Inspection on 27/09/05 for Elmhurst Residential Home

This inspection was carried out on 27th September 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

Elmhurst Residential Home 27/06/07

Elmhurst Residential Home 21/09/06

Elmhurst Residential Home 24/05/05

Elmhurst Residential Home 21/10/04

Elmhurst Residential Home 15/06/04

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 Elmhurst Residential Home 81-83 Holden Road North Finchley London N12 7DP Lead Inspector Tom McKervey Unannounced Inspection 27th September 2005 09:45 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 Elmhurst Residential Home DS0000010404.V249500.R02.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. Elmhurst Residential Home DS0000010404.V249500.R02.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Elmhurst Residential Home Address 81-83 Holden Road North Finchley London N12 7DP 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 8445 6501 020 8446 5419 Mrs Bernadette Tisdall Miss Elaine Margaret Tisdall Care Home 30 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (30) of places Elmhurst Residential Home DS0000010404.V249500.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th May 2005 Brief Description of the Service: Elmhurst is a privately run care home, first registered in 1967 for 30 older people, some of whom may have dementia. The stated aim of the home is to promote the dignity and privacy of service users who are frail and have dementia, thus ensuring their maximum quality of life. The home is a large two storey, detached building. The bedrooms are located on both floors. There are twelve single bedrooms and nine double bedrooms. Three bedrooms have en-suite facilities. A passenger lift provides access to the first floor. The communal lounge, dining area, office, laundry and kitchen are all on the ground floor. There is a car park at the front of the building and there is an attractive garden at the rear of the building, which is partly paved and accessible to service users. The home is located in a pleasant residential area of North Finchley and close to Woodside Park tube station. It is well served by a variety of shops, restaurants, transport and other community facilities located along Ballards Lane and the High Road, North Finchley. Elmhurst Residential Home DS0000010404.V249500.R02.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was completed in a period of three hours and fifteen minutes. The registered manager was on maternity leave at the time of the inspection and the deputy manager and senior carer assisted the inspector in the process. The inspection consisted of a tour of the premises observation of, and discussions with, the staff and residents. Residents’ case files and documents relating to the running of the home were also examined as part of the inspection process. What the service does well: What has improved since the last inspection? What they could do better: Care plans must be kept at the home and available for staff for guidance, and better attention to recording medication is required. Appropriate storage should be provided for unused Zimmer frames, and not stored in one resident’s Elmhurst Residential Home DS0000010404.V249500.R02.S.doc Version 5.0 Page 6 bedroom. Several maintenance issues must be addressed, particularly regarding a fire door on the first floor. The manager must inform the Commission for Social Care Inspection in writing that she is absent from the home for more than 28 days, and must also ensure that her deputy has access to all records and documents. These documents must be available for inspection while the manager is on extended leave. 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. Elmhurst Residential Home DS0000010404.V249500.R02.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 Elmhurst Residential Home DS0000010404.V249500.R02.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): 3, 4 & 5. (Standard 6 does not apply). Appropriate assessments are carried out for potential users of the service, and prior visits are arranged, to enable service users and their representatives to assess the suitability of the home. EVIDENCE: The case files of four recently admitted residents were examined. Where local or health authorities funded the person, full needs assessments had been carried out. Assessments were also provided for these residents, and for those who were privately funded, by the senior staff in the home. Follow-up reviews were carried out after a six-week trial period to determine if the placement was appropriate. At the time of the inspection there were two vacancies. There was evidence in the diary of visits to the home by relatives prior to service users coming to live there. Those residents who were spoken to, and were able to express their opinions, stated that they were very satisfied with the service. Elmhurst Residential Home DS0000010404.V249500.R02.