Inspection on 04/09/07 for Elmleigh House Care Home

This inspection was carried out on 4th September 2007.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Elmleigh House Care Home 21/01/09

Elmleigh House Care Home 06/11/06

Elmleigh House Care Home 21/12/05

Elmleigh House Care Home 25/07/05

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 Inspection 4th September 2007 02:10 Elmleigh House Care Home DS0000008671.V348911.R01.S.doc Version 5.2 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.V348911.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V348911.R01.S.doc Version 5.2 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 22 Category(ies) of Learning disability (22) registration, with number of places Elmleigh House Care Home DS0000008671.V348911.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Elmleigh Homes Limited is registered to provide accommodation and personal care at 131a; 131b and 133 Elmleigh House Care Home for service users of both sexes who primary needs fall within the following categories and numbers: Learning Disabilities (22) 6th November 2006 Date of last inspection Brief Description of the Service: Elmleigh house comprises a two-storey adapted property with an extension on the same site as two detached two-storey houses, one housing three residents, the second housing four residents, and a self contained house for one service user. A separate office is situated on the site. The home currently provides care for up to twenty-one residents who have learning disabilities; it also caters for five 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. Information was provided by the registered person about fees charged at the home on the 5/9/2007, which range from £377.50 per week. Additional fees are charged for individuals with higher dependency needs. Extras were hairdressing, personal newspapers and toiletries. Information about the home can be found in the manager’s office. Elmleigh House Care Home DS0000008671.V348911.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service users and their views on the service provided. This process considers the provider’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provision that need further development. This inspection was conducted unannounced on Tuesday 4th September 2007 and was concluded on Wednesday 5th September 2007. Seven hours in total were spent at the home. On this occasion an Expert by Experience who spoke with three service users, contributed to the inspection process and provided a separate report, accompanied us. Comments and observations are reflected in this report The main method of inspection used was called ‘case tracking.’ This involves selecting six service users and looking at the quality of the care they receive by talking to them, examining their care files and discussing how support is offered to them by staff members. Six members of staff, the manager and two of the Registered Providers were spoken with as part of this inspection, documents were read and medication inspected to form an opinion about the quality of the care provided to residents. Prior to completing this visit the inspector assessed the homes previous inspection reports, the service history including complaints and adult protection referrals. What the service does well: Currently staff are developing new care plans and reviewing the assessed needs of individuals as part of the process. The few care plans that were in place were well detailed including service user likes and wishes. The philosophy of care mentioned a non-discriminatory approach and the document had a clear complaints process. Elmleigh House Care Home DS0000008671.V348911.R01.S.doc Version 5.2 Page 6 Observation of staff practice on the day of the inspection demonstrated that staff interacted with service users in a respectful manner and engaged with them within the daily routines and whilst undertaking personal care. Service users interviewed said they were happy living at the home and that staff were nice and that they enjoyed their meals. Service users receive some personal support in the way they prefer and require and their healthcare needs were mostly met, they live in a homely, comfortable and clean environment and are supported by a trained, supervised and committed staff team. Robust recruitment practice ensures service users safety. What has improved since the last inspection? What they could do better: Provide better evidence to show how the needs of service users are being met including those with challenging behaviour and those of service users that live with them of how their needs are being supported. Elmleigh House Care Home DS0000008671.V348911.R01.S.doc Version 5.2 Page 7 Provide more evidence of how you are meeting the communication needs of service users. Care plans and risk assessments need to be implemented as specified, as to how the service users needs in respect of his health and welfare are to be met. Documentation of monitoring in all areas requires improvement, as does the management of medication to ensure service users needs are fully met. Service users do not have their own copy of the service user guide and this needs to be addressed. Ensure that service users receive personal support in the way they prefer. Consult service users about their meal choices. Provide service users with a choice as to when they go shopping. A staffing review is needed to ensure that staffing levels, skill mix is appropriate to meet the needs of all service users. More training for staff is needed to ensure service users needs are fully met. The management and administration systems in the home require improvement. Safeguarding and financial record keeping, require improvement to ensure service users are fully protected from harm. Nine requirements are made and twenty good practice recommendations. