Inspection on 16/01/06 for Elmfield House

This inspection was carried out on 16th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 10/10/05

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 Pauline Long Unannounced Inspection 16th January 2006 10:00 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.V277827.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. Elmfield House DS0000013637.V277827.R01.S.doc Version 5.1 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.V277827.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Of the 10 Residents accommodated up to 3 may fall within the category DE(E) or MD(E) The age/age range of the persons to be accommodated will be: OVER 65 YEARS OF AGE 10th October 2005 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.V277827.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second Inspection of the CSCI year April 2005- March 2006 and was unannounced. The inspection was carried out by one inspector and lasted for four hours. The manager was unavailable on the day. The service had a homely, welcoming and relaxed atmosphere. During the inspection process, discussions were had with the residents and staff. Documents inspected, included the residents files, care plans, and the homes policies and procedures and records. A full tour of the home took place. CSCI would like to thank the residents and staff for their hospitality and cooperation during the inspection. What the service does well: What has improved since the last inspection? All of the requirements made as a result of the previous inspection have been met. The home is in the process of recruiting new staff. A new needs assessment format has been developed and is in the draft stage. Elmfield House DS0000013637.V277827.R01.S.doc Version 5.1 Page 6 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.V277827.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 Elmfield House DS0000013637.V277827.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): 2,4,5,6 Files sampled, evidenced that resident’s contracts were in place. Residents indicated that were invited to view the home before admission, and that they felt the home could meet their needs. The home does not provide for an intermediate care service. EVIDENCE: Three residents files were sampled, each contained a contract of care service provided. The contracts had been signed by the resident or their representative. Discussions were had with residents, who commented that before they were admitted to the home they were encouraged to visit and assess the suitability of the accommodation. They were then able to make a decision as to whether or not the home could meet their needs. The senior carer in charge of the home commented, that whilst the home does not provide an intermediate care service, they do provide a respite service. Elmfield House DS0000013637.V277827.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): 7,9,10,11 Each resident has an individual plan of care. The home has robust policies and procedures for medication administration. Resident’s are treated respectfully and their privacy is upheld. Resident’s wishes regarding their death are treated sensitively. EVIDENCE: The residents care plans were good, and included needs assessments, risk assessments with regard to manual handling, and potential risks to pressure areas. However there were no risk assessments in respect of the challenges faced by those resident’s who may have dementia. There were records with regard to the activities and care given being kept. These records were kept in the homes communication book and only documented if any thing significant occurred involving a resident. Nothing is recorded in an individuals file and this was a cause for concern, in respect of confidentiality and continuity of care. This practice was discussed with the senior carer on duty, who stated this method of recording would be discussed with the manager on her return. Discussions were had on the need for records to provide a holistic overview of a resident’s day. Elmfield House DS0000013637.V277827.R01.S.doc Version 5.1 Page 10 The homes medication systems were sampled and were found to be robust, in respect of storage and safety. Medication record sheets were well completed and no gaps were noted. However it was noted that some of the residents were prescribed medications on a “as required basis”, the home should consider as to whether or not their method of recording the administration of this medication is appropriate. There were tubs of medicated skin creams with out a resident’s names sitting in one of the offices demonstrating that these were used communally. This was discussed with the senior carer, who stated that if a resident required a cream, then some would be decanted from the stock tub into a smaller tub for their individual use . This was viewed as poor practice, and the senior carer was advised of the requirement for each resident to have access to their own individual creams and ointments. Through out the inspection process, staff were observed carrying out various aspects of personal care for the residents. This was carried out in a respectful manner, bedroom and bathroom doors were not left open, staff were observed knocking on doors and waiting to be invited in, before entering rooms. Residents commented that the staff are always respectful. Discussions were had with the senior carer about how the home deals with death and dying and residents wishes in this respect. She stated that this was a difficult subject to raise, and that it would not be discussed in the first few weeks. However as the resident settled into the home it would then be discussed. There was evidence in the files sampled, that this issue had been discussed and that a resident’s wishes had been documented. Requirements and a recommendation have been made in these areas. Please refer to page 21 and 22 of this report. Elmfield House DS0000013637.V277827.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): 12,14 The home encourages the residents to maintain lifestyles which match their expectations. Residents are encouraged and supported to exercise choice and control over their lives. EVIDENCE: Residents commented that, the lifestyle in the home was like any ordinary home, one stated it “was like home from home”. Another commented, the home does provide activities such as a crossword morning. The senior carer explained that there were various activities offered in the home, some of the residents joined in with the pottery classes and some enjoyed bingo. On the day of inspection some of the residents were enjoying morning television. Through out the inspection, staff were observed offering residents choices. For example, several resident’s had chosen to eat their breakfast in their bedrooms. One staff member was heard to offer a resident her choice of clothing for the day, and discussed with her where she would prefer to spend the day, either in her bedroom or the sitting room. Elmfield House DS0000013637.V277827.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): 16,18 The home has satisfactory policies and procedures and training in place for dealing with the protection of the residents, and for addressing concerns and complaints. EVIDENCE: CSCI have received no complaints about this home since the last inspection. The home has a complaints/compliments folder. There were no records of written complaints being received at the home. The senior carer stated that the residents were quite vocal and that if they had any concerns or complaints that would voice their concerns. Discussions with the residents evidenced that they would complain if there was a need to and that the complaint would be dealt with in a timely manner. Various scenarios in respect of adult abuse situations were discussed with the care assistant on duty. It was pleasing to note that she was aware of and had a good understanding the homes Protection of Vulnerable Adults procedures. Elmfield House DS0000013637.V277827.