived at the home for a number of years, stated that she had greatly improved the environment. She is in the process of completing the NVQ4 in Care and the Registered Manager’s Award. The manager stated that she had booked for herself and the member of staff responsible for organising activities to attend a four-day course on ‘The Promotion of Health and Active Life in Older People’. Elmfield House DS0000013637.V257437.R01.S.doc Version 5.0 Page 20 The manager encourages residents’ meetings and is positive and inclusive in her approach, this was confirmed in interviews with the staff. Residents spoken with appreciate her commitment to them. Records confirmed that staff supervision is offered four times per year covering all the topics as required and ensuring the staff team are well supported to support the residents. Elmfield House DS0000013637.V257437.R01.S.doc Version 5.0 Page 21 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 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 4 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 3 X X X 3 X X STAFFING Standard No Score 27 X 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 X X X 3 X X Elmfield House DS0000013637.V257437.R01.S.doc Version 5.0 Page 22 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. 1. Standard 1 Regulation Schedule 1 4(1)(c) 5(1)(a-f) Requirement The Registered Manager must ensure that The Statement of Purpose includes the information required. The Registered Manager must ensure the Service User Guide includes the information as required. The Registered Manager must ensure that a suitably qualified person prior to the admission of residents completes a full care needs assessment. The Registered Manager must ensure the Criminal Records Bureau number is recorded on the staff personnel file. Timescale for action 10/11/05 2. 1 10/11/05 3. 3 14(1)(ad) 10/11/05 4. 29 Schedule 2 7(a) 10/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Elmfield House DS0000013637.V257437.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Elmfield House DS0000013637.V257437.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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