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Elmleigh House Care Home DS0000008671.V348911.R01.S.doc Version 5.2 Page 8 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.V348911.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users have their needs assessed and are issued with a contract, however they do not have their own copy of the service user guide and this needs to be addressed. EVIDENCE: A combined Statement of Purpose/ Service User Guide was available in the manager’s office; however there was no evidence found that service users had received their own copy. The document did not contain details of the scale of charges. The philosophy of care mentioned a non-discriminatory approach and the document had a clear complaints process with reference to the commission. Information was not however available in picture symbol formats. A copy of the inspection report was viewed in the managers office, but there was no information about this in the Statement of Purpose/ Service User Guide therefore it is recommended that the registered person explores ways to ensure service users and visitors to the home are informed how they can access a copy of the inspection report. Elmleigh House Care Home DS0000008671.V348911.R01.S.doc Version 5.2 Page 10 The terms and conditions/contract between the home and service user were seen within the plan. Currently staff are developing new care plans and reviewing the assessed needs of individuals as part of the process. Assessments undertaken prior to people moving to the home were viewed. Staff need to ensure that the new care plans are derived from all information in the assessments. There was limited evidence of development in meeting the communication needs of service users and it is recommended that the home consider production of communication tools such as pictures and symbols. Elmleigh House Care Home DS0000008671.V348911.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7, 8 and 9 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users needs are assessed and generally reviewed, however there was not sufficient evidence to make the same professional judgement in relation to the needs of service users being met. EVIDENCE: Although evidence was seen that a new care planning system was in place and being developed, there was not sufficient evidence available to determine whether service users needs were being met in respect of the following priority areas: • • • Pressure Area/tissue viability Management of Diabetes Dementia Care DS0000008671.V348911.R01.S.doc Version 5.2 Page 12 Elmleigh House Care Home • • • • • Epilepsy Management of Continence Mental Health needs Older persons needs Challenging behaviour A Previous requirement with timescale of 30/12/06 has not been met. The few care plans that were in place were well detailed including service user likes and wishes. There was evidence that input from the psychologist and consultant psychiatric was already in place or being sought in relation to individuals challenging behaviour. There was evidence within some of the service users care notes that they are involved in advocacy groups and staff confirmed this and said that the service users were self- advocating within their home environment. One resident said she used to go for self-advocacy meetings but does not go any more. We left a contact for the Self-advocacy group for the region. General risk assessments were seen for holidays, bathing and challenging behaviours and manual handling but otherwise there were no specific risk assessments in place for individuals. Elmleigh House Care Home DS0000008671.V348911.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users enjoy their lifestyle however there was not sufficient evidence to make the same professional judgement in relation to whether their individual aspirations are being supported. The food provided is nutritious but service users are not consulted about their meal choices. EVIDENCE: Three service users who were interviewed said they were happy living at the home and that staff were nice. All service users go to the same Day Centre on the mini bus. Staff said that even though some people are of retirement age, they choose to still attend. Staff reported that some service users have special friends or relationships and that they mutually visit each other’s homes. There was however no Elmleigh House Care Home DS0000008671.V348911.R01.S.doc Version 5.2 Page 14 care/support plans in place in respect of supporting people with their relationships. Service users have various contacts with relatives and where possible relatives are involved in care reviews. There were no issues raised in relation to sexual relationships between service users or their friends. Service users can see their visitors in private. They have a quiet room (blue room), which they can use to entertain their visitors. However there was a general feeling of lack of privacy in the home. The house phone is located in the dining room. While we were there, one service user received a phone call from her mother and carried on with her conversation with others listening in. One