Inspection on 26/06/07 for Elmfield House

This inspection was carried out on 26th June 2007.

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 16/01/06

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 Kenneth Dunn Unannounced Inspection 26th June 2007 09:30 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.V342472.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Elmfield House DS0000013637.V342472.R01.S.doc Version 5.2 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.V342472.R01.S.doc Version 5.2 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 16th January 2006 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. Fees range £495.00 to £520.00. Elmfield House DS0000013637.V342472.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was part of a key inspection. The visit was unannounced and took place over four and half hours. The visit was carried out by Mr. K Dunn Regulation Inspector and Mrs. L Marsh Registered Manager represented the establishment. The inspector spoke to a random sample of people who use the service to gain their views on the care provided. The people who use the service requested that they be referred to as residents because this was their home and some felt that the word service did not represent Elmfield House. The CSCI has received comment cards from residents and in addition two relatives comment cards were also received. A tour of the premises took place. Information was examined which was provided by the manager with the pre- inspection questionnaire. Staff training records, care plans and policies and procedures were sampled. The inspector would like to thank the people using the service and staff for their time, assistance and hospitality during this inspection. What the service does well: The home has an experienced registered manager who provides management stability, leadership and direction to the staff team. Meals at the home are good and offer variety, choice and health eating options. During discussions a resident commented ‘‘the food is always very good’’. The home values equality and diversity and staff have value-based training in privacy, dignity, rights and respect. Care plans reflect the unique needs of individual residents. During discussions with residents she commented ‘‘it is a happy place and the staff look after everyone awfully well’’. The home has good procedures for needs assessment and care planning is based on best practice. Family links are promoted with flexible visiting times. Activities are organised with opportunities for gentle exercise, board games, reminiscence, arts and craft and a crossword puzzles. Quality assurance at the home is good and the home used questionnaires to obtain feedback about the home. Elmfield House DS0000013637.V342472.R01.S.doc Version 5.2 Page 6 The home had a good complaints procedure and a review of records confirmed no complaints were recorded about the home. The inspector noted the CSCI had no record of safeguarding adult matters pertaining to the home and during discussions a residents commented ‘‘I get on with staff very well’’. On the day of the inspection the home was clean, nicely presented and free from mal odour and during discussions a member of staff stated ‘‘the home is always clean and comfortable’’. 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. The summary of this inspection report can be made available in other formats on request. Elmfield House DS0000013637.V342472.R01.S.doc Version 5.2 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.V342472.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 3 & 6 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service The homes statement of purpose and service user guide are well designed ensuring prospective residents have up to date information on which to make decisions about admission to the home. The arrangements for care planning are robust and ensure prospective residents needs are assessed before admission to the home. EVIDENCE: The home had a statement of purpose and service user guide written in plain English and nicely presented. The manager has reviewed and updated both documents in line with a requirement from a previous site visit. The information contained within these documents fully complies with the National Minimum Standards. However there were areas in both documents that did not fully represent the service especially in respect to the staffing figures and the qualifications of the staff. It is therefore recommended that the manager reviews the statement of purpose and service users guide on a regular bases Elmfield House DS0000013637.V342472.R01.S.doc Version 5.2 Page 9 to ensure that they remain accurate and current to the services provided by Elmfield house and the staff group. The home had a policy on assessing the needs of potential residents. The manager stated that all prospective residents would only be admitted to the home following a full assessment of needs. The inspector sampled the files of three of the most recent resident to move into the home. This review confirmed the home had a pre-assessment form completed for each resident, which included a proposed care plan covering personal care, health needs and social support. The manager stated that she visits all prospective residents are assessed “preferably in their own homes” but she will visit them wherever they are living at the time the application. The residents also have the opportunity to visit the home ensuring that the new person would be compatible with the current group of people living in the home. Elmfield House DS0000013637.V342472.