Inspection on 25/07/05 for Elmleigh House Care Home

This inspection was carried out on 25th July 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 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

Elmleigh House Care Home 21/01/09

Elmleigh House Care Home 04/09/07

Elmleigh House Care Home 06/11/06

Elmleigh House Care Home 21/12/05

Elmleigh House Care Home 11/03/05

Elmleigh House Care Home 10/05/04

Elmleigh House Care Home 15/05/03

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Elmleigh House Care Home 133 Vernon Road Kirkby in Ashfield Nottinghamshire NG17 8ED Lead Inspector Jayne Hilton Unannounced 25 July 2005 at 2.00 pm th 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 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 Stationary 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 C02 C53 S8671 Elmleigh V235580 250705 Stage 4.doc Version 1.40 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 478434 Telephone number Fax number Email 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 Ltd Susan Beet Care Home 20 Category(ies) of 20 - Learning Disability registration, with number of places Elmleigh House Care Home C02 C53 S8671 Elmleigh V235580 250705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 11/3/05 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 service users who are over 65, although there is little equipment presently to facilitate their potential increased needs, so placement would have 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 C02 C53 S8671 Elmleigh V235580 250705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on 25th July 2005 at 2pm by Jayne Hilton and was unannounced. The inspection methodology focused on the requirements and recommendations set at the previous inspection and some of the standards not assessed at the previous visit. Seven service users and three staff were spoken with as part of the inspection observations. Records examined included staff rotas, service user plans, fire safety records, training records, business plans, staff personal files, statement of purpose, service user contracts, risk assessments, health and safety records etc. There are plans to develop a respite care service and a variation application for this has been submitted. The inspection was completed at 5.30pm What the service does well: What has improved since the last inspection? Systems are now in place for water outlet temperatures and the prevention of legioenlla. Radiator covers are being fitted on a programme of risk assessment and priority. All windows are now fitted with restrictors. Staff personal files have been organised and the staff team have undertaken training in food and nutrition. Service users now have their own individual bank accounts, which has been achieved after a long and difficult process. The systems for Medicines management have also been improved. Elmleigh House Care Home C02 C53 S8671 Elmleigh V235580 250705 Stage 4.doc Version 1.40 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 C02 C53 S8671 Elmleigh V235580 250705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Elmleigh House Care Home C02 C53 S8671 Elmleigh V235580 250705 Stage 4.doc Version 1.40 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 standard(s) 1, 2, 3, 5 Prospective and existing service users are provided with information confirming that the home can meet their needs and wishes, and have their needs fully assessed prior to admission, and by an ongoing review process. EVIDENCE: A comprehensive combined statement of purpose and service user guide is provided, and was fully assessed as meeting the standard. Service users are issued with a copy on enquiry or admission. The Registered Provider has developed a new assessment document which care plans are to be developed. It is recommended that all existing service users are reassessed, by using this comprehensive document. Extended community Care assessments were seen where appropriate. Person Centred plans are in place and there was noted improvement in their completion. Service users goals are documented. Service user contracts were examined and found to meet the standard. Elmleigh House Care Home C02 C53 S8671 Elmleigh V235580 250705 Stage 4.doc Version 1.40 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 standard(s) 6, 8,9,10 Service users will benefit from the further review and development of their care plans and associated risk assessments. Service users are clearly supported in making decisions about their life styles, and participate in the running of the home wherever able. Service users can be confident in the staff team that they carry out their responsibilities of handling confidential information about them appropriately. EVIDENCE: Person Centred plans have been implemented within the home, but have been recently discussed by the staff team as to how the system could be developed and improved upon. The Inspector identified some areas which had noticeable gaps in information, cross- referencing, and monitoring and evaluation. Where service users are identified as being assisted with independence training, or road safety training; appropriate training programmes, risk assessments and evaluation documents should be in place. Service users’ signatures were evident and most were aware of their notes when spoken with. Service users were observed to make choices during the inspection. Elmleigh House Care Home C02 C53 S8671 Elmleigh V235580 250705 Stage 4.doc Version 1.40 Page 10 Service users said that house meetings are held 2 to 3 monthly where people can air their views, and they also said they are consulted about decorative changes and any proposed alterations. Service user satisfaction questionnaires are completed regularly, and the Directors draw up action plans to address any issues raised. A newsletter is