Inspection on 15/11/05 for Elmglade

This inspection was carried out on 15th November 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Elmglade 19/06/07

Elmglade 03/04/06

Elmglade 23/05/05

Elmglade 06/07/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Elmglade 399 London Road North Cheam Surrey SM3 8JH Lead Inspector Deborah Yapicioz Unannounced Inspection 15th November 2005 11.50 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 Elmglade DS0000007141.V265830.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. Elmglade DS0000007141.V265830.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Elmglade Address 399 London Road North Cheam Surrey SM3 8JH 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) 020 8393 5593 020 8393 5593 nihal888@hotmail.com Mr Tissa Nihal Atapattu Mrs Nelum Vijayanthi Atapattu Mr Tissa Nihal Atapattu Care Home 20 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (10) of places Elmglade DS0000007141.V265830.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd May 2005 Brief Description of the Service: Elmglade is owned and managed by both Mr and Mrs Atapattu. The home is now registered with the Commission to provide personal care and support for up to ten older people, not falling within any other category, and ten older people with associated dementia/cognitive impairments. The home itself is a large detached property (formally two houses joined together) situated in a residential area of North Cheam. Built over two floors it comprises of sixteen single and two double bedrooms. There are two separate dinning areas/open plan lounges on the ground floor and sufficient numbers of bathroom and toilet facilities are conveniently located throughout the home. The kitchen and laundry facilities are well equipped and clean. The home also has a well-maintained garden with a fishpond. There is ample space for parking vehicles in the front drive. Elmglade DS0000007141.V265830.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the homes second inspection for the year 2005/6. The inspection was unannounced and took place on 15th November 2005. The home was inspected under the National Minimum Standards Care Homes for Older People. A previous inspection took place on 23rd May when most of the standards that the Commission for Social Care Inspection considers as key standards were inspected. Methods of inspection included meeting with the service users, a partial tour of the premises, and observations of contact between staff and service users as well as talking to members of staff. The inspector would like to thank the service users and the staff team for their help in facilitating the inspection. There was limited access to records held by the home as the home owner/manager was on leave at the time of the unannounced inspection. This made it difficult to ascertain compliance with previous requirements. A further visit will take place before the end of the inspection year to look at staff and supervision records. What the service does well: What has improved since the last inspection? The home has had a problem with subsidence, which has been monitored over recent years. The house has been underpinned since the last inspection. Some areas of the home have been redecorated since the last inspection. Elmglade DS0000007141.V265830.R01.S.doc Version 5.0 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. Elmglade DS0000007141.V265830.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 Elmglade DS0000007141.V265830.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, The home provides information and introduction opportunities for prospective service users and their families to make an informed choice about moving to the home. EVIDENCE: The home has a statement of purpose and service users guide in place, which, are given to any prospective service users. The homes latest report is available on request. A needs assessment is requested from the referring care manager and the home management team also completes the in-house assessment to ensure that the home is suitable and the service users needs can be met. Residents are invited to view the home and to stay for a trial period before a final decision is made for the placement to be long term. Most residents have involved relatives who also participate in this process. This home does not offer intermediate care therefore standard six does not apply. Elmglade DS0000007141.V265830.R01.S.doc Version 5.0 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, The service users have individual care plans, which if used in a more appropriate way will ensure the service users changing needs are met. Medication records at the home are not filled in correctly which could potentially place service users at risk. EVIDENCE: The home has a system in place for updating care plans. Care staff at the home updates the records on a regular basis, however the quality of the recording is not good in that it does not provide much information on how the service users individual needs were met and what care was provided. On the day of the inspection, regularly used statements used on the ‘Cardex’ system included “no problems” and “nothing special” which give no detail of how the service users emotional and physical needs are met by the home. The home manager must