service user took us to her bedroom. We realised that the resident did not have a lock on the door. She said she did not have a key to lock her room. However most of the privacy door locks in service users bedrooms and bathroom were found not to be in working order which compromises service users privacy. Service users did not have a choice as to when they went shopping as all shopping trips are organised by the manager and they go as group in the minibus. The provider said that service users have two holidays a year and service user meetings showed discussion about these, however holidays are pre - chosen then offered to service users, who go as a group. There was also a lack of evidence of opportunities or support for individual service users to follow individual interests and hobbies. A staff member said staff on duty on evenings and weekends may arrange a pub outing for a group of people and that college courses are arranged at the home. The variety of food recorded appeared balanced and nutritional. Food stocks were ample and fresh fruit was seen in the kitchens. There did not seem to be any personal choice and service users were not involved in planning the menu. One staff member said ‘we generally know what they like to eat’. There was also no evidence that service users had chosen alternatives to the main meal served, this needs to be developed further to ensure that service users have an informed choice. Elmleigh House Care Home DS0000008671.V348911.R01.S.doc Version 5.2 Page 15 Elmleigh House Care Home DS0000008671.V348911.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users receive some personal support in the way they prefer and require and their healthcare needs were mostly met, however care planning and documentation of monitoring requires improvement as does the management of medication to ensure service users needs are fully met. EVIDENCE: The routine healthcare needs of service users are well monitored and although kept separate to the care file, documentation is kept of routine chiropody dental and ophthalmic checks. Healthcare checks include annual well person checks, breast screening etc and where needed aids and equipment were provided. Where service users reach 60 years plus their care plans need to address ageing processes and ensure that regular reviews are held to ensure the home can continue to meet the individual needs. Elmleigh House Care Home DS0000008671.V348911.R01.S.doc Version 5.2 Page 17 Weight records are in place, but do not have space for comments by staff regarding any significant weight loss or gain and effect on well being/mental health status. The inspector explained to staff that weight records were a fundamental component of a service users care plan/well being and the system in place should be reviewed to reflect this. One service user is a diabetic and is supported by the District Nurse and staff who undertake, blood sugar monitoring and insulin injections. Appropriate training records were viewed. Incidents of aggression are recorded on incident sheets and in the daily notes but there were no care plans in place in respect of this. Care plans need to inform staff of the likely situations that the service user may present challenges to the service and overall the guidance for staff in dealing with challenging behaviour and strategies for minimising risks to other service users appeared insufficient. A contingency plan provided by outside professionals for dealing with challenging behaviour for one person was posted on display in the office, which is not good practice and also the information was not duplicated in the individuals care plan. Information within service users care records provided evidence of specialist input regarding psychiatrists and occupational therapists etc, however there were no care plans or risk assessments completed on service users medical conditions and behaviour which indicated actions to be taken by staff. Staff spoken with were able to give verbal updates on service users medical treatments etc. Evidence within the care plans that were completed, promoted personal choice about how personal care should be delivered and individuals are encouraged to be independent for their personal hygiene wherever possible. Medicines management was assessed but were not fully satisfactory as where staff handwrite any prescriptions onto the medication administration records and these were found, not to be checked and signed by two members of authorised staff to minimise error. A prescription of eye drops which had stated directions that they should not be refrigerated were found stored in the fridge. Elmleigh House Care Home DS0000008671.V348911.R01.S.doc Version 5.2 Page 18 Elmleigh House Care Home DS0000008671.V348911.