Inspection on 06/11/06 for Elmleigh House Care Home

This inspection was carried out on 6th November 2006.

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 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 7 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 04/09/07

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 Judith Avill Key Unannounced Inspection 6th November 2006 1.45 Elmleigh House Care Home DS0000008671.V315873.R02.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.V315873.R02.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.V315873.R02.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 21 Category(ies) of Learning disability (21) registration, with number of places Elmleigh House Care Home DS0000008671.V315873.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to provide personal care for service users of both sexes whose primary needs fall within the following categories:Learning disability (21) 21st December 2005 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, and possible further developments are planned to provide a respite care bed. 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. Fees at the time of inspection were £356.50 - £372.00. Elmleigh House Care Home DS0000008671.V315873.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was undertaken using a review of all the information available to the inspector regarding the service history of Elmleigh, and through undertaking a visit to the home. The fieldwork visit took place over five hours. The main method of inspection used was called case tracking which involved selecting four residents and tracking the support they receive through the checking of their records, discussion with them, the care staff and observation of practice. A tour of the main house and Sapling 1 and 2 was undertaken with the manager and one of the staff. Documents connected with the running of the home were also inspected. Twenty-one comment cards were returned and all contained positive feedback. The responsible person/company secretary had also completed a Pre inspection questionnaire. What the service does well: What has improved since the last inspection? Fire records are maintained up to date. A college course for residents commenced at the home is well attended. Elmleigh House Care Home DS0000008671.V315873.R02.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Elmleigh House Care Home DS0000008671.V315873.R02.S.doc Version 5.2 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.V315873.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good procedures for introducing new residents to the home and an assessment is conducted to ensure that residents needs can be met. EVIDENCE: The manager reported prospective residents have an initial assessment by the social worker, any other professional involved. Where possible the prospective resident visits the home prior to admission to meet other residents and staff and decide if they want to live at the home. Resident’s files seen evidenced assessments prior to admission, records of visits to the home prior to admission and details of resident’s preferences being discussed. Staff spoken with demonstrated a good knowledge of residents and confirmed they were informed about new residents before they were admitted. Elmleigh House Care Home DS0000008671.V315873.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Care plans do not accurately describe residents care needs over a 24 hour period. Risk assessments on medical conditions do not indicate action to be taken by staff. EVIDENCE: Care plans have a record of the personal details of residents. Some of the information on one of the four residents case tracked was not up to date and did not include accurate information on who to contact in an emergency. A resident with a medical condition had no risk assessment and no written record of action to be taken by staff. Staffs spoken with were aware of action to be taken if a change occurred in the resident’s condition. Care plans seen stated ‘resident needs full support’. No record of what this means, personal preferences or instructions for staff to take was evidenced. The manager reported one resident could present with a behaviour which could upset residents or staff. There was no risk assessment to outline what strategies staff should take if this behaviour occurred. Residents finances were well organised, were secure and maintained up to date. Information from a Elmleigh House Care Home DS0000008671.V315873.R02.S.doc Version 5.2 Page 10 member of staff about a resident who was supported in the management of their finances and the care plan seen no evidence of a record of the support provided by staff to was seen. Elmleigh House Care Home DS0000008671.V315873.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Leisure opportunities, the promotion of independence and living skills are good within the home. EVIDENCE: Residents commented ‘they like living here’ ‘enjoy going out with staff’ and ‘enjoy the college course at the home’ that includes life skills and food hygiene. One resident said they help clean their room and liked choosing things for their bedroom. Staff spoken with reported residents visit local shops and each resident file seen included details of leisure activities such as visits to local pubs and the cinema. Records of contact with family and friends were evidenced and residents and staff confirmed that relatives and friends can visit at any time. The residents eat in each of the houses. During the inspection residents were observed helping with the preparation of food. All the houses have domestic Elmleigh House Care Home DS0000008671.V315873.R02.S.doc Version 5.2 Page 12 kitchens. The menu provided with the pre questionnaire states only one choice but residents said and staff confirmed that choices are available if required. The menu provided was varied and food viewed appeared nutritious. Staff reported and residents confirmed they are encouraged to be involved in the preparation of the breakfast, evening meal and weekend meals. All residents spoken with said the food was good. Elmleigh House Care Home DS0000008671.V315873.R02.