This inspection was carried out on 21st December 2005.
CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.
The inspector found no outstanding requirements from the previous inspection report,
but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.
CARE HOME ADULTS 18-65
Elmleigh House Care Home 133 Vernon Road Kirkby in Ashfield Nottinghamshire NG17 8ED Lead Inspector
Judith Avill Unannounced Inspection 21st December 2005 02:10 Elmleigh House Care Home DS0000008671.V276336.R02.S.doc Version 5.1 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 Elmleigh House Care Home DS0000008671.V276336.R02.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 Adults 18-65. 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. Elmleigh House Care Home DS0000008671.V276336.R02.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Elmleigh House Care Home Address 133 Vernon Road Kirkby in Ashfield Nottinghamshire NG17 8ED 01623 753 837 01623 478 434 info@elmleighhomes.com 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) Elmleigh Homes Limited Mrs Susan Jane Beet Care Home 20 Category(ies) of Learning disability (20) registration, with number of places Elmleigh House Care Home DS0000008671.V276336.R02.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 25th July 2005 Brief Description of the Service: Elmleigh house comprises a two-storey adapted property with a new extension on the same site as two detached two-storey houses, each housing three service users, and a self contained house for one service user. A new separate office has been built on the site, and possible further developments are planned to provide a respite care bed. The home currently provides care for up to twenty residents who have learning disabilities; it also caters for 4 service users who are over 65, some equipment presently is in place to facilitate their potential increased needs, so placements need to be carefully considered. Unless a ground floor bedroom were available the home would not be suitable for people with mobility difficulties. The home sits unobtrusively in a residential street, which is sited close to local shops, transport and other facilities. There is a private car park and a driveway at the property where visitors can park; it is also possible to park on the street. There are pleasant gardens surrounding the property. Elmleigh House Care Home DS0000008671.V276336.R02.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The second unannounced inspection took place on the 21st December 2005 at 2.10 pm by Judith Avill. The inspection focused on the requirements and recommendations issued from the previous inspection and some of the standards not assessed at the previous visit. Records examined included staff rotas and files; fire training record, medication records, risk assessments and residents personal files. Application has been made to increase the home to accommodate 21 residents. Progress on the extension of bedrooms was viewed during the visit. The inspection was completed at 4.25 pm. What the service does well: What has improved since the last inspection?
Fire safety plan and risk assessments are in place. Assessments on the health and ageing needs of residents have been completed. Equipment and adaptations to meet individual needs have been provided. Elmleigh House Care Home DS0000008671.V276336.R02.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. Elmleigh House Care Home DS0000008671.V276336.R02.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Elmleigh House Care Home DS0000008671.V276336.R02.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were inspected at the last inspection EVIDENCE: Elmleigh House Care Home DS0000008671.V276336.R02.S.doc Version 5.1 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 7& 9 Service users are encouraged and supported to make decisions about their lives. Risk assessments on medical conditions were not recorded. EVIDENCE: Person centred plans viewed evidenced service users involvement in making decisions about their activities, entertainment and independence training and financial arrangements. Residents signatures were recorded in the person centred plans. Person centred plans are stored securely and service users signatures were evident in plans viewed. Risk assessments on individual residents medical conditions and action to be taken by staff were not recorded. Elmleigh House Care Home DS0000008671.V276336.R02.S.doc Version 5.1 Page 10 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 16 Service users are involved in appropriate activities and are respected by staff. EVIDENCE: Details of individual leisure and interest were evidenced in person centred plans. 8 service users were spoken with during the inspection. They told the inspector that they were respected by staff and managers at the home and were involved in making decisions, offered choices to be alone or join in activities. Staff reported that service users are offered a key to their room and the individual unit they reside in. Elmleigh House Care Home DS0000008671.V276336.R02.S.doc Version 5.1 Page 11 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Medication management at the home is satisfactory. The remaining key standards were inspected at the last inspection. EVIDENCE: Medication practices were checked in one of the units. Method of storage, administration and recording were satisfactory. Medication records include photographs details of the effects of medication and methods of administration. Elmleigh House Care Home DS0000008671.V276336.R02.S.doc Version 5.1 Page 12 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Residents are safeguarded from abuse in accordance with local adult protection guidelines. Residents can be confident that their concerns will be listened to and addressed in an appropriate timescale. EVIDENCE: The home has a complaints procedure in place. No complaints have been recorded since the last inspection. Resident’s spoken with said they would raise concerns with the proprietor and manager and senior staff. Staff files viewed evidenced references and checks are obtained prior to appointment of new staff. Two resident’s personal finances were checked, only one signature was seen on the records viewed. It is recommended that two staff signatures be obtained for all transactions. Elmleigh House Care Home DS0000008671.V276336.R02.S.doc Version 5.1 Page 13 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,26 Service users have some specialist equipment they require to maximise their independence. Continual assessment of individual needs will ensure this is maintained. EVIDENCE: Residents over 65 years have adaptations to meet their needs at the time of the inspection. The home was clean well maintained safe and free from offensive odours provided sufficient and suitable heat and ventilation on the day of inspection. Individual bedroom’s viewed were well personalised. Elmleigh House Care Home DS0000008671.V276336.R02.S.doc Version 5.1 Page 14 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 Recruitment practices ensure the residents are protected. Training records were well maintained EVIDENCE: Two staff files were seen and included two references and satisfactory checks completed before commencement of employment. Staff files viewed were well- organised and included records of training. Elmleigh House Care Home DS0000008671.V276336.R02.S.doc Version 5.1 Page 15 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home is well managed. Feedback is sought from residents and relatives. Policies and procedures are in place, which comply with current legislation. Records of names of staff attending fire drills are not maintained. EVIDENCE: The home is run as a family business, managed by the registered manager, responsible individual and other family members. Residents said they are able to discuss anything with all members of staff. At induction and new staff read policies and procedures and sign that they have read and understood. During discussion it was recommended that staff record which individual policy and procedure they have read and understood. Records are maintained of fire drills attended by staff but there is no record of which staff attended. Elmleigh House Care Home DS0000008671.V276336.R02.S.doc Version 5.1 Page 16 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 X 3 X 4 X 5 X X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 2 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 2 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 X 3 X 3 3 X 2 X Elmleigh House Care Home DS0000008671.V276336.R02.S.doc Version 5.1 Page 17 NO 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 YA9 Regulation 13 Requirement The registered person must ensure that risk assessments are recorded on residents medical conditions and include action to be taken by staff Immediate requirement issued The registered person must ensure that details of staff attending fire drills are recorded Timescale for action 21/12/05 2 YA42 17 09/01/06 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. 2. Refer to Standard YA23 YA40 Good Practice Recommendations Provide two signatures on all financial transactions Provide staff signatures for individual policies and procedures read and understood by staff Elmleigh House Care Home DS0000008671.V276336.R02.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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