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): 21,22,23,25,26 The standard of the environment within this home is good, and meets the needs of the residents, providing a clean, attractive, homely and safe place to live. Resident’s have specialist equipment as required. There was a malodour in one of the bedrooms. EVIDENCE: The home is fairly spacious, comfortable and for the most part clean and free from malodour, apart from one of the resident’s bedrooms which had a malodour. All of the resident’s bedrooms were personalised for example: photographs of family members and other personal items. Some of the bedrooms had a television and music centres. Each bedroom had an en-suite toilet and wash hand basin, which the residents could use as required. The residents have access to two toilets on the ground floor and one in the upstairs bathroom. The upstairs bathroom contains a fixed bath hoist, which would be used as required by a resident. The senior carer commented that the home also had a mobile hoist, but it was not in use and was stored in the attic. Elmfield House DS0000013637.V277827.R01.S.doc Version 5.1 Page 14 There were various hoist slings stored in the bathroom. Residents can access the upstairs of the home by using a stair lift, which on the day was in working order. Water temperatures were checked in various rooms through out the home and were found to be satisfactory. Elmfield House DS0000013637.V277827.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,29 The staffing arrangements in place on the day of inspection were sufficient to meet the needs of the service users. The home could not demonstrate that Protection of Vulnerable Checks (POVA) are routinely carried out. Recruitment practices were poor. EVIDENCE: There were two members of care staff on duty on the morning shift on the day of inspection. The dependency levels of the residents on the day indicated that the staffing levels were adequate. One staff file sampled did not contain the information required to evidence that adequate recruitment checks had been completed. The service needs to ensure that one of the written references for staff are from the most recent employer: this was unclear in the two staff files sampled at the time of the inspection. It was also noted that a written reference in respect of one member of staff had not been received/requested directly from the referee and there was no written record available to indicate that this had been checked for authenticity. However, the manager of the home later advised the Commission that a telephone check had been carried out in respect of this matter. All of the files had a Criminal Records Bureau Checks(CRB) disclosure numbers. The senior carer stated that the records in respect of protection of vulnerable adults checks (POVA) checks The regulation inspector was unable to sample evidence of POVA checks and was advised by the senior member of staff on duty that these were securely stored with the key retained by the registered manager, Elmfield House DS0000013637.V277827.R01.S.doc Version 5.1 Page 16 who was not available at the time of inspection. This will therefore form part of the focus for the next inspection of the service. Requirements have been made in these areas. Please refer to pages 21 and 22 of this report. Elmfield House DS0000013637.V277827.R01.S.doc Version 5.1 Page 17 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): 33,34,35,37,38 The home is run in the best interests of the residents. The home was not able to evidence their accounting and financial procedures and records in respect of the service or residents monies. Record keeping was satisfactory and health and safety is promoted. EVIDENCE: On the day staff it was clear that there was an atmosphere of openness and respect. Residents and staff appeared confident and relaxed in each others presence. Staff were observed discussing the plans for the day with some of the residents. Comments from a resident indicated that home promotes good communication and that they are kept up to date with any issues concerning the home. Throughout this inspection the home’s records in respect of residents care plans and staff recruitment files were accessed. The recordkeeping was of a satisfactory standard. All records were stored appropriately and confidentially. Elmfield House DS0000013637.V277827.R01.S.doc Version 5.1 Page 18 The inspector was unable to gain access to all of the records required on the day. Health and safety checks are routinely carried out. Fire extinguishers and fire alarm bells were checked on 10/01/06, the last fire drill was carried out on 04/12/05. Records in respect of food hygiene regulations were sampled and were found to be in good order. The senior carer stated that the stair lift and the hoist had been recently serviced, however there were no records to evidence this, nor could records be produced to evidence that water temperatures were tested. Requirements have been made in these areas. Please refer to pages 21 and 22 of this report. Elmfield House DS0000013637.V277827.R01.S.doc Version 5.1 Page 19 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 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X 2 3 X 3 2 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 2 2 X 2 2 Elmfield House DS0000013637.V277827.R01.S.doc Version 5.1 Page 20 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 OP4 Regulation 12(1)(a) 13(4(b(c Requirement The registered(s)persons must ensure that comprehensive risk assessments are carried out on those residents who have dementia and that these risk assessments are documented. The registered person(s) must ensure that all equipment used in the home is regularly serviced and fit for purpose, and that records are kept. The registered person(s) must ensure that all of the residents have access to their own creams and lotions and that GP prescriptions are requested for such items. The registered person(s) must ensure that recruitment practices improve. Staff files must contain all of the required information as documented in Schedule 2 of the Care Homes Regulations as amended. One of the required references must be sought from a staff members previous employer and not from a work colleague. The registered person(s) must DS0000013637.V277827.R01.S.doc Timescale for action 16/03/06 2 OP22 12(1)(a) 23(2(c 16/02/06 3 OP8 12(1(a 13(1(b 16/02/06 4 OP29 19 Sch 2 16/02/06 5 OP38 12(1(a 23/01/06 Page 21 Elmfield House Version 5.1 13(4(a(b (c 6 7 OP26 OP37 16(2(k 17 ensure that all cleaning materials are stored in compliance with COSHH (Control of Substances Hazardous to Health) regulations. They must be locked away. The registered person(s) must 23/01/06 ensure that all areas of the home are kept free from malodours. The registered person(s) must 16/02/06 ensure that all records required for inspection, are available for inspection. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP37 Good Practice Recommendations The registered person(s) should consider reviewing how the home reports and records on daily living activities. They should consider keeping daily records on each resident and keeping these records in the residents care plan file. Elmfield House DS0000013637.V277827.R01.S.doc Version 5.1 Page 22 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. 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