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems are in place for complaints but safeguarding protocols and financial record keeping, require improvement to ensure service users are fully protected from harm. EVIDENCE: There is a complaints procedure and this is displayed around the home, however there were no complaints procedures seen in symbol or pictorial versions also. There have been no complaints recorded since the previous inspection. Staff reported, numerous incidents including some of challenging behaviour between service users. Although the registered provider had contacted various outside professionals, the Commission for Social Care Inspection have not been notified of these events as required by Regulation 37, neither was there any evidence that the Nottinghamshire Safeguarding Adults Protocols had been followed. The registered person must submit notifications for the incidents discussed, retrospectively, including ‘Safeguarding Adults’ referrals and ensure that notifications are made as required by regulation for any future events/incidents and it was recommended that the senior management team and the providers attend training in the referral process under safeguarding adults protocols. Elmleigh House Care Home DS0000008671.V348911.R01.S.doc Version 5.2 Page 20 There is a very basic policy in place for staff, regarding the use of service users monies but this does not include guidance for staff making purchases on service users behalf, which should include that staff must not benefit from service users transactions. The policy needs further developed which clearly identifies that staff must not use their bonus point schemes, credit cards etc. A member of staff was asked how service users access their money. She said they all have individual bank accounts and each service user has a money tin in their bedroom. Staff said they have been provided with training regarding dealing with challenging behaviour and safeguarding adults but there were no records of this to support the statement. Staff said that the training had provided them with more confidence; skills and knowledge in dealing with aggression presented by service users. Observation of staff practice on the day of the inspection demonstrated that staff interacted with service users in a respectful manner and engaged with them within the daily routines and whilst undertaking personal care. Elmleigh House Care Home DS0000008671.V348911.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in a homely, comfortable and clean environment, however service users safety, some issues identified at the inspection may compromise privacy and security. EVIDENCE: A range of comfortable and fully accessible shared space is provided both for shared activities and for private use. All of the communal areas were clean and smelled fresh. Some redecoration has been undertaken and some was in process on the day of the inspection. The service users’ bedrooms were inspected; all were personalised and clean, but not all were fresh smelling. Action is needed by the registered person in order to eliminate offensive smells in the identified rooms. Elmleigh House Care Home DS0000008671.V348911.R01.S.doc Version 5.2 Page 22 Most of the privacy door locks in service users bedrooms and bathroom were found not to be in working order which compromises service users privacy. Radiator covers have been fitted to most radiators and some and windows have restrainers fitted. However it was observed on arrival at the inspection that most ground floor windows had their restrainers catches off and the windows opened wide. Although there were no service users at home at the time, this did leave the homes several buildings vulnerable to intruders and therefore it is recommended that the registered provider undertake a security review, which takes into account the duty to protect service users and their belongings. The flooring in one of the bathrooms was observed to have a join, which is starting to lift/separate, and this may potentially be a trip hazard to service users and staff. Rugs were noted in bathrooms, which may present a trip hazard to service users, risk assessments should be undertaken in respect of their use. The water outlet temperatures were sampled against the records kept by the home. An entry made in July 2007 for one of the bathrooms showed the temperature a 41 degrees, however the sample taken on the day of the inspection was 48 degrees. The Registered provider stated on 5/9/07 that action has been taken to reduce the water outlet temperature to a safe level of 43 degrees and that this would continue to be monitored. Disposable gloves and practices for infection control were observed in the home but there were no records seen of training for staff in infection control. There was also no evidence of a policy for continence management or training for staff in the topic. Three of the houses have laundry facilities which include a washer and drier, however there are no sluice facilities on the washing machines despite service users needs indicating this would be required. The registered provider must seek advice from the Environmental Health Officer in respect of sluicing facilities. Elmleigh House Care Home DS0000008671.V348911.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A trained, supervised and committed staff team supports Service users. Robust recruitment practice ensures service users safety. Improved record keeping is needed to ensure all training records are kept up to date. EVIDENCE: Since the last inspection the staffing levels had been reviewed and staffing numbers increased. A copy of the staff rota was viewed and this evidenced generally four support staff throughout weekdays and weekends with one staff member on sleep in, in each of the three buildings. Three of the registered providers work at the home also. Staffing levels are arranged around the number of service users who are at the home at the time. However the staffing numbers provided might limit individual support for service users to undertake their individual interests and meet their individual needs. Elmleigh House Care Home DS0000008671.V348911.R01.S.doc Version 5.2 Page 24 Thorough recruitment policy