ensure that recording on the service users plans are more detailed, use appropriate language and reflect how the service users needs are being met at the home. It is the homes policy that all medicines administered are recorded on Medicine Administration Record Sheets. On the day of the inspection the medication records were incomplete. This was a requirement of the previous announced inspection and is a matter of concern that there are still gaps in the records. The home owner/manager must ensure that all medication records are complete in the future. Elmglade DS0000007141.V265830.R01.S.doc Version 5.0 Page 10 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 has an open visitors policy to ensure family links are maintained. Dietary needs are catered for with meals that are nutritionally well balanced, nicely presented, and based on the service users food and drink preferences, providing them with daily variation and healthy eating options. EVIDENCE: There is an open visitors policy and families are welcome to visit at any time, although the service users can choose who they wish to see. One of the service users was celebrating her 90th Birthday on the day of the inspection. Her family were due to visit her to bring her a cake and presents to celebrate her birthday. Visitors can be seen in any part of the home including bedrooms. The service users at Elmglade are offered three meals a day as well as morning and afternoon tea’s. Any dietary needs are recorded in the service users care plan. On the day of the inspection the main meal on offer was beef stew with seasonal vegetables. One of the service users does not eat meat and an alternative meal of fish was available. The inspector spoke with a group of service users who commented positively on the food offered at the home. Elmglade DS0000007141.V265830.R01.S.doc Version 5.0 Page 11 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 There is complaints policy and procedure, which facilitates good access to the complaints system for the residents, their family or their representatives. The home has the appropriate policies in place to ensure the protection of vulnerable service users. EVIDENCE: Elmglade has a complaints procedure, which outlines how a complaint is dealt with and timescales for action. The home keeps a record of any comments or complaints made about the service. There have been two complaints referred directly to the Commission for Social Care Inspection over the last twelve months. As a result of those investigations the inspector has set a number of requirements The home has a vulnerable adults policy and any concerns would be referred in line with the Vulnerable Adults Procedure. The home has a copy of the local authority Adult Protection Policy on site. Elmglade DS0000007141.V265830.R01.S.doc Version 5.0 Page 12 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): 24,25,26 Generally the home is homely and provides the service users with comfortable surroundings that they say meets their needs. A locked door policy needs to be developed based on risk assessment to give the service users greater freedom. EVIDENCE: The home was originally two semi-detached houses that have been joined together. The home is built over two floors and there is no lift. Access to the second floor for service users unable to use the stairs is via a stair lift fitted to the staircase nearest the kitchen. The home has two large lounge/dinning areas on the ground floor, which are suitable for the range of interests and activities preferred by service users. Communal areas appeared comfortable, and were furnished appropriately to a satisfactory standard with adequate facilities for service users and their visitors to meet in private. On the day of the inspection there was still a smell of urine on the ground floor entrance hall area of the home. This issue has been discussed with the homeowner on previous inspections. At previous inspections the home the home manager has been asked to develop a “localised” locked door policy to protect individual service users Elmglade DS0000007141.V265830.R01.S.doc Version 5.0 Page 13 rights to choice of freedom and movement. The policy was not available on the day of the inspection; this requirement has been carried over from previous inspections and needs to be actioned. The homeowner must send a copy of the policy to the Commission for Social Care Inspection croydon office. Elmglade DS0000007141.V265830.R01.S.doc Version 5.0 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): 29 The appropriate Criminal Records Checks for all staff are not all in place and this may put residents at risk from employees who are unsuitable to work with vulnerable adults. EVIDENCE: Staff files at the home are not kept in good order, which made it difficult to ascertain if the correct information is on file. At the last announced inspection 23rd May 2005 not all staff had a copy of their Criminal Records Check on their files. This was discussed with the homeowner at the announced inspection and a further visit in June. The homeowner explained that he has recently had some problems with the “umbrella organisation completing the homes Criminal Records Checks. As a result of this the home manger decided to apply directly for staff Criminal Records checks. All staff