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, 8, 9, & 10 A range of healthcare professionals is meeting the healthcare needs of service users. More attention is needed to ensure the safe administration of medicines. The privacy of a resident is being compromised by their room being used for the storage of Zimmer frames. EVIDENCE: It was intended to examine the care plans of the four new residents. However, the inspector was informed that two of these documents had been taken away for them to be updated by the deputy manager at home. A requirement is made for care plans to always be available in the home for staff to refer to. The care plans that were seen were well constructed and clear, and they were reviewed monthly. Manual handling risk assessments had been carried out. The files contained records of healthcare appointments, including visits by the G.P, and district nurse, opticians and dentist. The weights of the residents were being monitored monthly. The accident book was appropriately completed and was up to date. Elmhurst Residential Home DS0000010404.V249500.R02.S.doc Version 5.0 Page 10 None of the service users were self-medicating. With one exception, where a medication had not been signed for, the administration of medicines records was accurately maintained. A requirement is made to address this error. Two residents were on Controlled Drugs. These were recorded in a special register. The tablets were counted and tallied with the register. It was noted that several Zimmer frames were being stored in a bedroom, situated by the lounge. As this bedroom was currently occupied, this is an abuse of that resident’s privacy and a requirement is made to provide appropriate storage facilities for these frames. Elmhurst Residential Home DS0000010404.V249500.R02.S.doc Version 5.0 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, 13, 14 & 15 The residents have a good quality of life, and are offered appropriate activities, which they can choose to participate in. Religious and cultural needs are being met, and the food provided is wholesome and well presented. EVIDENCE: There is an activities programme for residents that include music, exercise, and art and craft sessions. An occupational therapy session is held twice a week. The therapist conducts sessions on keep-fit, reminiscence and reality orientation. A mobile library visits the home and some residents attend the “Wednesday Club” in a nearby church hall. There were records of residents going to church, and religious services being held once a month in the home. Elmhurst Residential Home DS0000010404.V249500.R02.S.doc Version 5.0 Page 12 There is and open visiting policy, with relatives able to visit whenever they wish, and the visitors book indicated frequent visits to the home Residents who were spoken to stated that they were able to rise and go to bed when they preferred, and that they could choose their meals. Some residents preferred not to participate in organised activities and would rather stay in their rooms, reading or watching television. Evidence of choices and decisions was seen in residents’ daily records. The kitchen was clean, well equipped and well stocked. The record of daily fridge and freezer temperatures was satisfactory. The meals eaten by residents were recorded. The menu was varied and balanced, and residents stated that they were generally satisfied with the quality and quantity of food served. A Jewish resident was provided with an appropriate choice of meals. Elmhurst Residential Home DS0000010404.V249500.R02.S.doc Version 5.0 Page 13 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 Service users’ best interests and welfare are protected by appropriate procedures, and by staff training. EVIDENCE: There is an appropriate complaints procedure in place and residents said that they were of their right of complaint. However, they were satisfied with the service they received. The last recorded complaint was in May 2005, which had been properly responded to. Staff who were spoken to, were knowledgeable about abuse issues and how to report any concerns. They had also received training in adult protection procedures. Elmhurst Residential Home DS0000010404.V249500.R02.S.doc Version 5.0 Page 14 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, 21, 22, 23, 25 & 26 The standard of maintenance is generally good and the residents live in a homely and pleasant environment. A service user’s comfort is compromised by poor ventilation in their bedroom, and a rug in the lounge is a potential health and safety hazard. EVIDENCE: A tour of the premises was carried out. There is a good standard of internal décor throughout the home. There were attractive hanging flower baskets at the front of the home. The garden looked very attractive and was well maintained. The home was generally well maintained; however, the window frames at the front of the building need repainting. There was a cracked windowpane in room 18, and only one window could be partially opened. A large rug in the communal lounge was frayed in places and needs to be repaired or disposed of. These issues were identified at the last inspection, and a requirement to address these matters is restated in this report. Elmhurst Residential Home DS0000010404.V249500.R02.S.doc Version 5.0 Page 15 Two further requirements are made to repair or replace the patio doors at the rear of the building, which are very difficult to open, and to ensure that the fire door between Rooms 14 & 15 closes properly to prevent the spread of fire. Several bedrooms were visited. They were attractively decorated and