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 & 10 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents are provided with an individual care plan, which records their needs, goals and fully detailing their health needs. The management of medications at the home is well balanced and designed to promote good health. Dignity respect and privacy is a core element of the service and upheld. EVIDENCE: The care plans are drawn up with the involvement of the residents and or their representatives the plan sets out in details the action needed to ensure needs can be met. Care plans sampled indicated that there is clear information for the staff to follow to ensure that the needs of the individuals are paramount when offering care. There is evidence in the residents files that they are registered with a local GP’s and have access to hearing, sight tests, chiropody and dental services within the local area. The manager stated that the home “will support Elmfield House DS0000013637.V342472.R01.S.doc Version 5.2 Page 11 resident’s to maintain their registration with their existing GP if it is appropriate and the doctor is willing to maintain they status quo”. The home has a policy on medications in line with the National Minimum Standards. Medications were appropriately stored and medication record sheets were dated and signed by staff. Staff have training in the administration of medications and attendance dates were in staff training files. The manager must compile risk assessments on the residents not taking their own medications to ensure that the service is not taking away a skill that could with assistance be maintained. The home has a policy guaranteeing the residents privacy and dignity. Staffs were seen knocking on doors before entering bedrooms and appeared to be respectful when engaging with individuals. One resident stated that staff were always very pleasant when they were assisting her and they were aware of not disturbing her privacy. Elmfield House DS0000013637.V342472.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home arranges a wide range of activities, which enhance the lives of its residents. Meals are nutritiously balanced and offer a healthy and varied diet for the service users living at Elmfield House. EVIDENCE: The residents preferred social and leisure interests are recorded in their care plans. The inspector sampled records that demonstrates what activities are undertaken at the service, which are appropriate and designed for the residents. The home offers a variety of activates including crossword afternoons, games afternoon and genital exercises. Individual residents have the opportunity to participate in religious ceremonies as their faith so determines. The resident’s religious needs are discussed with the person and recorded in their individual files to ensure that their wished are respected and upheld. The manger stated that in some specific cases the families of the residents coordinate the persons religious participation, however the has not been written up on the persons files. It is therefore recommended Elmfield House DS0000013637.V342472.R01.S.doc Version 5.2 Page 13 that the manager should ensure that the resident’s files contain clear information on how the individual’s religious needs are being met. The manager stated the home had a visitor’s policy and visitor’s information was available in the service user guide. A review of records confirmed relatives visited the home and the residents went home regularly to spend time with family and friends. Menus appeared to be varied, balanced and seemed to provide a good choice of home cooked meals. The one residents was very complementary about the meals offered at the home and said it had “give her appetite back and that the meals were nicely cooked and very tasty”. Elmfield House DS0000013637.V342472.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The policies and procedures in operation at the home for making a complaint is good. The arrangements for safeguarding adults have been strengthened to safeguard the welfare of the residents. EVIDENCE: The manager stated that the home has not received any complaints since the previous site visit by the CSCI and review of the complaints log substantiated this. The residents that spoke to the inspector felt that they could easily make a complaint if they felt there was a need to and they were all confident that they would be listened to if they did complain. A review of the policies and procedures demonstrated that residents wishing to make a complaint can do so easily and in a format that is non discriminatory. The residents and or their representatives can make formal complaints in any format that suits their needs. The home had a policy on protection of vulnerable adults and a copy of the local authority (Surrey County Council) procedures on safeguarding adults was available for staff to refer to if the need arose. Further evidence confirmed the home had a whistle blowing policy and training is continues for staff in dementia awareness to ensure the emotional needs of the residents are understood and dealt with appropriately. A review of information confirmed no Elmfield House DS0000013637.V342472.R01.S.doc Version 5.2 Page 15 adult protection matters were recorded about the home since the last previous site visit by the CSCI. Elmfield House DS0000013637.V342472.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 & 26 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The premises are good ensuring the residents live in a homely and comfortable environment. The arrangements for hygiene are good ensuring the home is clean and hygienic. EVIDENCE: The home is, well maintained and safe. The home is decorated and furnished to a good standard. There is unfortunately limited but, well-maintained grounds for residents to access. All areas in the home are accessible by two chair lifts. Call bells are provided in every bedroom. Information was provided to the inspector that subject to planning approval an extension to the home is planned to enhance the facilities. Elmfield House DS0000013637.V342472.R01.S.doc Version 5.2 Page 17 Observations confirmed the home had adequate laundry facilities and staff practiced infection control measures by washing their hands regularly to prevent the spread of infection in the home. A review of staff training records confirmed staff have training in infection control and the inspector noted the home was clean, nicely presented and free from mal odour. A number of positive comments were received from residents and relatives in respect of the décor and cleanliness of the home and included, “First class”; “spotless” ‘‘the home is always clean and comfortable’’. Elmfield House DS0000013637.V342472.