members have had Criminal Records Checks applied for, although they have not all been seen by the inspector. The staff records were not available for inspection at the time of this visit. A follow up visit will be arranged with the homeowner to ascertain compliance with this requirement. The homeowner was also asked to insure that copies of all information relevant to the immigration status of staff members at the home are kept on file. A further requirement was made stating that all staff must be given a copy of their terms and conditions (contract) of employment at the home and a signed copy of the working time directive agreement. This will also be checked on the follow up visit. Elmglade DS0000007141.V265830.R01.S.doc Version 5.0 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): 32,36,37 Although the management style appears open with clear lines of accountability, record keeping, and administration at the home is poor this makes it difficult to ascertain that service users needs are being met. Staff supervision is spasmodic and appears to be on an “ad hoc” basis, which could have an adverse effect on service users care. EVIDENCE: Elmglade DS0000007141.V265830.R01.S.doc Version 5.0 Page 16 Mr Atapattu, the registered manager, is a psychiatric nurse (RMH) and has substantial experience in a care setting. There appears to be little delegation at the home, which means that it is difficult to access records and ascertain compliance with requirements when he is not on duty at the home. This unannounced inspection took place whilst the manager was on leave. Administration is not of a good standard and recording on service users file is brief. The home has small chalkboards on the wall of the dining room, which are supposed to have the days date, lunch menu and the daily activity listed. The inspection took place on 15th November; the date displayed on the chalkboard was 23rd May. At the previous inspection it was evident that the staff supervisions were not being carried out as often as required. The recorded supervision sessions should be kept in greater detail and cover all aspects of practice; philosophy of care in the home, and career development needs of the staff. It was suggested at previous inspections that it would be easier to keep the level of supervisions up to date if other senior staff were trained to carry out supervisions. Fire drills have been taking place on a regular basis. The fire risk assessment was not available for inspection. A fire blanket was seen in the kitchen and extinguishers are placed around the home. Elmglade DS0000007141.V265830.R01.S.doc Version 5.0 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 3 X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 X X X X X 2 3 3 STAFFING Standard No Score 27 X 28 X 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 2 X X X 2 2 X Elmglade DS0000007141.V265830.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? Yes 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 OP24 Regulation 13(4)15(1 17(1) 3.3 Requirement The registered person must ensure the home develops a ‘localised’ locked door policy that protects individual service users rights to choice and freedom of movement. In addition, all the homes service users who are willing and able to access the keypad system must be provided with a key and/or the code, unless a risk assessment suggests otherwise The registered person must ensure that recorded supervisions are kept in greater detail and cover all aspects of practice; philosophy of care in the home, and career development needs of the staff Staff files must contain all the information required under schedule two of the care standards act. Recorded supervisions must take place at least six times a year. The home manager must ensure all medication records are correctly filled in at all times The home manager must ensure DS0000007141.V265830.R01.S.doc Timescale for action 15/11/05 2 OP36 18(2) 15/11/05 3 OP29 17(2) 2, 4. 18(1) 17(1)3 3.(I) 19.(5) 15/11/05 4 5 6 Elmglade OP36 OP9 OP29 15/11/05 15/11/05 15/11/05 Page 19 Version 5.0 17(2) 2,4 7 OP29 17(2) 4 7 8 OP29 4 reg 6. (d)(e)(f) copies of all information relevant to the immigration status of staff members at the home are kept on file. The full name of all staff members at the home must be used on the duty roster and the number of hours worked by each staff member. All staff must be given a copy of their terms and conditions (contract) of employment at the home and a signed copy of the working time directive agreement. 15/11/05 15/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP32 Good Practice Recommendations Staff files at the home are not kept in good order, which made it difficult to ascertain if the correct infrmation is on file. The home manager should ensure all staff records at the home are kept in a more orderly manner. The inspector recommends that the registered person should consider training sufficient numbers of the senior staff team carry out supervisions to ensure each member of staff receives at least six a year 2 OP37 Elmglade DS0000007141.V265830.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Elmglade DS0000007141.V265830.R01.S.doc Version 5.0 Page 21 - 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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