there was evidence of personal possessions. There were portable screens in the double rooms to ensure privacy. The bathrooms and toilets were accessible and were furnished with appropriate aids and adaptations to assist mobility. At the time of the inspection, the home was clean and tidy and there were no unpleasant odours. There is a control of infection policy in place and disposable aprons and gloves are provided for staff. Elmhurst Residential Home DS0000010404.V249500.R02.S.doc Version 5.0 Page 16 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, 28 & 30 There are sufficient numbers of staff on duty at all times and staff are being appropriate training to meet residents’ needs. EVIDENCE: The staff rota was examined. There is a deputy manager and a senior carer in post. The rota showed that six care staff are normally on duty during the daytime, and three waking night staff. The care staff are supported by cooks, cleaners and a laundry worker. The deputy manager said that two staff had recently attained National Vocational Qualification level 2, and four other staff were starting training in the next week. Foundation training and training in dementia care had also taken place recently. Elmhurst Residential Home DS0000010404.V249500.R02.S.doc Version 5.0 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): 31, 32, 36, 37 & 38 It is important to ensure that in the prolonged absence of the registered manager, the deputy has access to all records and important documents in the home. EVIDENCE: At the time of the inspection, the registered manager was on maternity leave and the home was being managed by the deputy and senior carer. The Commission for Social Care Inspection has not been formally notified about the manager’s leave and a requirement is made to address this issue. Residents and staff who were spoken to, said that they were confident that the home was being managed effectively in the manager’s absence. However, it was not possible to examine staff recruitment, supervision records and residents’ contracts, as the deputy manager did not have the keys to the filing cabinets where these were held. A requirement is made that access to all Elmhurst Residential Home DS0000010404.V249500.R02.S.doc Version 5.0 Page 18 records in the home is delegated to a senior person when the manager is absent for long periods. Staff said that they had team meetings and described the supervision that they now receive regularly. One member of staff said; “ Supervision is useful as you can discuss personal problems and training needs, and managers can give you feedback about your work”. The temperatures of fridges and freezers were recorded daily. The fire log showed that the alarms were tested weekly and the fire extinguishers had been serviced in the last year. However, as commented under Standard 19, the fire door on the first floor does not close fully which constitutes a fire hazard. Elmhurst Residential Home DS0000010404.V249500.R02.S.doc Version 5.0 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 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 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 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X X 2 2 Elmhurst Residential Home DS0000010404.V249500.R02.S.doc Version 5.0 Page 20 Yes Are there any outstanding requirements from the last inspection? 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 OP7 7 Regulation 15(2)(1) Requirement The registered person must ensure that residents’ care plans are available for staff at all times in the home. The registered person must ensure that staff sign for all administered medicines. The registered person must provide appropriate storage for Zimmer frames. The registered person must ensure that: 1.The rug in the lounge is disposed of. 2. The woodwork at the front of the building is repainted. 3. The windowpane in Room 18 is replaced and at least two windows in that room can be opened. This requirement is restated form the last inspection. The previous timescale was 31/7/05 The registered person must repair or replace the patio doors at the rear of the building. The registered person must ensure that the fire door DS0000010404.V249500.R02.S.doc Timescale for action 31/10/05 2 3 4 OP9 OP10 OP19 13(2) 12(4)(a) 13(4) & 23(2)(b) 31/10/05 30/11/05 31/12/05 5 6 OP19 OP38OP19 13(4) & 23(2)(b) 13(4)(a) 31/01/06 31/10/05 Elmhurst Residential Home Version 5.0 Page 21 7 OP31 38(1)(b) 8 OP37 17(3)(b) between Rooms 14 & 15 closes properly. The registered person must inform the Commission for Social Care Inspection in writing when the manager is absent from the home for more than 28 days. The registered person must ensure that all records are available for inspection when the manager is on prolonged leave. 31/10/05 31/10/05 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 Elmhurst Residential Home DS0000010404.V249500.R02.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Southgate Area Office Solar House, 1st Floor 282 Chase Road Southgate London N14 6HA 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 Elmhurst Residential Home DS0000010404.V249500.R02.S.doc Version 5.0 Page 23 - 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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