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28, 29 & 30 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for staffing are good ensuring sufficient numbers of staff on duty to meet the needs of the residents. Training in National Vocational Qualification (NVQ) is good ensuring the resident are in safe hands at all times. Recruitment and vetting practices are good safeguarding the welfare of the residents. The arrangements for induction training are good ensuring staff are trained to do their jobs. EVIDENCE: The manager stated the home had adequate staffing levels that were calculated using an approved formula and the inspector noted the manager had responsibility for planning the home’s duty roster. The inspector noted the home had one waking night staff and one sleep-in staff with management cover provided for additional support if required. The home is committed to staff training and development and a review of records confirmed a 3 carer had completed NVQ Level 3 in Care with a further 5 have either gained or are working towards an NVQ level 2 in care in addition the service has one member of staff trained as an NVQ assessor. Elmfield House DS0000013637.V342472.R01.S.doc Version 5.2 Page 19 It is recorded in a visitor’s questionnaire that the home and especially the staff make Elmfield House ‘‘ a happy place” and more directly when referring to the staff “and you look after everyone very well’’. The home had a policy on staff recruitment and the manager confirmed prospective employees are vetted before being employed by the home. The inspector sampled staff recruitment files which contained completed application forms, written references, statement of terms and conditions, training records, CRB (Criminal Record Bureau) disclosure information, a recent photograph of the employee and staff have copies of the GSCC (General Social Care Council) code of practice to safeguard the welfare of service users. The inspector noted staff recruitment files were securely stored to promote confidentiality. The home has a robust policy in place for staff induction. The inspector sampled induction training records which were dated and signed by the employee and supervisor and covered the role of the worker, communication, health and safety, policies and procedures, individuality, rights, choice and other relevant and appropriate areas of training to ensure staff are competent to do their jobs. Elmfield House DS0000013637.V342472.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 & 26 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements for the day-to-day management of the home are good. The systems for quality assurance are robust ensuring the home is run in the best interest of the residents. Policies and procedures are designed to safeguard the financial interests of the residents. The arrangements for health and safety are good promoting safe working practices. EVIDENCE: The home has an experienced registered manager who holds a RMA (Registered Manager Award) qualification and an NVQ level 4 in care. The management style ensures that the home provides stability, leadership and direction to the staff team. The inspector noted the home had a management Elmfield House DS0000013637.V342472.R01.S.doc Version 5.2 Page 21 structure with clear lines of communication. During discussions a resident commented ‘‘I am delighted with the home’’ and ‘‘management is acceptable’’. The home had a policy on quality assurance, meetings with the residents and used questionnaires to obtain feedback about the home. The inspector noted the home had a report dated the 20th of October 2006 which reflected the findings from satisfaction questionnaires and available for information. The manager has acted on the recommendations made by the CSCI and policies and procedures have been revised and updated to reflect changing legislation and good practice. The home had a policy statement on money and valuables and the manager confirmed relatives have responsibility for the residents’ money. The inspector noted the manager did not act as appointee and relatives safeguarded the financial interests of service users. The home had a policy on health and safety and staff have training in health and safety, fire safety, food hygiene, infection control and other relevant and appropriate training. Further evidence confirmed the home had a policy on COSHH (Control of Substances Hazardous to Health) with products stored in a locked cupboard to promote safety. Observations confirmed the kitchen appeared clean and hygienic with food hygiene arrangements and practices in place to promote food safety. Elmfield House DS0000013637.V342472.R01.S.doc Version 5.2 Page 22 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 3 X 3 X X 3 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 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Elmfield House DS0000013637.V342472.R01.S.doc Version 5.2 Page 23 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 OP9 Regulation 13(2) Schedule 3.3 (I&k) Requirement Risk assessment must be completed on resident selfmedicating to ensure the service is not deskilling the individual. Timescale for action 22/08/07 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 OP1 Good Practice Recommendations The statement of purpose and service users guide should be expanded to ensure that it accurately reflects the current practices, staff and the qualifications obtained by all the staff. The resident’s files should contain clear information on how the individual’s religious needs are being met. 2. OP12 Elmfield House DS0000013637.V342472.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Elmfield House DS0000013637.V342472.R01.S.doc Version 5.2 Page 25 - 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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