produced by the home with one of the service users acting as “roving reporter.” Although service users do not sit on interview panels, they get to meet all prospective staff and to air their views before their probation period is completed. Policies and procedures are focussed on the needs of service users. Risk assessments were seen in the PCP’s that were examined, however these tended to be around bathing and were in standard formats. Risk assessments should be developed alongside goal plans and in enabling service users to make decisions regarding their daily lifestyle routines. Advice was given about how to improve the documentation and practical process of linking risk assessments to care plans and goals. The manager on duty on the day of the inspection explained that they would be undertaking a review of the care plan structures, daily report system and healthcare monitoring. The manager reported that staff were given information for confidentiality and Data Protection in their induction, and that staff are clear about when information should be passed on and how this is communicated to service users should they make a disclosure. Care plans are stored securely. Elmleigh House Care Home C02 C53 S8671 Elmleigh V235580 250705 Stage 4.doc Version 1.40 Page 11 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 standard(s) 11, 12,15,17 Service users have opportunities for development but the documentation for this is not being put into place. Service users benefit from a varied programme of social and leisure activities. Staff and service users are developing healthy eating programmes in the home. EVIDENCE: As stated previously, goal plans are in place and service users are encouraged to learn skills for independence, the manager explained how the team had assisted a service user to be confident and competent in using public transport, however there was no documentation to evidence this, consequently there was no documentation to prompt a review/evaluation of this newly acquired skill. There are numerous activities accessed by service users, which are mainly community based, including Gateway club, Fellowship meetings, local pubs and clubs are visited, there are summer barbeques and in addition an activities organiser is employed. In house activities have included massage, arts and crafts, keep fit; some service users attend the gym, some have been doing pottery and glass painting. Elmleigh House Care Home C02 C53 S8671 Elmleigh V235580 250705 Stage 4.doc Version 1.40 Page 12 The home now has two minibuses and a people carrier, and a driver is employed to facilitate trips out in the day or evenings. Service users confirmed that they have two holidays a year to Hunstanton and Skipsea. Holidays abroad have also been arranged for some service users. They also reported that a barbeque was held last Thursday. Relatives were invited and are clearly very involved in the home’s meetings and social events. Care plans noted relative contacts, and there are no restrictions imposed on behalf of service users at the moment. The staff team has previously supported a service user’s wishes and implemented risk assessments regarding visiting restrictions in certain circumstances. The staff team have recently undertaken training on food and nutrition, and are currently developing healthy eating programmes with service users. Nutritional assessments are not yet completed in service user care plans. Elmleigh House Care Home C02 C53 S8671 Elmleigh V235580 250705 Stage 4.doc Version 1.40 Page 13 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 standard(s) 18,19,20 Service users receive personal support in a way they prefer and require and which meets their physical and emotional needs, improvement of the care notes and health records will further enhance this. Medicines management in the home is satisfactory. EVIDENCE: Two service users need Insulin injections, one of who self-administers. Staff have had training from the District Nurse on this issue and the nurse has assessed their competence. There is a bath chair in place to assist service users who may need support. Healthcare needs appeared to be met as far as one could tell from the records kept. It is highly recommended that all healthcare checks for dental, optician, chiropodist, speech therapy, GP etc are kept on separate sheets which would provide a running history of events, which is easily trackable and easy to reference for ensuring follow ups. There were records in place for one service user regarding diabetes and epilepsy. Service users did not have medication profiles on their care plans, and a running record of medication changes is recommended as good practice. Annual health checks are now being arranged with the medical practices. The new assessment document covers mental health needs of service users, which will enhance the care plan package. Elmleigh House Care Home C02 C53 S8671 Elmleigh V235580 250705 Stage 4.doc Version 1.40 Page 14 The manager has obtained a copy of the Royal Pharmaceutical Society’s guidance booklet for medicines in the home, and is currently devising updated policies for the management of medicines in the home. Staff are assessed for competency and confidence before having responsibility for dispensing medicines. Temperatures are taken, however the actual temperature reading should be recorded and signed by the person undertaking this. Photographs are used for identification and sample signatures were evident. A drug error policy is posted in the medicines cabinet for staff to access easily should one occur. The home has no controlled drugs currently, but through discussion it was evident that the home was aware of the procedures needed for this to be put into place and monitored. The British National Formulary was in date. Elmleigh House Care Home C02 C53 S8671 