and procedures were in place. Three personal staff files were examined and found to contain the required documentation. There are contingency plans for cover for vacancies and sickness. Additional training had been introduced since the last inspection. This had included adult protection training, care planning, food hygiene and Dementia Care. Staff spoken with had some understanding of equality and diversity having covered this in NVQ [National Vocational Qualifications] and LDAF [working with people with a learning disability] training, but there was a lack of evidence throughout the inspection that the staff team had embraced equality and diversity within their day to day work and that the service was tailored to meet individual needs. Future training should include Equality and Diversity, the Mental Capacity Act 2005, support for people with communication difficulties, risk taking and risk assessments, infection control and management of continence All staff receive mandatory training for health and safety, first aid, fire safety, food hygiene and manual handling and additional training is also provided in Challenging behaviour, managing diabetes, epilepsy, food and nutrition, adult protection and working with people with a learning disability. Elmleigh House Care Home DS0000008671.V348911.R01.S.doc Version 5.2 Page 25 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management and administration systems in the home require improvement to ensure that service users are fully consulted that record keeping meets the required standards and that service users health safety and welfare is fully promoted and protected. EVIDENCE: The manager had been in post for many years, she has not yet completed the registered managers qualification. Staff said they had confidence in the manager. The registered providers also work at the home most days of the week. Elmleigh House Care Home DS0000008671.V348911.R01.S.doc Version 5.2 Page 26 There was evidence of some of quality assurance used by the home, Regulation 26 visits are carried out and records of these were seen. A service user survey was undertaken in March 2007 but the questionnaire used was observed to be not service user friendly and staff had assisted service users with them and said they had found them difficult to use with service users. A member of staff said they do not have regular service user meetings and that they hold these if there is a problem. Minutes were viewed which showed resident meetings take place periodically but not as routine. Consultation and feedback with service users, relatives and visiting professionals needs to be improved as does general auditing systems in the home. Service users are supported with their finances and a sample of records examined. The record keeping in this area was found to be inefficient as one persons receipt was not entered on the record sheet at all, another had no sheet at all to audit for receipts and another receipt identified that gift vouchers had been used to make payment for clothing but there was no reference to the gift vouchers on the service users account and identified cash amounts only. The registered person must investigate the discrepancies and provide details of the outcome of the investigation to the Commission For Social Care Inspection. Health and Safety records examined on the day were mostly satisfactory, these included fire safety records, accident, incident, water outlet temperatures, systems in place for prevention of legionella, electrical circuit testing and the gas safety certificate. A recommendation has been made in respect of out of date Portable Appliance test records Record keeping in the home should be improved and should be audited regularly. There is a health and safety policy in place and generic risk assessments were viewed. The fire risk assessment was completed, but did not reflect the use of wooden door wedges observed on the day of the inspection or door guards in place. The fire officer had visited the home in July 2007, no requirements were made. Elmleigh House Care Home DS0000008671.V348911.R01.S.doc Version 5.2 Page 27 A member of staff said that they did not have regular fire drills. However records showed that fire drills had been undertaken and included the names of the people that had been involved. Staff commented ‘If the fire bell goes off the residents always think it is the phone’. It is recommended that action be taken to ensure the fire alarm and telephone bells have different sound alarms. Another staff member said that service users forget what they need to do should the fire alarm sound. It is recommended that all staff have opportunity to be involved in fire drills and that these are undertaken more frequently with service users. The Environmental Health Officer undertook a food safety inspection in July 2007, no requirements were made, however on the day of the inspection opened food items [tuna and mayo mix] was not date labelled despite colour coding systems being in place in the home and food probing records had lapsed in the recent weeks. Elmleigh House Care Home DS0000008671.V348911.R01.S.doc Version 5.2 Page 28 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 2 2 X 3 2 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 2 27 2 28 X 29 2 30 2 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 X 1 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 2 15 X 16 1 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 2 X 2 X 2 2 X Elmleigh House Care Home DS0000008671.V348911.R01.S.doc Version 5.2 Page 29 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 YA18 YA6 Regulation 15 (1) Timescale for action Care plans must be implemented 05/10/07 as specified, as to how the service users needs in respect of his health and welfare are to be met. Priority areas are as follows: • • • • • Pressure Area/tissue viability Management of Diabetes Dementia Care Epilepsy Management of Continence Mental Health needs Older persons needs Challenging behaviour Requirement • • . Previous Timescale 30/12/06 Not Met. Elmleigh House Care Home DS0000008671.V348911.R01.S.doc Version 5.2 Page 30 Urgent Action required. 