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Details of residents personal support needs and preferences are not specific. There are good arrangements to ensure health needs are met. EVIDENCE: Care plans seen did not include night care plans or explain how residents are guided and supported. Staff spoken with said what they did before one resident retired to bed and what time she assisted them in the morning but no record of this was seen on the care plan. Additional support and advice from other professionals such as district nurses was well documented. Resident’s health checks are carried out and records of follow ups well maintained. Medication records seen were maintained up to date, medication is stored securely and training for staff was evidenced. No evidence of any resident’s self-medicating was seen. Elmleigh House Care Home DS0000008671.V315873.R02.S.doc Version 5.2 Page 14 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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents have confidence that staff will take complaints and concerns seriously and feel safe living at the home. EVIDENCE: The home has had one complaint since the last inspection, which has been referred to the Adult Protection team and is still undergoing investigation. A new member of staff spoken with demonstrated knowledge of action to take and who to contact in the event of an alleagtion. No evidence of adult protection training was seen in staff files. All residents spoken with said they would talk to the staff or one of the proprietors if they were not happy. Elmleigh House Care Home DS0000008671.V315873.R02.S.doc Version 5.2 Page 15 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): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. All buildings provide a comfortable well decorated and maintained environment for residents to enjoy EVIDENCE: The home has a maintenance person who decorates and does repairs as required to all the houses. Changes to one en -suite room have been completed since the last inspection. An extra bedroom with en-suite facilities has been completed. at the time of inspection the Commission is considering an application made for an extension to the number of bedrooms and residents accommodated. The main house has a bedroom for the ‘sleep in staff’ and in the three and four bed houses (Sapling 1 and 2) staff sleep in the lounges. No staffs sleep in the ‘little house’ that accommodates one resident. Residents bedrooms seen are well personalised. There is one double bedroom call alarms are in place in some of the rooms for residents over 65. On the day of inspection one resident over 65 had no call alarm. Elmleigh House Care Home DS0000008671.V315873.R02.S.doc Version 5.2 Page 16 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): Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Staffs are trained supported and motivated. The home has no assessment of the needs of individual residents by night. EVIDENCE: The staff rota seen on the day of inspection did not accurately reflect the staff on duty for that day or week. Two of the staff recorded as on duty were on annual leave. Changes in rota to cover for staff on annual leave were not identified on the rota seen on the day of inspection. The manager reported and the rota evidenced that night cover is by sleep in staff. The rota seen stated staff work from 9-9 for night duty work. Staff spoken with confirmed that they sleep in the lounge area of the two houses Sapling 1 and 2. The manager reported and staff confirmed that there are no awake staffs on duty at night. Domestic duties are covered by a member of staff working from 7.30 am to 8.30 as a carer and then until 3.00pm as a domestic. These roles are not recorded on the rota. Staff commencing work a 3.00pm do domestic duties as identified on the rota. The residents are out at college, day centres during the day, monday to friday. The rota provided with the pre questionnaire and the one seen on the day of inspection contained no evidence of roles or responsibilities of staff. Elmleigh House Care Home DS0000008671.V315873.R02.S.doc Version 5.2 Page 17 Staff files seen on the day of inspection evidenced that the home follows the homes recruitment procedure for satisfactorily obtaining two references and Criminal Record Bureau checks prior to staff commencing work at the home. New staff working at the home said they had completed application forms, attended for interview, provided information for references, and obtained satisfactory Criminal Record Bureau checks before commencing work at the home. Staff records showed that they had attended required mandatory training, plus more specialist training over the past year. New staff spoken with said they received excellent support from senior staff and that their induction had been helpful. No evidence of training on adult protection was seen. Elmleigh House Care Home DS0000008671.V315873.R02.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is well organised and managed. EVIDENCE: The manager reported she is undertaking the National Vocational Qualification (NVQ) at Level 4.The home is well organised and managed. The manager reported that the registered provider works at the home in an administrative capacity. This role is not recorded on the rota. Staff and residents said they can discuss concerns with the manager and owners of the home. The manager reported that the registered person is developing a system to monitor quality in the home. The Responsible person conducts regular visits. Policies and procedures are updated as required. Health and safety documentation is up to date. Records of fire drills attended by staff and residents seen contained no information on which staff or Elmleigh House Care Home DS0000008671.V315873.R02.S.doc Version 5.2 Page 19 residents were present at the drill. This requirement is outstanding from the previous inspection. Elmleigh House Care Home DS0000008671.V315873.R02.S.doc Version 5.2 Page 20 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 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 2 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 3 x 3 x N/A x x 3 x Elmleigh House Care Home DS0000008671.V315873.R02.S.doc Version 5.2 Page 21 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 YA42 Regulation 17 Requirement The registered person must ensure that details of staff attending fire drills are recorded Outstanding requirement 2. YA6 YA18 15 (1) The registered person must ensure that the care plans detail as to ‘how’ the residents needs in respect of his personal needs are to be met The registered person must ensure that risk assessments are completed on residents medical conditions, behaviour and indicate action to be taken by staff The registered person must ensure that there are adequate staff by day and by night as are appropriate for the health and welfare of the residents Immediate requirement issued 6/11/06 The registered person must ensure that rota includes records of staff working at the home, in what capacity and hours worked The registered person must DS0000008671.V315873.R02.S.doc Timescale for action 10/11/06 30/12/06 3 YA9 13 (4) (c) 30/12/06 4 YA33 18(1) 10/11/06 5 YA33 17 Schedule 47 23 (4) 30/12/06 5 YA42 10/11/06 Page 22 Elmleigh House Care Home Version 5.2 consult with the Fire safety officer re the fire precautions, detection equipment and escape system in Sapling 1and 2 and the Little House Immediate requirement issued 6/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Elmleigh House Care Home DS0000008671.V315873.R02.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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.V315873.R02.S.doc Version 5.2 Page 24 - 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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