Elmleigh V235580 250705 Stage 4.doc Version 1.40 Page 15 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 standard(s) 22,23 Service users know how to make complaints and feel safe in the home. EVIDENCE: There is an appropriate complaints procedure in place (including a signs and symbols version), and this is displayed in the home, the service user guide and each service user’s bedroom. The Directors attend service user meetings and also undertake regular service user satisfaction surveys. There have been no complaints in the past year. Service users interviewed were aware of their right to complain and said they would do so if needed. Standard 23 was fully assessed at the previous inspection and was mostly met apart from an issue regarding appointee-ship and bank accounts for service users. This appears to be now resolved with direct payment being made into service user bank accounts and direct debits for benefits and fee payments, which were examined at this inspection. Elmleigh House Care Home C02 C53 S8671 Elmleigh V235580 250705 Stage 4.doc Version 1.40 Page 16 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 standard(s) 29, Service users have some specialist equipment they require to maximise their independence. Continual assessment of individual needs will ensure this is maintained. EVIDENCE: Where service users require bath seats for mobility and confidence, this is documented in care plans. Grab rails are sites on all baths and non- slip mats are provided. Currently all service users are fully mobile. Call systems are sited in all bathrooms and bedrooms, and have a self-check system inbuilt for any faults that may occur. As service users age or mobility decreases, assessment and care plans should be devised which include the involvement of occupational and physiotherapists as necessary to ensure that the bathing equipment provided continues to be suitable for individual needs. There was a number of requirements set for the environmental standards at the last inspection and these were assessed as met. Elmleigh House Care Home C02 C53 S8671 Elmleigh V235580 250705 Stage 4.doc Version 1.40 Page 17 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34, 35, 36 Service users are supported by an appropriately recruited, trained and supervised staff team. EVIDENCE: An up to date training programme was examined and training provision assessed as satisfactory. Evidence was seen regarding induction and LDAF [Learning disability accreditation framework] for new staff. A sample of three staff personal files were examined and found to be satisfactory. Formal staff supervision is in place and sample of records of this were examined. Elmleigh House Care Home C02 C53 S8671 Elmleigh V235580 250705 Stage 4.doc Version 1.40 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42, 43 The health, safety and welfare of service users are promoted and protected and supported by a competent and accountable management of the service. The completion of the fire safety plan and risk assessment is required. EVIDENCE: Health and safety practices were fully assessed at the previous inspection, requirements set regarding water temperature outlet temperatures, radiator temperatures and legionella, and Control of substances hazardous to health have been addressed and are therefore now met. Risk assessments for safe working practice topics have been carried out and are being further developed. Fires safety records were examined and were satisfactory. The fire plan and fire safety assessment has been commenced but not yet completed fully. The home has a business plan in place and financial systems were made available for inspection. The home is reported to be financially viable and clear management structures are in place. The registered provider and Director’s work at the home on a daily basis, and two registered managers are also in post. Regulation 26 visits are made unannounced by one of the Directors and the reports for these were seen in the home. Elmleigh House Care Home C02 C53 S8671 Elmleigh V235580 250705 Stage 4.doc Version 1.40 Page 19 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 x 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x 3 x Standard No 11 12 13 14 15 16 17 3 3 x x 3 x 2 Standard No 31 32 33 34 35 36 Score x x x 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Elmleigh House Care Home Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 3 C02 C53 S8671 Elmleigh V235580 250705 Stage 4.doc Version 1.40 Page 20 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 YA 42 Regulation 23 Requirement Ensure the fire safety plan and risk asssessments are completed fully. Timescale for action 27/9/05 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. 2. 3. 4. 5. 6. Refer to Standard YA6 YA11 YA17 YA18 YA19 YA29 Good Practice Recommendations Further review and develop the care package for service users and link, care plans, risk assessments and personal goals as is appropriate. Ensure training programmes and risk assessments are appropriatly documented on all occasions. Include nutritional assessments within care plans. Include details of healthcare checks in care plans and seperate out each topic on records sheets. Include medication history profiles and review information within the care package documentation. Continually assess service users regarding the ageing processes, and refer service users as required for occuapational therapy services to ensure disability equipment in the home/aids and adaptations are suitable to meet individual needs. Elmleigh House Care Home C02 C53 S8671 Elmleigh V235580 250705 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Edgeley House Tottle Road Riverside Business Park Nottingham, NG2 1RT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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