2. YA9 13 (4) (c) The registered person must 05/10/07 ensure that risk assessments are completed on service user’s medical conditions and behaviour and indicate action to be taken by staff Previous Timescale 30/12/06 Not Met. Urgent Action required 3. YA16 YA18 16[2][c] and 23[2][e] 12[4][a], Ensure service user’s privacy is respected and facilities provided are in full working order. Urgent Action required. 05/10/07 4 5 YA24 YA20 YA23 13[2] 17,37 6. YA24 YA42 13 [4] [a] 7. YA26 16[2][k] 8 YA23 YA41 13[6], 17 9 YA41 17 Ensure the medication systems are safe in respect of correct storage of eye drops Ensure notifications are made as required by regulation 37 and safeguarding referrals to ensure service users are protected from harm. Ensure the bathroom flooring is made safe/replaced as this may present a trip hazard. Urgent Action required. Eliminate the offensive odours in the identified bedrooms to promote a comfortable and hygienic environment for service users The registered person must investigate the discrepancies in the service user finance records and provide details of the outcome of the investigation to the Commission For Social Care Inspection. Improve record keeping DS0000008671.V348911.R01.S.doc 05/11/07 05/11/07 05/10/07 05/11/07 05/11/07 05/11/07 Page 31 Elmleigh House Care Home Version 5.2 practices in the home as required by Regulation 17 schedules 3 and 4 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 Refer to Standard YA1 YA1 YA2 Good Practice Recommendations Further develop ways to ensure service users and visitors are informed how to access a copy of the inspection report. Ensure service users receive their own, up to date copy of the Service User Guide. There was limited evidence of development in meeting the communication needs of service users and it is recommended that the home consider production of communication tools such as pictures and symbols. Ensure information about the fees charged is included in the Service User Guide. Service user support plans should include details about service users choices, individual aspirations and goals and how staff will support these, including daytime occupations, leisure interests and holidays and also support for personal relationships. 4 5 YA5 YA14 YA15 YA16 YA18 YA7 YA16 YA7 YA17 6 7 Re-locate the pay phone to promote privacy A pre-agreed menu should offer at least two options to service users to choose from. Evidence of the choice should be documented. The use of communication aids, such as menus in symbol or photographic formats should be explored and implemented to promote informed choice Weight records are a fundamental component of a service users care plan/well being and the system in place should be reviewed to reflect this. Add a comments section to the weight record sheet. Where prescriptions are handwritten on the medication administration record, this should be checked and signed DS0000008671.V348911.R01.S.doc Version 5.2 Page 32 8 YA19 9 YA20 Elmleigh House Care Home 10 11 12 13 14 YA23 YA23 YA30 YA33 YA35 15 YA39 by a second staff member Further develop the financial policies and procedures for staff shopping on service users behalf. The senior management team should undertake training in referral protocols for safeguarding adults. Consult with the EHO in respect of sluicing facilities as specified in the report and develop a policy for the management of continence in the home. Review staffing levels to ensure service users needs and aspirations are fully supported. Provide training for staff in Equality and Diversity and the Mental Capacity Act 2005,support for people with communication difficulties, risk taking and risk assessments, infection control and management of continence . Develop ways to obtain service users views, such as by using outside professional support or advocacy services in service user surveys etc and service user consultation meetings. Expand quality monitoring surveys to include consultation with relative and visiting professionals It is recommended that action be taken to ensure the fire alarm and telephone bells have different sound alarms. It is recommended that all staff have opportunity to be involved in fire drills and that these are undertaken more frequently with service users. Undertake a security review of the premises in respect of discussions about window restrainers and open doors at the inspection. Portable Appliance testing needs to be kept up to date Ensure food safety practices are maintained at all times. 16 17 18 19 20 YA42 YA42 YA42 YA42 YA42 Elmleigh House Care Home DS0000008671.V348911.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Elmleigh House Care Home DS0000008671.V348911.R01.S.doc Version 5.2 Page 34 - 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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